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PubMed2005

Acute respiratory distress syndrome: underrecognition by clinicians and diagnostic accuracy of three clinical definitions.

OBJECTIVE: To determine and compare the diagnostic accuracy of three clinical definitions of acute respiratory distress syndrome (ARDS): (1) the American-European consensus conference definition; (2) the lung injury score; and (3) a recently developed Delphi definition. A second objective was to determine the accuracy of clinical diagnoses of ARDS made in daily practice. DESIGN: Independent comparison of autopsy findings with the daily status of clinical definitions, constructed with data abstracted retrospectively from medical records. SETTING: Tertiary intensive care unit. PATIENTS: One hundred thirty-eight patients from the period 1995 through 2001 who were autopsied after being mechanically ventilated. INTERVENTIONS: Clinical ARDS diagnoses were determined daily without knowledge of autopsy results. Charts were reviewed for any mention of ARDS in the clinical notes. Autopsies were reviewed independently by two pathologists for the presence of diffuse alveolar damage. The sensitivity and specificity of the definitions were determined with use of diffuse alveolar damage at autopsy as the reference standard. MEASUREMENTS AND MAIN RESULTS: Diffuse alveolar damage at autopsy was documented in 42 of 138 cases (30.4%). Only 20 of these 42 patients (47.6%) had any mention of ARDS in their chart. Sensitivities and specificities (95% confidence intervals) were as follows: American-European definition, 0.83 (0.72-0.95), 0.51 (0.41-0.61); lung injury score, 0.74 (0.61-0.87), 0.77 (0.69-0.86); and Delphi definition, 0.69 (0.55-0.83), 0.82 (0.75-0.90). Specificity was significantly higher for both the lung injury score and Delphi definition than for the American-European definition (p < .001 for both), whereas comparisons of sensitivity, which was higher for the American-European definition, were not significantly different (p = .34 and p = .07, respectively). CONCLUSIONS: Acute respiratory distress syndrome appears underrecognized by clinicians in patients who die with this syndrome. In this population, the specificities of existing clinical definitions vary considerably, which may be problematic for clinical trials.

Aged↗

PubMed2000

Setting health priorities in a Swiss canton: what do different methods tell us?

STUDY OBJECTIVE: Despite excellent mortality indicators, there is clear evidence that the health status of the population of Geneva could be improved if more attention and resources were devoted to prevention strategies. To identify a set of robust health priorities an original approach was used triangulating results between three methods. METHODS: The study calculated potential years of life lost, disability adjusted years of life lost, and conducted a Delphi survey to gather the opinion of health professionals and the general public. MAIN RESULTS: Several health conditions were unanimously selected by all three methods as top priorities: cardiovascular diseases, AIDS, respiratory cancer, breast cancer for women, suicide and traffic accidents. In addition, two determinants-alcohol abuse and tobacco abuse-for which a clear conceptual link could be established between all methods were chosen. Connections between priorities identified through the DALY and the Delphi method lead to further inclusion of chronic back pain and depression. Some issues solely identified through the Delphi survey were included as they were consistently considered important by professionals and the lay public alike-violence in the family, unemployment, social exclusion. CONCLUSIONS: These results indicate that health priorities, and by extension health care priorities, would benefit from using a mix of quantitative and qualitative research methods. The triangulation of results allows for a broader perspective and makes results more acceptable.

Attitude↗

PubMed1984

Estimating physician requirements for neurology: a needs-based approach.

Applying the adjusted needs-based model developed by the Graduate Medical Education National Advisory Committee (GMENAC), physician requirements in neurology were estimated for the year 1990. A Delphi panel of physician experts estimated appropriate patterns of treatment for 56 neurologic conditions. Their median estimates implied a need for 14,500 neurologists in 1990, suggesting a shortage relative to the projected supply. An advisory panel of former GMENAC members reviewed those estimates and recommended certain adjustments to ensure internal consistency and compatibility with those for other specialties. Adoption of these adjustments significantly reduces requirements, implying a total need for 8,400 neurologists--a figure in near balance with the projected supply of 8,650. The difference between the Delphi and Advisory Panel estimates reflects divergent views, apparent as well among the Delphi panelists, of the appropriate role of neurologists--consultants versus principal care providers.

