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PubMedDate not supplied

[Health sentinel networks in Spain. Consensus for a guide of principles and methods].

Since the eighties, health sentinel networks have been active in our country, but with a variety of objectives, methods and different development levels in the autonomous communities. The necessity of standardising the management and harmonising the indicators has concluded in a research project on the Spanish health sentinel networks, one of whose objectives is to establish a guide for work principles and methods. A panel of 23 experts has made a study using the Delphi method to agree, in three consecutive phases, a definition of sentinel network, the objectives and the management principles and other aspects related to the organisation and functioning. Altogether, 41 questions were gathered from a previous draft which needed 80% of consensus in the first phase and 70% in the second. All the experts participated in the first phase, 22 in the second and 20 in the third. A consensus was achieved on 36 questions in the first phase and in 4 of the remaining ones in the second. In the third phase the shape of the guide document was given. The Delphi consensus method has been extremely useful in the resolution of discrepancies and divergences. The experts who were selected outside of the sentinel networks contributed with a wider vision on the objectives and applicability of the health sentinel networks in Spain.

Population Surveillance↗

PubMedDate not supplied

Immunization of asymptomatic HIV-infected children with measles vaccine: assessment of risks and benefits.

Because HIV infection is associated with immunologic abnormalities, concerns have been expressed about the safety and efficacy of vaccination of infected children with live virus vaccines. The authors used decision analysis to assess the likely impacts of four alternative policies for immunization of asymptomatic HIV-infected children with measles vaccine. Probabilities for vaccine efficacy, vaccine-related adverse events, and measles complications in HIV-infected children and the prevalence of HIV infection in the birth cohort were obtained from a modified Delphi survey. Using median estimates from the Delphi survey, there were no major differences in outcomes under any proposed policy. Using the most extreme estimates, serologic testing and exclusion of seropositive children from vaccination or exclusion of all high-risk children decreased vaccine-associated adverse events without greatly increasing measles complications, primarily because of the current low incidence of measles. Under conditions assumed to exist in the United States today, alternate immunization policies have only minor differences in societal impact although costs would certainly differ.

Acquired Immunodeficiency Syndrome↗

PubMedDate not supplied

A critical pathway for intimate partner violence across the continuum of care.

OBJECTIVE: The authors developed an interdisciplinary critical pathway for intimate partner violence (IPV) assessment and intervention for use across health care settings. Intimate partner violence may be emotional, physical, and/or sexual and involves coercion and control by one partner over the other. DESIGN: A pathway developed with input from focus groups of battered women was subjected to a modified Delphi technique to improve the pathway's scientific accuracy and feasibility. SETTING: The study was conducted in one urban, one suburban, and one rural hospital with IPV advocacy programs in the mid-Atlantic region of the United States. PATIENTS/PARTICIPANTS: Four researchers and 13 clinicians participated in the validation, with at least one physician, one nurse, and one social worker or IPV counselor from each hospital. MAIN OUTCOME MEASURES: Each element of the pathway was analyzed for the degree of consensus on scientific accuracy and feasibility. RESULTS: Consensus on the scientific accuracy and feasibility of the pathway was achieved after three rounds of the Delphi process. CONCLUSIONS: This is the first known critical pathway for IPV. It addresses physical and mental health and safety and has content validity affirmed by an interdisciplinary panel of experts. Further process and outcome evaluation is warranted and invited.

Battered Women↗

PubMed2005

Service providers' reflections on the affective domain and its influence on decision-making about treatments for chronic pain.

OBJECTIVES: This study sought to explore why service providers, working within the complex area of chronic pain, do not believe that the affective domain influences their decision-making about treatments. METHODS: These results were extrapolated from a larger multistage study based on a series of iterative postal questionnaires. Stage 1 of the large study identified, via postal survey, what treatment components service providers identified as 'important'. In stage 2, a constructivist framework was used to develop an iterative Delphi questionnaire to explore service providers' rationale for these choices. Stage 3 also employed a Delphi process and asked participants to reflect on their previous comments. Stages 2 and 3 used postal questionnaires and summary reports from preceding rounds for background information. RESULTS: Most service providers clearly felt that 'affect' and 'self-image' had little influence on their decision-making compared to 'coherence' and 'purposiveness'. This report presents the findings of the Stage 3 questionnaire, in which participants were asked to reflect and comment on this low level of endorsement for the influence of affect and self-image. Seven themes emerged from the coded data: professionalism, self-protection, affect and experience, lack of reflective skills, ethos of altruism, lack of understanding, and model of practice. Analysis of these themes indicates a tension between what service providers feel they should do and what they actually do. DISCUSSION: Service providers felt that affect and self-image had little influence on their decision-making. However, there is growing evidence in the literature to suggest that it is not possible, or preferable, to divorce emotion from the clinical encounter. Chronic illnesses are complex systems that do not respond optimally to linear problem-solving. Access to a wide range of information, including the affective domain, is important for effective decision-making.

