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PubMed2001

What do master surgeons think of surgical competence and revalidation?

BACKGROUND: There has been on-going debate and public interest in surgical competence in recent years. METHODS: A Delphi reiterative opinion survey was conducted among master surgeons on selection of surgical trainees, methods of assessment of progress of surgical trainees, and revalidation of established consultant surgeons. RESULTS: Selection-the current methods of trainee selection were considered inadequate and in need of revision. The important attributes recognized by group are cognitive factors, innate dexterity, and personality. Important aspects of personality include decision-making ability, insight, team spirit, and emotional stability. Assessment during training-the majority view was that this should be based on clinical judgement/skills, operative skills, and cognitive ability. Assessment of technical ability should be based on standardized checklists. Research within training programs was encouraged but academic achievement does not reflect surgical competence. There was a majority verdict for an exit clinical examination. Revalidation-the group agreed on the need for competence checks during the professional career of surgeons. These should cover knowledge, clinical, operative, and humanistic skills; but expressed concern on the feasibility of a revalidation system that can reliably assess the range of skills needed for surgical competence. There was a majority vote against an internal appraisal system. External assessment by nationally appointed 'assessors' was considered preferable. CONCLUSIONS: Both selection and assessment of surgical trainees require changes and standardization. Although revalidation is necessary, concern was expressed on the reliability and validity of existing and proposed systems.

Clinical Competence↗

PubMed1996

Function-based payment model for inpatient medical rehabilitation: an evaluation.

OBJECTIVE: To describe the components of a function-based prospective payment model for inpatient medical rehabilitation that parallels diagnosis-related groups (DRGs), to evaluate this model in relation to stakeholder objectives, and to detail the components of a quality of care incentive program that, when combined with this payment model, creates an incentive for provides to maximize functional outcomes. DATA SOURCES: This article describes a conceptual model, involving no data collection or data synthesis. DATA SYNTHESIS: The basic payment model described parallels DRGs. Information on the potential impact of this model on medical rehabilitation is gleaned from the literature evaluating the impact of DRGs. The conceptual model described is evaluated against the results of a Delphi Survey of rehabilitation providers, consumers, policymakers, and researchers previously conducted by members of the research team. CONCLUSIONS: The major shortcoming of a function-based prospective payment model for inpatient medical rehabilitation is that it contains no inherent incentive to maximize functional outcomes. Linkage of reimbursement to outcomes, however, by withholding a fixed proportion of the standard FRG payment amount, placing that amount in a "quality of care" pool, and distributing that pool annually among providers whose predesignated, facility-level, case-mix-adjusted outcomes are attained, may be one strategy for maximizing outcome goals.

Activities of Daily Living↗

PubMed2003

The New Zealand development and trial of mental health nursing clinical indicators--a bicultural study.

This paper describes the development and validation of bicultural clinical indicators that measure achievement of mental health nursing practice standards in New Zealand (ANZMCHN, 1995, Standards of practice for mental health nursing in New Zealand. ANZCMHN, Greenacres). A four-stage research design was utilised including focus groups, Delphi surveys, a pilot, and a national field study, with mental health nurses and consumers as participants. During the national field study, consumer files (n=327) from 11 District Health Boards, and registered nurses (n=422) completed an attitude questionnaire regarding the regularity of specific nursing and service activities. Results revealed a variation in the mean occurrence of the clinical indicators in consumer case notes of 18.5-89.9%. Five factors with good internal consistency, encompassing domains of mental health nursing required for best practice, were derived from analysis of the questionnaire. This study presents a research framework for developing culturally and clinically valid, reliable measures of clinical practice.

Attitude of Health Personnel↗

PubMed1987

Development of a functional assessment questionnaire for geriatric patients: the Comprehensive Older Persons' Evaluation (COPE).

Several sources of data were used to identify questions worthy of inclusion in a functional assessment questionnaire for older patients. Community hospital use of the Functional Assessment Inventory was reviewed to identify questions that discriminated between inpatients and outpatients. Repeated administrations of the Older Americans Resources and Services questionnaire with elderly patients were reviewed to identify questions that discriminated between community and nursing home status and predicted nursing home placement. Twenty clinicians providing geriatric care identified clinically important questions in a modified Delphi survey. Questions were retained if they: were considered clinically essential; discriminated between inpatients and outpatients and between independent living and nursing home status; predicted nursing home placement; and showed changes in responses over 6 months that predicted subsequent nursing home placement. These questions were organized into a brief, clinically relevant functional assessment questionnaire, known as the Comprehensive Older Persons' Evaluation (COPE), that may facilitate the efficient provision of geriatric care.