Neurology↗

PubMedDate not supplied

Pharmacy executives: leadership issues and associated skills, knowledge, and abilities in the U.S. Department of Defense.

OBJECTIVES: To identify the issues or problems that current and aspiring U.S. Department of Defense (DoD) pharmacy executives will face in the future and to define the skills, knowledge, and abilities (SKAs) required to successfully address these issues. DESIGN: Delphi method for executive decision making. SETTING: DoD. PARTICIPANTS: Ninety-three pharmacists serving in the military grades of lieutenant colonel/commander and colonel/captain, as well as pharmacists selected for promotion to those grades. INTERVENTIONS: iterations of the Delphi method for executive decision making separated by an expert panel content analysis. MAIN OUTCOME MEASURES: Round 1--participants identified five major issues believed to be of greatest importance to pharmacy executives and reported specific SKAs that might be needed to successfully manage those issues. An expert panel sorted these issues into meaningful domains, then provided an appropriate title for each domain. Round 2--on a 7-point scale, respondents rated the SKA items according to their assessment of how much a future DoD pharmacy executive would need each SKA. RESULTS: Response rates were 44.1% and 46.2% for Delphi rounds 1 and 2, respectively. The first round generated 62 unique issues facing pharmacy executives. The expert panel reviewed and sorted the issues into eight domains and selected an appropriate title for each domain. The domains identified by the panel were human resources, pharmacy operations/business practices, information management and technology, financial resources, formulary management, drug therapy management, pharmacy benefit management, and leadership. During round 2, 73.3% of the top 15 rated SKAs came from the drug therapy management, leadership, and formulary management domains. The three highest-rated SKAs were "ability to see the big picture," "ability to build strong relations with medical staffs," and "skills in both writing and verbal communication." CONCLUSION: The issues facing future DoD pharmacy executives will require them to expand their clinical abilities as well as their ability to collaborate and communicate with other professionals.

Data Collection↗

PubMed2005

Four commonly used dual-energy X-ray absorptiometry scanners do not identically classify subjects for osteopenia or osteoporosis by T-score in four bone regions BIz11.5.

We investigated whether four commonly used dual-energy X-ray absorptiometry (DXA) scanners (DPX, DPX-L,and Prodigy by GE Lunar, and Delphi-A by Hologic) could classify identical subjects as osteopenic or osteoporotic using the T-score for bone mineral density in four regions of interest: PA spine (L1-L4), femur (total), forearm (total),and 33% radius in 77 adults (38 females) free of treatment for bone metabolic disease (age range 20-81 yr). There were no significant differences between T-score means for posterior-anterior spine by DPX, DPX-L, and Prodigy, but they were higher than the mean T-score by Delphi-A (p < 0.05). Prodigy gave the lowest and DPX and Delphi-A gave the highest T-score for 33% radius (p < 0.05). No subject was classified as osteoporotic in the femur region by the four scanners, although other classifications varied by region and scanner. No two scanners classified subjects identically for osteopenia in any of the four regions. These results indicate that classification of bone density in individual subjects using T-scores varies by different DXA scanners, even the scanners were made by the same manufacturer.

Absorptiometry, Photon↗

PubMedDate not supplied

Preventable drug-related morbidity indicators in the U.S. and U.K.

OBJECTIVE: To qualitatively describe differences between a series of preventable drug-related morbidity (PDRM) indicators in the United States (U.S.) and the United Kingdom (U.K.), after transfer from the U.S. to the U.K. health care setting. METHODS: A preliminary validation was undertaken of the U.S.-derived indicators within the University of Manchester School of Pharmacy, followed by a 2-round Delphi questionnaire of a sample of general practitioners (n=6) and primary care pharmacists (n=10). The main outcome measures were (1) relevance of the U.S. indicators to U.K. primary care prescribing as determined by preliminary validation and (2) the establishment of consensus among the Delphi participants that an indicator represented PDRM. RESULTS: After preliminary validation, 7 of the U.S. indicators and a part of 2 indicators were considered of insufficient relevance to take any further part in the validation process. A further 18 of the U.S.-derived indicators failed to achieve consensus as PDRMs by the U.K. Delphi panel. At the end of the validation process, 19 indicators remained. CONCLUSIONS: Many of the U.S.-derived indicators lacked relevance in the U.K. due to differences in transatlantic clinical practice. In addition, there may be differences in the philosophical viewpoints of health professionals practising in the U.S. and the U.K. In practice, it is therefore inappropriate to transfer quality indicators of this nature directly from the U.S. to the U.K. However, if some form of validation process is undertaken, indicators derived in one health care setting appear to provide a very useful starting point for those developed in another.

