Resource
The 12-rung ladder: evidence → recognition → authority → adoption → consequence
NextConsensus models medical change as a sequence of recognition states. We observe upstream, forecast resolvable transitions, enable downstream decisions.
Select a rung
Twelve rungs, three layers
Formal recommendation change by a recognized guideline body: grade shift, new/retracted endorsement, population expansion/restriction.
Evidence emergence
New trial results, replications, subgroup analyses, novel mechanisms, or new indications enter the public record.
Replication & strengthening
Independent confirmation, effect consistency across populations, endpoint coherence, and methodological rigor.
Expert recognition & KOL convergence
Field-level interpretation shifts: review articles, conference narratives, advisory-board consensus, editorial positions.
Real-world confirmation
RWE accumulation, registry data, claims analyses, practice-pattern shifts, and post-market surveillance.
Guideline action
Formal recommendation change by a recognized guideline body: grade shift, new/retracted endorsement, population expansion/restriction.
Regulatory action
Label/indication change, approval action, REMS modification, or withdrawal by FDA, EMA, PMDA, Health Canada, etc.
Payer/coverage action
NCD, LCD, formulary change, step-therapy revision, or access expansion/restriction by CMS, MACs, or major commercial payers.
Institutional policy adoption
Hospital system pathway updates, P&T formulary decisions, clinical protocol revisions, EHR order-set changes.
Clinical adoption
Prescribing behavior shifts, guideline-concordant care metrics, specialist vs. PCP uptake divergence, academic vs. community practice gaps.
Commercial strategy adjustment
Promotional claim changes, field force redeployment, patient support program modifications, pricing/contracting strategy shifts.
Market repricing
Analyst narratives change, consensus estimates move, valuation assumptions reset, a clinical thesis becomes priced in, a previously ignored risk becomes conventional.
Patient-access / outcome consequences
Time-to-treatment changes, health equity impacts, long-term outcome shifts, budget impact on health systems.
Product architecture
Two products, different evaluation criteria
The ladder architecture makes the product separation explicit. Discovery operates at rungs 1–4 — identifying which transitions are worth watching. Authority-Transition Forecasting operates at rungs 5–7 — scoring whether a named authority acts by a deadline. They have different targets, different evaluation metrics, and different maturity.
Discovery
Target: Rungs 1–4
Question: Which emerging institutional transitions are worth watching before a proposition is registered?
Surfaces questions for review without assigning a forecast probability.
Authority-Transition Forecasting
Target: Rungs 5–7
Question: Is a named authority likely to take a defined public action by a deadline?
Registers a defined question and evaluates it against the public outcome.
Canonical proposition
What every proposition declares
Core metric
Lead time over rung
Lead time is useful only when reported with the quality and alert burden of the underlying forecast. The comparison point and observation rule are declared with any published result.
Transition modeling
The public commitment is limited to the outcome: define the transition, freeze the evidence, register the estimate, and publish the result with its limits. The internal modeling approach is not a public reconstruction recipe.