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KMID : 9000220160010140194
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NECA Research Report
2016 Volume.1 No. 2 p.1 ~ p.194
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Choi Ji-Eun
Park Chong-Yon
Choi Seul-Ki
Choi Ha-Young
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Abstract
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? Background
The round table conferences of the National Evidence-based Healthcare Collaborating Agency (NECA) called “NECA Resonance” organize discussions on core issues of public health and medical care to seek consensus among a wide range of interested parties. Since its establishment in 2009, NECA has been holding round table conferences to resolve conflicting issues in healthcare by developing policies based on rational decision-making processes. The name “NECA Resonance” originates from a branding process of NECA round table conferences in order to preserve the literal meaning of “resonance,” which is to empathize with others’ thoughts, emotions, and behaviors, as well as to create a healthier society based on a social consensus of a sense of resonance.
? Objective
The purpose of this research is threefold: first, to improve the operation of round table conferences by identifying possible improvements based on previous round tables; second, to derive a social consensus by narrowing the gap between theory and field, and finding a resolution among stakeholders for round table topic conflicts; and finally, to ensure the use of round table results as a basis for health policy decisions.
? Research Results: Electronic Cigarettes
I. Management Plan and Detailed Operating Procedures
The first steering committee discussed the approximate dates and possible locations for future meetings, as well as potential organizers, programs and participants, presentation and discussion topics, and possible ways to reach agreements (2015. 1. 8). The second steering committee, in cooperation with the Ministry of Health and Welfare, finalized the round table proposals based on the first steering committee’s discussions (2015. 1. 13).
The NECA round table plenary session, “Scientific Evidence about the Safety of Electronic Cigarettes and Their Effectiveness” took place at the Yein Hall, Sejong Center. The purpose was to reach a consensus on the safety of electronic cigarettes and their effectiveness in smoking cessation, and to develop a management plan.
Ⅱ. Results of the Plenary Session
Since the sole purpose of this round table was to reach a consensus, the panel discussion mainly focused on the contents of the agreement and modification of the wording. The agreement was first drafted by the operational team in advance, and it was finalized after a careful review by the chair and the presenters. Panel members modified specific phrases in the agreement based on the presentation content, which focused largely on four topics ? safety of electronic cigarettes, their effectiveness in smoking cessation, future research areas, and the development of a management plan. Due to time limitations, complete modification of phrases was not possible, but a framework for the overall agreement was completed. Additional modifications to wording were to be completed through reviews by panel members via e-mail at a later date.
Ⅲ. Follow-up Measures
The complete agreement, which reflected the views of all the panel members in the plenary session, was released to the press (04/06/2015). In addition, results of a survey of the general public and health professionals were used as the basis for the NECA resonance and were published under the title of 'Survey of the General Public and Health Professionals on Electronic Cigarettes” in Korean Society for Research on Nicotine and Tobacco (2015. 7. 6).
? Research Results: Bariatric Surgery
I. Management Plan and Detailed Operating Procedures
A steering committee composed of NECA Department of Policy Cooperation and outside experts on bariatric surgery was formed to share ideas on discussion topics, direction of the panel discussion, presenter and panels, potential moderators, program, time, and place of the session (2015. 7. 2).
Invited plenary moderators and presenters attended the preliminary meetings which had been organized for the purpose of obtaining consultation from external experts about the steering committee discussions as well as to set up a detailed management plan. The preliminary meetings were held twice. The first preliminary meeting invited the Knowledge and Information Dissemination team, the Internal Department of Policy Cooperation team, two presenters and one moderator (2015. 8. 3), and the second preliminary meeting invited the Knowledge and Information Dissemination team, the Internal Department of Policy Cooperation team, and one presenter (2015. 8.10).
The plenary session took place in the NECA Conference Room (2015. 9. 8). The main theme of the session was "Round table for Ensuring Safety During Bariatric Surgery," and the agenda included indications, safety, and management plans for bariatric surgery. Various medical experts on obesity, and patient representatives shared and reviewed domestic and international research, and based on this evidence, participants discussed future challenges.