Affect↗

PubMed2002

Consensus guidelines on analgesia and sedation in dying intensive care unit patients.

BACKGROUND: Intensivists must provide enough analgesia and sedation to ensure dying patients receive good palliative care. However, if it is perceived that too much is given, they risk prosecution for committing euthanasia. The goal of this study is to develop consensus guidelines on analgesia and sedation in dying intensive care unit patients that help distinguish palliative care from euthanasia. METHODS: Using the Delphi technique, panelists rated levels of agreement with statements describing how analgesics and sedatives should be given to dying ICU patients and how palliative care should be distinguished from euthanasia. Participants were drawn from 3 panels: 1) Canadian Academic Adult Intensive Care Fellowship program directors and Intensive Care division chiefs (N = 9); 2) Deputy chief provincial coroners (N = 5); 3) Validation panel of Intensivists attending the Canadian Critical Care Trials Group meeting (N = 12). RESULTS: After three Delphi rounds, consensus was achieved on 16 statements encompassing the role of palliative care in the intensive care unit, the management of pain and suffering, current areas of controversy, and ways of improving palliative care in the ICU. CONCLUSION: Consensus guidelines were developed to guide the administration of analgesics and sedatives to dying ICU patients and to help distinguish palliative care from euthanasia.

Analgesics↗

PubMed2005

Top 10 health care ethics challenges facing the public: views of Toronto bioethicists.

BACKGROUND: There are numerous ethical challenges that can impact patients and families in the health care setting. This paper reports on the results of a study conducted with a panel of clinical bioethicists in Toronto, Ontario, Canada, the purpose of which was to identify the top ethical challenges facing patients and their families in health care. A modified Delphi study was conducted with twelve clinical bioethicist members of the Clinical Ethics Group of the University of Toronto Joint Centre for Bioethics. The panel was asked the question, what do you think are the top ten ethical challenges that Canadians may face in health care? The panel was asked to rank the top ten ethical challenges throughout the Delphi process and consensus was reached after three rounds. DISCUSSION: The top challenge ranked by the group was disagreement between patients/families and health care professionals about treatment decisions. The second highest ranked challenge was waiting lists. The third ranked challenge was access to needed resources for the aged, chronically ill, and mentally ill. SUMMARY: Although many of the challenges listed by the panel have received significant public attention, there has been very little attention paid to the top ranked challenge. We propose several steps that can be taken to help address this key challenge.

Attitude↗

PubMed1986

On national needs for neurologists in the United States.

Estimates of the number of neurologists needed in the United States have been widely divergent. For direct patient care needs alone in a US population of 243.5 million, the Joint Commission on Neurology (ANA-AAN) estimate was 14,000 neurologist, the Delphi Panel median (Battelle/GMENAC) 11,200, and the Advisory Panel (Battelle/GMENAC) 6,200; our review suggests a need for 12,600. Total needs for clinical neurologists including faculty were 8,400 (Advisory Panel), 14,500 (Delphi Panel), and 16,500 (ours) for respective rates of 3.44, 5.96, and 6.76 neurologists per 100,000 population.

Humans↗

PubMedDate not supplied

Identification of serious drug-drug interactions: results of the partnership to prevent drug-drug interactions.