Aged↗

PubMed1999

Direct expenditures for the treatment of allergic rhinoconjunctivitis in 1996, including the contributions of related airway illnesses.

BACKGROUND: Previous estimates of the national economic burden of allergic rhinoconjunctivitis (AR/AC) have relied on data analyses in which AR/AC was the primary International Classification of Diseases-ninth revision-Clinical Modification (ICD-9-CM)-coded diagnosis. These studies ignore the costs when AR/AC was a secondary diagnosis to other disorders such as asthma and sinusitis. OBJECTIVE: We sought to determine the national direct cost of illness for AR/AC. METHODS: An expert panel used the Delphi technique to estimate the proportion of visits coded by other primary ICD-9-CM diagnoses in which AR/AC was a significant secondary comorbid condition. The costs of this proportion were deemed to be "attributable" to AR/AC and were added to the costs when allergic rhinitis and allergic conjunctivitis were the primary diagnoses. RESULTS: The cost when AR/AC was the primary diagnosis was $1.9 billion (in 1996 dollars). The cost when AR/AC was a secondary diagnosis was estimated at $4.0 billion, giving an estimate of $5.9 billion for the overall direct medical expenditures attributable to AR/AC. Outpatient services (63%, $3.7 billion), medications (25%, $1.5 billion), and inpatient services (12%, $0.7 billion) accounted for the expenditures. Children 12 years and younger accounted for $2.3 billion (38.0%). CONCLUSION: Upper airway allergy is an expensive disease process because of its readily apparent manifestations as AR/AC and its contribution to other airway disorders.

Adult↗

PubMed1990

Critical features of a curriculum in health care quality and resource management.

In response to mounting demands for quality and accountability in health care, a science of health care quality and resource management (QRM) has evolved, but too slowly and without the academic base needed to prepare practitioners to assume new roles and fulfill requirements to regulate their practice. To develop such a base, The University of Houston and The University of Texas Health Science Center sponsored a needs assessment survey to identify areas of knowledge and skills to be included in a master's degree curriculum in QRM. The study used a three-cycle Focus Delphi technique to secure experts' refinement of the survey instrument and consensus among participants, who included practitioner-members of the National Association of Quality Assurance Professionals (NAQAP), of health care administration educational program directors, and hospital administrators. Starting with a listing based on a competency outline obtained from NAQAP, the study identified critical learning needs and elaborated a framework with 12 broad categories and 108 specific knowledge and skill areas.

Curriculum↗

PubMed1996

Which groups of patients benefit from helicopter evacuation?

BACKGROUND: The evacuation of emergency cases by air, usually by helicopter, is controversial because of the cost of the programme, the possibility of an accident (especially in an urban area), and unproven benefit. But such evacuations cannot be studied by a random intervention (eg, air versus ground ambulance). We used an expert-panel approach to estimate the health outcome for patients transferred by emergency helicopter compared with the potential outcome if they had gone by surface ambulance. METHODS: The helicopter programme is based at the University Hospital of Tromsø in northern Norway. 370 case-reports of helicopter evacuation from rural areas were screened by anaesthetists for routine and case-specific data. Two expert panels assessed the cases for potential additional health benefit arising from the fact of helicopter evacuation. The panels used a modified Delphi technique to reach consensus in life-years gained. One panel met for cases aged under 15 and pregnant women, the other for older cases. FINDINGS: 240 of the 370 cases were male (65%); the age range for both sexes was 0-86 years. The most common diagnosis for the 55 cases aged under 15 was infection (49%); in older patients, cardiovascular disease dominated (50%). Trauma accounted for just under a fifth of cases in both groups. On average, the patients arrived 69 min (range 0-615) earlier in hospital than if they had gone by ground transport. For 283 cases, the initial screening by the anaesthetists indicated no additional benefit compared with that obtainable by ground-ambulance transport. The main reason was that no treatment was given during the flight or early on in hospital that could not have been given otherwise. 90 cases entered the expert panel system. Of these 90, 49 cases were judged to have received no additional benefit. This left 41 (11% of the total of 370 evacuated) who were judged to have benefited, gaining 290.6 life-years. 96% of the total number of life-years gained was achieved in nine patients, six of whom were aged below 7 (four were aged 0-7 months). The life-year-gain per adult patient with cardiovascular disease was 0.54. INTERPRETATION: We conclude that an emergency helicopter service can provide considerable health benefits for selected patients, at least in this rural setting. Given the costs and risks of such a service, the benefits for most patients are small.