Ⅱ. Results of Plenary Session
1. Current bariatric surgery indications
The guidelines followed by many countries ? the United States (NIH), the United Kingdom (NICE), and Japan ? specify indications for bariatric surgery as Body Mass Index (BMI) of 35Kg / ㎡ or more with comorbidities, or BMI of 40Kg / ㎡ or more.
2. Necessity of developing guidelines for bariatric surgery indication
Guidelines for bariatric surgery differ by country and region. In Korea, relevant academic societies have their own guidelines which differ from each other, and thus standardized guidelines are needed. First, academic societies should set priorities on the research topics that are necessary and relevant to health insurance benefits guidelines, and then NECA, the National Health Insurance Corporation, or the government should conduct research accordingly.
3. Research areas and design for guideline development
Well-designed research targeting Koreans with a BMI of 30 ~ 35 Kg / ㎡, and other research areas that reflect Korean BMI and other health characteristics (abdominal obesity, diabetes, blood pressure, etc.) is necessary. Long-term research on patients with BMI of 30~35 Kg/㎡ with and without comorbidities is also needed.
4. Management plan for safe bariatric surgery
Obesity is a chronic disease, so patients should receive treatment and lifelong management (nutrition, behavior modification, medications) from qualified specialists and hospitals. Policy options would include a medical specialist system, physician certification system, and an institutional accreditation system. A management plan should be established through collaboration of relevant academic societies; for example, in addition to external treatments, a multidisciplinary management team (family medicine, psychiatry, nutrition, etc.) should be formed to offer treatment.
Ⅲ. Follow-up Measures
Since the round table session also functioned as a policy debate, participants decided not to create a separate agreement document; rather, they agreed to write a report that included a summary of the opinions of the panelists. The report was presented to the public and clinical experts at the '67th Congress of KSS Joint Symposium NECA-KSMBS'.
? Research Results: Government-supported clinical research
Ⅰ. Management Plan and Detailed Operating Procedures
The steering committee included the internal Department of Policy Cooperation team and internal experts on clinical research, and addressed the discussion topics, presenters and panels, potential moderators, programs, and possible dates and places for upcoming sessions (2015. 4. 20).
The first plenary session discussed development plans for government-supported clinical research and the role of NECA (2015. 5. 19). Clinical research experts were invited to the second plenary session whose theme was "Round table for Development Plans of Government-supported Clinical Research." Various topics were on the agenda, including the roles of NECA, national health clinical research (NHCR) projects, and collaborative planning (2015. 11. 9).
Ⅱ. Results of the Plenary Session
1. Differentiation between NECA and NHCR research strategies
NECA should aim for policy-oriented research and NHCR should focus more on generating policy-relevant evidence and on basic clinical studies.
2. Collaborative strategies for NHCR and NECA to achieve synergy effects
(1) Unified survey channel to investigate research topics in demand
Currently NHCR and NECA conduct separate surveys, but from the respondents’ perspective, there is little difference between the surveys. Therefore, it would be more effective to integrate survey channels to determine all potential research topics and then assign the appropriate research topics to NHCR and NECA respectively.
(2) NHCR research for supplementing insufficient evidence
Some NECA research had insufficient evidence to draw valid conclusions, thus could only indicate that further research was needed. If NHCR can follow up and supplement the evidence from the NECA research, NECA and NHCR could initiate a positive chain reaction.
3. Expansion of clinical research experts in peer review pool
The number of clinical researchers included in the current peer review pool is insufficient for proper research evaluation. Currently, more experts who are familiar with clinical research are needed in the peer review pool in order to evaluate research properly.
4. Budget expansion needs for government-supported clinical research
Because we need to expand clinical research budgets, but government-support is limited, it is necessary to consider seeking funding from industry. If clinical research is necessary for medications already on the market, conducting expensive research would be a burden for both pharmaceutical companies and the government. In this case, it would be beneficial if pharmaceutical companies could support researchers without conditions, and if the researchers could establish a collaborative framework to conduct research with NECA or NHCR. Following the example of The National Institute for Health and Care Excellence (NICE) based in the United Kingdom, which has been involved in various types of publicly-funded research collaboration with pharmaceutical companies, NECA, NHCR and pharmaceutical companies should collaborate on research adapted to Korea.