Journal Article↗

PubMed2006

Dietitians' opinions and experiences of client-centred nutrition counselling.

PURPOSE: The concept of "client-centredness" was explored within a nutrition counselling relationship. METHODS: A two-round reactive Delphi survey was used. The first survey was sent to 65 Dietitians of Canada members who indicated in the member database that they had advanced counselling skills. Following analysis of the data, the second-round questionnaire was developed and sent to participants with a report of the first-round results. Analysis of the second-round survey indicated that participants' responses had remained stable, and the Delphi survey was terminated. RESULTS: Participants agreed that most of the issues identified in the Delphi questionnaire should be included in a client-centred approach to practice; however, when participants were asked about their experience in these areas, median responses and/ or the interquartile ranges changed, indicating some difficulty in implementing the client-centred approach. Comments also indicated that the reality of their workplaces did not allow participants to be as client-centred as they thought they should be, and suggested that the concept of "client-centredness" is not universally understood by dietitians. CONCLUSION: If a client-centred approach to practice is truly important, we need to start a dialogue within the profession to gain a deeper understanding of what this means and how it can be implemented.

Adult↗

PubMed1991

Observations of vaginal calculi in dolphins.

Vaginal calculi have been described from the common (Delphinus delphis), Pacific white-sided (Lagenorhynchus obliquidens) and spotted (Stenella attenuata) dolphins. We describe additional calculi found in six sexually mature D. delphis from southern California. Three calculi were large (ca. 7 x 5 cm), exhibited concentric layer crystallization, and were unique from previously published descriptions. One calculus described previously and one in our sample appeared to be a fetal skeleton and skull respectively. Using CAT scans of a first trimester northern right whale dolphin (Lissodelphis borealis) and of a near term Delphinus delphis, we discuss the potential origin and development of vaginal calculi through analysis of ossification in embryonic delphinids. We hypothesize that the calculi represented spontaneous incomplete abortion with retention of part or all of the fetus in the distal reproductive tract. The form of the calculus relates to the degree of skeletal development at the time of fetal death. Calculi from a pregnant dolphin provided one measure of residence time.

Abortion, Veterinary↗

PubMed2005

Performance of a rheumatoid arthritis records-based index of severity.

OBJECTIVE: To assess the performance of a rheumatoid arthritis (RA) records-based index of severity (RARBIS) developed by a Delphi panel process in a cohort of patients with RA. METHODS: We reviewed the medical records of 120 RA patients from the New England Veteran's Administration (VA) Healthcare System and collected data on markers of RA disease severity. Markers were refined through a Delphi panel process before developing the RARBIS based on chart review. The RARBIS includes 5 subscales on surgery, radiography, extraarticular manifestations, clinical status, and laboratory values. Factors that were regarded by the Delphi panel as highly related to severity of RA were assigned higher points on the index. We assessed the validity of the RARBIS by comparing it to the intensity of the actual RA treatment that these patients received: low, neither biologic nor disease modifying antirheumatic drug (DMARD) use; moderate, therapy with DMARD such as hydroxychloroquine, gold, or sulfasalazine; high, treatment with stronger DMARD such as methotrexate, azathioprine, leflunomide, and cyclosporine; and very high, use of any biologics. RESULTS: The RARBIS had a range of 0 to 8. All subscales except extraarticular manifestations were statistically significantly related to intensity of RA treatment (chi-square test p <or= 0.015); the overall index was linearly correlated with intensity of RA treatment (r = 0.35, 95% CI 0.18-0.55). After adjusting for age and sex in a linear regression, the RARBIS was found to be an independent predictor of intensity of treatment (beta for 1-point increase in score = 0.16, p = 0.002). CONCLUSION: A medical records-based index of RA severity was developed with attention to face and criterion validity that correlated moderately with RA treatment intensity (construct validity) in a VA population. Further tests of the RARBIS are recommended before it can be used as a tool to adjust for RA disease severity in performing epidemiologic studies on the safety of drugs.