OBJECTIVE: To develop a list of clinically important drug-drug interactions (DDIs) likely to be encountered in community and ambulatory pharmacy settings and detected by a computerized pharmacy system. DESIGN: Cross-sectional, one-time evaluation. SETTING: United States in fall 2001. PARTICIPANTS: An expert panel comprising two physicians, two clinical pharmacists, and an expert on DDIs. INTERVENTIONS: Systematic review of drug interaction compendia and published literature, ratings (on a 1 to 10 scale) of various clinical aspects of DDIs (e.g., clinical importance, quality and quantity of evidence, causal relationship, risk of morbidity and mortality), and a modified Delphi consensus-building process. MAIN OUTCOME MEASURE: Panelists' opinions about clinical importance of DDIs. RESULTS: The expert panel considered 56 DDIs. Of these, 28 had a mean clinical importance score of 8.0 or more. The ratings for clinical importance ranged from 3.2 to 9.6, with a mean +/- SD of 7.5 +/- 1.5 across the combinations examined. The mean score for the quality of literature suggesting the interaction exists ranged from 1.0 to 9.6, with a mean +/- SD of 5.8 +/- 2.5. In terms of substantiation of the interactions evaluated, the mean +/- SD rating was 6.3 +/- 2.2, with a range from 1.4 to 9.2. Through the modified Delphi process, the panel determined that 25 interactions were clinically important. CONCLUSION: Using an expert panel and a standard evaluation tool, 25 clinically important drug interactions that are likely to occur in the community and ambulatory pharmacy settings were identified. Pharmacists should take steps to prevent patients from receiving these interacting medications, and computer software vendors should focus interaction alerts on these and similarly important DDIs.

Community Pharmacy Services↗

PubMed2004

Pencil-beam vs fan-beam dual-energy X-ray absorptiometry comparisons across four systems: body composition and bone mineral.

We compared bone mineral density (BMD) and body fat percentage (%fat) between two pencil-beam (Lunar DPX and DPX-L) and two fan-beam (Lunar Prodigy, Hologic Delphi A) dual-energy X-ray absorptiometry (DXA) systems. We examined these values in the total-body, spine, femur, and forearm scans in 78 healthy adults across these four DXA systems. BMD and %fat values were highly correlated among the four instruments. DPX-L gave the lowest mean %fat and Prodigy gave the highest mean %fat for both sexes. The means were system dependent for %fat estimates across the four DXA machines. There was a significant difference detected in BMD estimates across manufacturers, with the Delphi A providing systematically lower values than the Lunar systems in the whole body, spine, and femur sites but higher values than the Lunar systems in the forearm. The present study results show that both %fat and bone mineral estimates between pencil-beam and fan-beam systems are highly correlated, but vary by system. Significant differences exist between the instruments, especially between different manufacturers, and most of the comparisons are sex dependent. We conclude that longitudinal studies should always be evaluated on the same system when possible, and translation models should be used to assess cross-instrument differences.

Absorptiometry, Photon↗

PubMed1988

Computerized assessment of fetal behavioral states.

Fetal heart rate and fetal movements provide information on the fetal condition. In the near term human fetus, four behavioural states have been described based upon heart rate patterns and presence or absence of eye and body movements. For our studies concerning fetal physiology as well as the influence of maternal antiepileptic medication and the effects of intrauterine growth retardation on the fetal condition, we developed a computerized system for acquisition and storage of fetal heart rate signals and observed fetal movements. Fetal heart rate is recorded using a commercially available monitor combined with a home-made computer interface. Fetal movements are observed using two real-time ultrasound units. The observers handle keyboards to mark occurrence and duration of various types of fetal movements, and pedals to mark the visibility of the observed part of the fetal body. Keyboards and pedals are scanned by the computer. Special techniques are used to store heart rate and movement signals in an efficient way. Three experts determine fetal heart rate patterns by application of a Delphi group opinion procedure. Fetal behavioral states are identified by the computer using the results of the Delphi procedure, and performing the so-called extended automatic window procedure. This procedure identifies periods of presence and periods of absence of fetal eye and body movements, and incorporates the loss of visibility of the ultrasound images during the recording session. Fetal heart rate variability indices and distributions of fetal movements can be computed in the context of the fetal behavioral state concept.

Cardiotocography↗

PubMedDate not supplied

Preventable drug-related morbidity in older adults 1. Indicator development.