Ⅲ. Follow-up Measures
Currently NECA is serving as the host research institution for NHCR’s government-supported clinical research and is conducting various studies. Therefore, the results of the NECA Resonance are shared with researchers in the National Health Clinical Research Coordinating Center in order to reflect the discussion outcome when implementing the actual research projects.
? Research Results: Rotator cuff tear
Ⅰ. Management Plan and Detailed Operating Procedures
In response to the need for expert consensus on appropriate treatments for rotator cuff tears, a round table conference steering committee composed of the principal investigators and participating researchers was convened (2015.6.30). Because subcommittees and experts had totally opposing opinions on the research topic, unlike conventional conferences, the round table agreed to utilize RAND’s Delphi technique to be able to reach a consensus. Researchers held two preliminary meetings, which included stakeholder such as orthopedic and rehabilitation specialists (2015. 7. 30, 2015. 8. 6). Each meeting was held separately for each subcommittee. Experts on methodology and preventive medicine also participated to provide consultation on the necessity of and methodology for the research topic. The first survey was conducted on 13 panel members for about ten days between November 17 and November 29, 2015, and a meeting was held at 6:00 p.m. on December 8, using results from the first survey as the agenda. The second survey was conducted for about a week from December 8 to Dec 14.
Ⅱ. Results of the Plenary Session
The first survey revealed that the respondents agreed in 69 vignettes, disagreed in 47 vignettes and neither agreed nor disagreed in 172 vignettes. In the face-to-face meeting that occurred sometime after the first survey, the discussion was mostly about the appropriateness of conservative and surgical treatments in a subset of 52 vignettes in which experts neither agreed nor disagreed. More specifically, the discussion focused on the survey questions related to indications, and particularly on how to interpret the survey question regarding “patients’ response to the previous treatment (conservative treatment).” The participants realized that the interpretation of this survey question was one of the most controversial issues in the first Delphi survey. Thus for the second Delphi survey, the participants agreed to interpret the survey question as “patients who responded or did not respond to treatment after receiving sufficient previous treatment (conservative treatment).” The participants also agreed to exclude 36 vignettes, particularly those that were very unlikely to happen, from the second Delphi survey. When the second survey was conducted, reflecting consensus reached in the previous meeting, the respondents agreed in 24 vignettes, disagreed in 105 vignettes, and neither agreed nor disagreed in 123 vignettes.
Compared to the first survey, in which the respondents agreed in 58 vignettes (not counting the vignettes that were excluded in the second survey), the respondents in the second survey agreed only in 24 vignettes, showing a decrease of 34 in the number of vignettes in which they were in agreement. In the case of vignettes in which they did not agree, the first survey revealed that the respondents disagreed in 47 items, which increased by 62 in the second survey, resulting in a total of 105 vignettes in which they disagreed. In the case of vignettes respondents neither agreed nor disagreed to, the first survey revealed that the respondents neither agreed nor disagreed in 150 vignettes, while the second survey showed respondents neither agreed nor disagreed in 123 vignettes, which is 27 vignettes fewer than the first survey.
Among the vignettes agreed upon by the meeting participants, conservative treatment instead of surgical treatment is recommended at the first medical examination in the following cases: 1) 50-69 year-olds, frail, vigorous physical activities expected after treatment, responsive to previous treatment (conservative treatment), partial rupture with severe damage, minor illness; 2) 50-69 year-olds, frail, normal daily activity expected after treatment, responsive to previous treatment (conservative treatment), partial rupture with severe damage, minor illness; 3) more than 70 years old, frail, normal daily activity expected after treatment, responsive to previous treatment (conservative treatment), partial rupture with severe damage, minor illness; 4) more than 70 years old, not frail, normal daily activity expected after treatment, responsive to previous treatment (conservative treatment), partial rupture with severe damage, minor illness. In other words, conservative treatment is recommended for those patients who are 50-69 years old, frail, and who have partial rupture with severe damage, only minor illness, and are responsive to previous treatments, regardless of the level of expected daily activities after treatment. Conservative treatment is also recommended for patients who are 70 years old or older and responsive to previous treatments with normal daily activity expected after treatment, regardless of frailty.