Activities of Daily Living↗

PubMed1995

A paradigm for consensus. The University Hospital Consortium guidelines for the use of albumin, nonprotein colloid, and crystalloid solutions.

OBJECTIVE: To develop contemporary, comprehensive guidelines for the appropriate and efficient use of albumin, nonprotein colloid, and crystalloid solutions. DESIGN: A systematic, literature-based, consensus exercise employing a modified Delphi method. PARTICIPANTS: Thirty-one medical and allied health professionals from 26 University Hospital Consortium (Oak Brook, Ill) member institutions were initially chosen to participate. Participants were selected on the basis of their recognized research in the use of albumin, nonprotein colloid, and crystalloid solutions, and/or experience in the review of appropriateness of such use. A total of 24 participants completed the exercise. MAIN OUTCOME MEASURES: Group responses were statistically analyzed in an iterative consensus development process. Five separate questionnaire rounds were designed to establish criteria for the appropriate use of albumin, nonprotein colloid, and crystalloid solutions. RESULTS: Consensus guidelines were developed outlining the appropriate use of these products for 12 clinical indications, including hemorrhagic shock, nonhemorrhagic (maldistributive) shock, hepatic resection, thermal injury, cerebral ischemia, nutritional intervention, cardiac surgery, hyperbilirubinemia of the newborn, cirrhosis and paracentesis, nephrotic syndrome, organ transplantation, and plasmapheresis. CONCLUSIONS: The Delphi method, a systematic, literature-based consensus process, was shown to be useful in the development of complex clinical practice guidelines for the use of albumin, nonprotein colloid, and crystalloid solutions. It is anticipated that the guidelines will assist health care providers to develop local institutional policies and procedures for the appropriate and efficient use of albumin and albumin alternatives. Institutions reviewing and updating existing local guidelines may use the University Hospital Consortium guidelines as a model for comparison.

Academic Medical Centers↗

PubMed1994

Histologic changes in prostate carcinomas treated with leuprolide (luteinizing hormone-releasing hormone effect). Distinction from poor tumor differentiation.

BACKGROUND: Treatment of patients with prostate carcinoma using drugs with antiandrogenic effects is increasingly common. One of the most popular agents is leuprolide (with or without flutamide), an agonist of luteinizing hormone-releasing hormone (LH-RH). Prostates exposed to antiandrogenic agents develop distinctive pathologic changes. The ability of a group of 18 pathologists to recognize these LH-RH effects on prostate cancers and to distinguish them from poor tumor differentiation was tested using a Delphi technique. METHODS: The Delphi method maximizes the opportunity for individual contributions by eliminating opportunities for group dynamics and confrontational interaction. In this study, participants were provided with a set of duplicate transparencies and a list of written definitions of both poor tumor differentiation and LH-RH effect. They were instructed to examine the cases privately using the definitions provided and to distinguish poor tumor differentiation from LH-RH effect. Responses of the participants were shared anonymously, and each was asked to reexamine the cases in light of this knowledge. RESULTS: After a learning experience accomplished by one round of examination and feedback, LH-RH effect could be correctly distinguished from poor tumor differentiation in greater than 90% of cases by 83% of the participants. A small percentage of cases confounded complete consensus, although every case was correctly identified by most participants. CONCLUSIONS: The pathologic effects associated with androgen deprivation with leuprolide (plus flutamide) are sufficiently distinctive to be recognized by knowledgeable pathologists. In most cases, the tissue shrinkage representing a favorable response to the drug can be distinguished from solid or infiltrating patterns of poorly differentiated carcinoma.

Cell Differentiation↗

PubMed2005

Recommendations for musculoskeletal ultrasonography by rheumatologists: setting global standards for best practice by expert consensus.