Adolescent↗

PubMed1998

Implementation of sequential therapy programs--a microbiologist's view.

Sequential antimicrobial therapy is not new, but confusion about the timing and nature of the switch often negates perceived advantages. A common problem is the choice of oral antibiotic to follow empirical administration of an intravenous second or third generation cephalosporin. Where guidelines do not exist, particularly when data are lacking as the the best option, the Delphi technique of obtaining a consensus agreement by review of a series of case histories is recommended. Majority verdicts are used to determine what is acceptable practice, and as such the approach is also suitable for audit. Savings through reduced drug acquisition costs and shorter lengths of stay have been highlighted. However, other less obvious potential benefits of sequential antimicrobial therapy include reduced incidence of intravascular catheter infection because of shorter line dwell times and less endoluminal contamination. Sequential antimicrobial therapy may also be used as part of a policy to reduce the selective pressure, particularly due to cephalosporin use, for endemic hospital pathogens such as Clostridium difficile and extended spectrum producing gram-negative baccilli.

Administration, Oral↗

PubMed2002

The medical treatment of depression, 1991-1996: productive inefficiency, expected outcome variations, and price indexes.

We examine the price of treating episodes of acute phase major depression over the 1991-1996 time period. We combine data from a large retrospective medical claims data base (MarketScan, from the Medstat Group) with clinical literature and expert clinical opinion elicited from a two-stage Delphi procedure. This enables us to construct a variety of treatment price indexes that include variations over time in the proportion of the "off-frontier" production, as well as the corresponding variations in expected treatment outcomes. We find that in general the incremental cost of successfully treating an episode of acute phase major depression has generally fallen over the 1991-1996 time period. Based on hedonic regression equations that account for the effects of changing patient mix, we find reductions that range from about -1.66 to -2.13% per year.

Cost of Illness↗

PubMed2001

The appropriateness of treatment of benign prostatic hyperplasia: a comparison of Dutch and multinational criteria.

Over the last decade, a number of organisations have developed clinical guidelines, typically at a national level, in order to increase appropriate health care. This raises the question as to whether it is possible to develop guidelines, applicable on the national level, at an international level. In order to examine this, we compared the appropriateness criteria for the treatment of benign prostatic hyperplasia ratings developed by two panels, one a single-nationality (Dutch) panel, the other a multinational (European) panel. The panels, both consisting of experienced urologists, used a modified Delphi process to rate 1152 indications for the most common treatments (surgery, alpha-blocker, finasteride and watchful waiting) on a nine-point scale. This article describes the similarities and differences between the ratings produced by the panels. The appropriateness ratings were identical for 84% of the indications (kappa=0.76). The difference in the scores for individual indications was zero in 41% of indications and less than or equal to two in 99% of indications. This study provides strong evidence that a multinational panel can deliver essentially the same appropriateness ratings for BPH as a national panel. Developing appropriateness criteria on an international level may result in significant savings and may help contribute to the reduction of undesirable practice variation.

Aged↗

PubMed2002

Use of explicit criteria for total hip joint replacement fixation techniques.

We developed a tool to judge the appropriateness of indications and fixation mechanisms for total hip joint replacement (THJR) and applied it to a sample of patients. Criteria were developed using a modified Delphi panel judgment process, following the RAND methodology (RAM). We recruited, during 1 year, patients with a diagnosis of osteoarthritis undergoing THJR in five public hospitals. The appropriateness of the THJR intervention and the fixation mechanism was judged by the explicit criteria developed by a panel of experts. Of the 216 scenarios scored by the panel for the use of each of three fixation mechanisms, the cemented fixation was considered inappropriate in 69.5%, versus just 33.3% for the non cemented. Of those scenarios considered appropriate, the most appropriate mechanism of fixation was considered to be non cemented (74.4%), while cemented (17.8%) and hybrid (7.8%) scenarios were scored as appropriate less often. The previous explicit criteria were applied to 583 real patients. After evaluation of the interventions, 30% of the fixation mechanisms used were considered appropriate, while 21.8% inappropriate. Appropriate use of fixation mechanisms varied among hospitals. RAM can provide explicit criteria to help in clinical decision making and evaluating indications for a THJR intervention. Nevertheless, in the case of the appropriateness of fixation mechanisms, due to the lack of evidence, the panel criteria were biased towards the non cemented technique, which had important implications for the evaluation of some hospitals.