OBJECTIVE: To develop viable clinical indicators of preventable drug-related morbidity (PDRM) in older adults. METHODS: A survey was constructed, listing the clinical outcome and pattern of care related to a number of possible PDRMs in older adults. Using the Delphi technique, a geriatric medicine expert panel of 6 physicians and one clinical pharmacist from a hospital-based health care system was asked to judge whether the outcome in each situation was foreseeable and recognizable, and whether causality was identifiable and controllable. The panel could also suggest additional PDRMs. RESULTS: Fifty-two consensus-approved clinical indicators of PDRM in older adults were developed after 2 rounds of the Delphi technique. There was a high degree of consensus among the expert panel: all 7 members agreed on 35 indicators; 6 of 7 members agreed on 15 indicators; and 5 members agreed on 2 indicators. Only 6 outcomes and patterns of care were rejected as indicators. CONCLUSIONS: This phase of the study showed that consensus on clinical indicators of PDRM can be reached among experts. These indicators could be used by a managed care organization to proactively identify patients at risk for a PDRM and to improve the quality, safety, and appropriateness of medication use. Additionally, the indicators form an important bridge between processes and outcomes of care and could be used in conjunction with HEDIS and other performance indicators.

Journal Article↗

PubMed1997

The use of consensus methods and expert panels in pharmacoeconomic studies. Practical applications and methodological shortcomings.

The use of expert opinion in pharmacoeconomic studies is widespread. A review of the relevant literature has shown that expert opinion is frequently used in decision analysis, Markov models and disease management, with estimates of potential values derived from Delphi panels, modified Delphi panels and expert round tables. These consensus-gathering methods are often applied as if potential drawbacks to their application were absent. This article reviews and summarises the use of these techniques in pharmacoeconomic research and evaluates the potential shortcomings of the methodology employed. In particular, several areas of concern are noted: the provision of baseline information or seed algorithms to panellists, the high attrition rate of panels, the criteria for selecting experts and the definition of consensus. This article offers recommendations for the future application of these techniques and concludes that expert opinion can still play a valuable role in pharmacoeconomic research.

Consensus Statements as Topic↗

PubMed2000

Bridging decision analytic modelling with a cross-sectional study. Application to Parkinson's disease.

The ideal study design for demonstrating the possible health outcomes and costs associated with a new drug would be a naturalistic prospective study. However, it is not often feasible to derive the required information from scientifically sound prospective studies. In these cases, decision analytic models may provide some of the missing information. However, the use of a Delphi panel to gather data for these models is a major concern because of potential bias and data accuracy. Because reimbursement of pharmaceuticals is often based on economic data derived from modelling studies, it is obvious that potential bias due to the use of Delphi panels should be minimised. In this manuscript we present an alternative data source for modelling studies: the cross-sectional study. Data from such studies can be used to yield costs and utilities for Markov health states. The overall combined design may be considered a hybrid between a naturalistic prospective study and a modelling study by maximising the pros and minimising the cons of both types of design, including an increase of external validity. This hybrid design is based on bridging the probabilities derived from the literature and clinical trials with information on costs and utilities from a cross-sectional study. This design also has logistical advantages, namely a shorter required study duration compared with prospective naturalistic studies for chronic diseases. This combined design was illustrated using a Markov model for Parkinson's disease.

Cross-Sectional Studies↗

PubMed2000

Expert judgement in pharmacoeconomic studies. Guidance and future use.

Research in the field of pharmacoeconomics has increased substantially during the past decade. Much of this research has been on the design and analysis of data concerning the relative merits of one drug or device compared with another in terms of costs and effects. Concomitant with these evaluations has been the development of guidelines for the conduct of economic evaluations in several countries. However, despite an increase in research, little attention has been paid to how different study designs may influence the results of a study. The use of expert judgement in decision analytic modelling is one area where design issues may influence the findings of a study. This issue is examined for the case of modified Delphi and Delphi panels. Although the use of expert opinion in modelling studies seems to be widespread, there is little consistent application, understanding or reporting of the techniques used. In particular, the definitions of techniques vary between studies, the criteria for determining when consensus is reached vary, and the reporting of these criteria is absent. Future studies using expert judgement should be more aware of the controversies surrounding the issue and provide more reporting of the techniques used. It is proposed that future validation exercises may assist researchers in determining the most appropriate application of methods.

Economics, Pharmaceutical↗

PubMed2004

Cost effectiveness of representatives of three classes of antidepressants used in major depression in the UK.