OBJECTIVE: To establish an expert consensus of best practice for rheumatologists performing musculoskeletal ultrasonography (MUS). METHODS: A panel of worldwide experts in MUS was identified by literature review, membership of teaching faculty, and peer recommendation. They were invited to take part in a 4-stage Delphi process employing 2 iterative rounds to establish a consensus of specific indications, anatomic areas, and knowledge and skills required by rheumatologists performing MUS. RESULTS: Experts in MUS were identified (n = 57; 37 radiologists, 20 rheumatologists). Successive rounds of this rigorous Delphi exercise enabled group consensus to be achieved in 30 of the proposed 37 categories comprising 8 of 13 indications (inflammatory arthritis, tendon pathology, effusion, bursitis, monitoring disease activity, monitoring disease progression, guided aspiration, and injection), 8 of 10 anatomic areas (hand, wrist, elbow, shoulder, hip, knee, ankle and heel, and forefoot), and 14 categories of knowledge and skills (physics, anatomy, pathology, equipment, clinical application and relevance, indications and limitations, artifact, machine function and operation, patient and probe position, planes and system of examination, image optimization, dynamic assessment, color Doppler, and power Doppler). CONCLUSION: We have produced the first expert-derived, interdisciplinary consensus of recommendations for rheumatologists performing MUS. This represents a significant advance that will not only direct future rheumatology MUS practice, but will facilitate informed educational development. This is an important step towards the introduction of a specific training curriculum and assessment process to ensure competent rheumatologist ultrasonographers.

Benchmarking↗

PubMed2005

Expectations and satisfaction of patients with low back pain attending a multidisciplinary rehabilitation service.

BACKGROUND AND PURPOSE: To identify the expectations of service, and degree of satisfaction, with a multidisciplinary service for patients with low back pain, and to examine the strength of association between patients' satisfaction and expectations. METHOD: A three-stage study design was used. concerns were identified by a focus group; priority issues were identified by ranking by use of a Delphi consensus questionnaire; satisfaction or expectation questionnaires were also used to rate patients' satisfaction and the degree to which expectations were met. SUBJECTS: Three convenience samples of patients with low back pain were recruited. Ten patients attended the focus group, 55 completed the Delphi consensus questionnaire and 40 completed the satisfaction or expectation questionnaires. RESULTS: Patients rated a clear diagnosis and effective treatment as important, and the ease with which they could access the service and post-discharge follow-up as important issues when judging satisfaction. Patients rated their overall satisfaction and meeting their expectations higher than specific service issues, and the strengths of the associations between the two constructs varied from concern to concern. CONCLUSION: Certain aspects of service provision are rated with greater importance than others when patients judge a service they have experienced. There are differences in the strength of associations between the constructs of patient satisfaction and meeting expectations of service, specific to the individual service concern that is being evaluated. The present study provides more evidence that specific concerns within service provision should be identified before evaluating patients' expectations and satisfaction with the service overall.

Adult↗

PubMed2000

Threshold Assessment Grid (TAG): the development of a valid and brief scale to assess the severity of mental illness.

BACKGROUND: Lack of consensus about the meaning of severe mental illness makes it difficult to prioritise the severely mentally ill for specialist mental health care. The goal of this study was to develop a valid and brief assessment of severity of mental illness. METHOD: Six search workshops (n = 57) using consensus techniques developed a draft assessment acceptable to users, carers, practitioners and policy makers. A two-round Delphi consultation (n = 58) was held to identify consensus on this instrument. RESULTS: Search workshops agreed seven domains relevant to identifying the severely mentally ill: intentional and unintentional self-harm, risk from and to others, and survival, psychological, and social needs and disabilities. The Delphi consultation indicated at least agreement with all aspects in both rounds. CONCLUSIONS: The Threshold Assessment Grid (TAG) is a brief method of identifying the severely mentally ill, which has adequate face, concurrent, construct and content validity.

Delphi Technique↗

PubMed2005

The Acute Care Undergraduate TEaching (ACUTE) Initiative: consensus development of core competencies in acute care for undergraduates in the United Kingdom.