There was a consensus that surgical treatment recommended at the first examination is appropriate whereas conservative treatment is not in the cases of those patients who are 50-69 years old, who are not frail, who have total rupture of 2 cm or more, and who are expected to be physically active after treatment for major illness, but who are non-responsive to the previous treatment (conservative treatment).
This study is significant for identifying the areas in which experts agreed and disagreed. Since the second survey had more dissent over the vignettes compared to the first survey, further research and continuous efforts to reach expert consensus are needed to provide scientific and objective information to the public on disputed and neutral scenarios.
Ⅲ. Follow-up Measures
This round table agreed to summarize the survey results in a report. This report will be presented to the public and clinical experts.
? Conclusions
NECA Resonance was held four times in 2015 to reach consensus on social and public healthcare agendas. This project was an extension of the ‘NECA Round table Conference for Social Consensus’ in 2014 and followed the same operational procedures, except for selecting research topics through two different methodologies: 1) through conducting surveys on research topics in demand and 2) through internal planning.
I. Major Achievements and Limitations of NECA Resonance Operations
1. Application of quantitative topic selection procedures
A survey on potentially desirable topics was conducted to ensure transparency in topic selection, and topic priorities were evaluated in a quantitative manner using a checklist for the topic’s ‘level of scientific evidence’ and ‘social values.’ However, these procedures (using quantitative measures for prioritizing topics) had to be administered twice due to low participation of staff members. Consequently, it became apparent that ensuring objectivity and transparency in the topic selection process is important, but developing strategies to increase participation rates of the internal staff members is also urgent.
2. Increasing participant numbers
In contrast to the Denmark citizen participation studies, NECA Resonance conducted national surveys as an alternative to actual citizen participation and used representatives from patient groups as panelists to represent all healthcare consumers, because of the restrictions imposed on NECA researchers. If human resources and funding are strengthened at a later time, and study periods can be lengthened, NECA should consider holding NECA Resonance on a larger scale such as the Danish consensus conferences.
3. Possible political advantages and outcomes
During the ‘Electronic Cigarette’ NECA Resonance, relevant associations, clinical experts, and some experts from the Ministry of Health and Welfare signed a written agreement on the safety of electronic cigarettes and their effectiveness for smoking cessation, and management plans, all of which can be used as practical evidence in the policy-making process. The ‘Bariatric Surgery’ NECA Resonance did not develop a written agreement since it functioned as a policy debate, but clinical experts and experts from the National Insurance Corporation both participated in the discussion so that the outcome could be reflected in the policy-making process in regards to the provision of national health insurance coverage for bariatric surgery.
4. Application of quantitative consensus methods
In the ‘Rotator cuff’ NECA Resonance, the RAND-UCLA Appropriateness Method (RAM) was used on a trial basis as a way of reaching quantitative consensus. This method was applied only once in 2015; however, in the future, it may help us secure transparency in reaching consensus during NECA Resonance if applied appropriately considering the topic characteristics.
II. Improvement suggestions for NECA Resonance
1. Evaluation results and performance of NECA Resonance
Satisfaction evaluation of participants (panelists, presenters, chairs) is necessary to improve the operational procedures of NECA Resonance.
2. Enhancement of the consensus process
To be able to enhance consensus in NECA Resonance, it is important to utilize quantitative consensus methods such as the Delphi technique or nominal grouping techniques if agreement is not reached through discussions, as well as to develop a reward system for panelists who dedicate a lot of time.
3. Need for increasing participation rates of internal principal investigators
To be able to increase participation rates of the internal principal investigators, it might be helpful to consider dividing round table conference research projects into primary subjects (research management subjects) and secondary subjects.
4. Setting guidelines for agreement in principle
Clear guidelines pertaining to ‘agreement in principle’ are needed for smooth consensus (for example, considering consensus to have been reached if more than 75% of the votes are in agreement).
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KEYWORD
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NECA Resonance, round table conference, consensus,
electronic cigarette, bariatric surgery, government-supported clinical
research, rotator cuff
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FullTexts / Linksout information
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