OBJECTIVE: To estimate the cost effectiveness of representatives of three different classes of antidepressants used in major depression in the UK NHS. DESIGN, PATIENTS AND INTERVENTIONS: A decision-tree model for the treatment of major depression was constructed by interviewing UK GPs and psychiatrists (as part of a Delphi panel). An important part of the tree was that patients in primary care were treated until remission (pre-morbid state). Three classes of antidepressants (serotonin and noradrenaline reuptake inhibitors [SNRIs; venlafaxine], selective serotonin reuptake inhibitors [SSRIs; fluoxetine, paroxetine and fluvoxamine] and tricyclic antidepressants [TCAs; amitriptyline]) were compared by populating the tree with clinical success rates determined by a meta-analysis and a clinical trial. Where there were insufficient data from clinical trials a Delphi panel was used. Costs within the tree were taken from UK data sources. Six-monthly costs and cost effectiveness were then calculated. MAIN OUTCOME MEASURES AND RESULTS: Treatment costs for 6 months were pound 1285 for venlafaxine, pound 1348 for SSRIs and pound 1385 for amitriptyline. Cost effectiveness as measured by cost per symptom-free day was pound 21 for venlafaxine, pound 26 for SSRIs and pound 32 for TCAs (2001 values). Incremental cost-effectiveness analyses showed a treatment strategy of using venlafaxine and switching if necessary to an SSRI was dominant over all other strategies considered. Sensitivity testing demonstrated that the cost of an SSRI could be reduced to 4 pence daily and amitriptyline to zero before the expected 6-monthly cost of venlafaxine ceased to be the lowest. CONCLUSION: The SNRI, venlafaxine, may be a cost-effective option compared with the SSRIs and TCAs when used as a first-line drug for depression in primary care in the UK. As this is a model, cost effectiveness can be suggested but not proven.

Antidepressive Agents↗

PubMed2005

Adaptation and validation of the parent-child conflict tactics scale for use in Sri Lanka.

OBJECTIVE: The purpose of the study was to validate the Parent-Child Conflict Tactics Scale (CTSPC) in Sri Lanka, for use with 12-year old children. DESIGN: A Delphi Process determined the consensual and content validity of the CTSPC. Test-retest reliability and internal consistency were determined by a large and a small group administration. SETTING: Professionals from the social and behavioural sciences were the judges in the Delphi Process. Conveniently located schools in the Gampaha District were chosen for determining the test-retest reliability and internal consistency. MEASUREMENTS: This included original CTSPC and its Sinhala translation, a structured interview schedule and a focus group guide. RESULTS: The Sinhala version of the CTSPC showed adequate consensual and content validity. Its test-retest reliability and internal consistency were satisfactory. The instrument is best administered in small rather than in large groups of children. CONCLUSION: The Sinhala version of the CTSPC is appropriate to be used with 12-year old Sinhala speaking schoolchildren in Sri Lanka.

Adult↗

PubMed2003

[Development of gerontological nursing curriculum model].

PURPOSE: This study was conducted to develop gerontological curriculum model which reflects the need of Korean society. METHOD: Three round Delphi survey method was applied to find consensus of gerontological nursing competencies (knowledge, attitudes and skills) for graduates of nursing schools from the panel of gerontological nursing practice experts. Important concepts in gerontological nursing were delineated from literature review and discussions of gerontological nursing educators. Based on these results the gerontological nursing curriculum model was developed and course structure outlined by the researchers as a group. RESULT: As the result of delphi survey, 32 items of knowledge, 29 items of attitude, and 21 items of skill were identified. The curriculum model constructed around a cube with three plane- functional capacity levels, settings, and nursing practice. Specific knowledge, attitudes and skills for gerontological theory and practicum course were suggested. Competency items were assigned to theory and/or practice. CONCLUSION: A curriculum model for gerontological nursing has been developed by a group of gerontological nursing educators. The curriculum model should be further tested and developed with detailed theory and practicum course outline and textbooks.

English Abstract↗

PubMedDate not supplied

Development of a quantitative weighted scoring instrument to evaluate bedside blood glucose testing programs.

The present assessment of laboratory quality is primarily a qualitative summary process. The objective of our study is to convert a qualitative standards document into a quantitative, weighted scoring system. We selected a laboratory testing standards document, Ancillary (Bedside) Blood Glucose Testing in Acute and Chronic Care Facilities, C30, developed by the National Committee for Clinical Laboratory Standards (NCCLS), as our prototype and used a two-stage, modified delphi technique. Sixty-nine criteria were identified from the C30 document. Using a two-stage, modified delphi technique, members of the NCCLS committee that developed the guideline weighted the relative importance of each criteria. This weighting system then was used to evaluate the quality of bedside glucose testing at the 14 general hospitals located within the city limits of Boston.

Blood Glucose↗