BACKGROUND: The care of the acutely ill patient in hospital is often sub-optimal. Poor recognition of critical illness combined with a lack of knowledge, failure to appreciate the clinical urgency of a situation, a lack of supervision, failure to seek advice and poor communication have been identified as contributory factors. At present the training of medical students in these important skills is fragmented. The aim of this study was to use consensus techniques to identify the core competencies in the care of acutely ill or arrested adult patients that medical students should possess at the point of graduation. DESIGN: Healthcare professionals were invited to contribute suggestions for competencies to a website as part of a modified Delphi survey. The competency proposals were grouped into themes and rated by a nominal group comprised of physicians, nurses and students from the UK. The nominal group rated the importance of each competency using a 5-point Likert scale. RESULTS: A total of 359 healthcare professionals contributed 2,629 competency suggestions during the Delphi survey. These were reduced to 88 representative themes covering: airway and oxygenation; breathing and ventilation; circulation; confusion and coma; drugs, therapeutics and protocols; clinical examination; monitoring and investigations; team-working, organisation and communication; patient and societal needs; trauma; equipment; pre-hospital care; infection and inflammation. The nominal group identified 71 essential and 16 optional competencies which students should possess at the point of graduation. CONCLUSIONS: We propose these competencies form a core set for undergraduate training in resuscitation and acute care.

Acute Disease↗

PubMed2006

Development of core competencies for an international training programme in intensive care medicine.

OBJECTIVE: The aim of this study was to define the core (minimum) competencies required of a specialist in adult intensive care medicine (ICM). This is the second phase of a 3-year project to develop an internationally acceptable competency-based training programme in ICM for Europe (CoBaTrICE). METHODOLOGY: Consensus techniques (modified Delphi and nominal group) were used to enable interested stakeholders (health care professionals, educators, patients and their relatives) to identify and prioritise core competencies. Online and postal surveys were used to generate ideas. A nominal group of 12 clinicians met in plenary session to rate the importance of the competence statements constructed from these suggestions. All materials were presented online for a second round Delphi prior to iterative editorial review. RESULTS: The initial surveys generated over 5,250 suggestions for competencies from 57 countries. Preliminary editing permitted us to encapsulate these suggestions within 164 competence stems and 5 behavioural themes. For each of these items the nominal group selected the minimum level of expertise required of a safe practitioner at the end of their specialist training, before rating them for importance. Individuals and groups from 29 countries commented on the nominal group output; this informed the editorial review. These combined processes resulted in 102 competence statements, divided into 12 domains. CONCLUSION: Using consensus techniques we have generated core competencies which are internationally applicable but still able to accommodate local requirements. This provides the foundation upon which an international competency based training programme for intensive care medicine can be built.

Clinical Competence↗

PubMed1993

Curriculum issues related to the newly developed nursing diploma courses.

This paper discusses the findings related to curriculum issues in the newly developed nursing diploma courses. The study, of which this aspect is a part, explored the emerging role of the nurse teacher within the new programmes in England. Data were collected by a Delphi Survey followed by in-depth interviews with a sample of the Delphi respondents. The findings from the interviews revealed that the six colleges involved had all adopted a process approach to the development of their new curricular. The educational philosophy and the curriculum approach in each college focused on the development of the individual and the adult theory of learning. A strategy for curriculum evaluation was found to be in the early stages of development for which no model or framework had been identified.

Curriculum↗

PubMed1995

Initial stages in the development of valid criteria for the replacement of amalgam restorations.

OBJECTIVES: Replacement amalgam restorations account for the largest single cost in the General Dental Services in Scotland. There is little practical advice available to practitioners on the maintenance and replacement of amalgam restorations. A distance learning package is being prepared for distribution to general dental practitioners in Scotland and this paper describes the initial stages in the development of the policy statements for the proposed package. METHODS: In the first stage proposals are being developed by a panel of dental academics using a modified Delphi technique. This technique is designed to produce a consensus view. Seventeen statements have been set out by the expert group. RESULTS AND CONCLUSIONS: While agreement was rapidly reached that 'ditching' of amalgam restoration margins did not justify their replacement and that repair was preferable to total replacement, some difficulty was experienced in arriving at a consensus view on the correct management of 'white spot' lesions at restoration margins and dentinal staining adjacent to amalgam restorations. The next stage in the development will be to present these statements to a selected panel of general dental practitioners and to develop their consensus view of the proposals, again using the Delphi technique.

Delphi Technique↗