Arthroplasty, Replacement, Hip↗

PubMed2004

Universal health coverage in Thailand: ideas for reform and policy struggling.

Inequality in health between rich and poor in Thailand was well documented; millions of informal workers and their families lacked health insurance; and the poor paid more proportionately in income for health care. The universal coverage is conceived as one of the means to redress the situation. But the term 'universal coverage' may mean differently among different groups of stakeholders. This paper, based on empirical research of health policy reform, collected perceptions and ideas from stakeholders and discusses the ways and strategies that universal coverage might take shape in Thailand. Two sources of information were taken: one from the questionnaire survey (according to the Delphi technique, two rounds of survey were taken), another an in-depth interview. Obtained information for policy formulation included how best, as conceived by stakeholders, to implement the universal coverage, sources of finance, fiscal implication for Thai government, ways to prevent higher demand for unnecessary services, and involvement of local government. Recent policy move in Thailand (the so-called 30 baht for all diseases) emerged in 2001 generated hot debate nationwide. The programme is currently in its early phase and is likely to evolve overtime--i.e. whether or not this programme will be financed by certain types of taxes or from annual government expense still unclear; and budget allocation among different health providers still unsettled. Anyhow this programme may be interpreted as a policy shift away from the pro-market based toward a government-supported egalitarianism.

Attitude to Health↗

PubMed1997

Future health scenarios as a tool in the surveillance of unintentional injuries.

Health policy needs effective public health surveillance systems. In order to support injury control in the Netherlands we established a surveillance system which monitors trends in the epidemiology of injuries due to traffic accidents, occupational accidents and home and leisure accidents. We introduced the combination of traditional monitoring methods with a new tool: the use of future health scenarios. Trends in the epidemiology of injuries since 1985 were compared with observations from the preceding period (1970-1985) and to future health scenarios (1985-2000). These scenarios were based on the opinions of 80 Dutch experts, which had been collected with the help of a Delphi-study. We identified interruptions of the actual injury mortality trends in the Netherlands. In the second half of the 1980s the rapidly declining injury mortality trends of the period 1970-1985 slowed down (traffic accidents), slightly reversed (occupational accidents) or stabilised (home and leisure accidents). The transitions into less favourable developments were already foreseen by Dutch experts. The future health scenarios appear to have added value for health policy. They offer a well-defined conceptual framework for monitoring and facilitate the early detection of trend interruptions. Moreover, they provide information on the most likely future development and on the feasibility of health policy goals. The results of our study show that health policy goals of the Dutch government will not be reached and that new initiatives in injury control are needed.

Accidents↗

PubMed1996

Panellist consistency in the assessment of medical appropriateness.

Where information about the appropriateness of a surgical procedure is lacking, expert panels have been used to establish guidelines for medical practitioners. Such a panel was convened to assess the appropriateness of percutaneous transluminal coronary angioplasty and coronary artery bypass graft surgery in the Netherlands. The panel, consisting of interventional cardiologists and cardiothoracic surgeons, used a modified Delphi process to rate 1126 clinical indications over two rounds. This article describes the degree of change in both agreement amongst members and in the appropriateness ratings over the two rounds, and examines the internal consistency of the ratings of individual panellists. Over the two rounds, agreement increased. Although most appropriateness ratings remained unchanged, there was significant movement from equivocal ratings to determinate ratings. While individual members showed some degree of inconsistency in their scoring, the panel as a whole scored very consistently. The observed changes in appropriateness were consistent with expectations, showing that the appropriateness method is used logically and consistently by panellists.

Angioplasty, Balloon, Coronary↗

PubMed1997

Expert opinion on the diagnosis of acoustic tumors.

Ideally, clinicians recommend diagnostic tests when the patient's risk of disease is sufficient to justify putting numerous similar patients through the morbidity required to diagnose disease in one patient. In the case of acoustic tumor diagnosis, there are few published data available to the clinician to help assess risk in an individual patient. The purpose of this study was to obtain information by an opinion poll of a group of experts. We used the Delphi method to poll clinicians trained at the House Ear Clinic. We asked these experts 20 questions related to acoustic tumor diagnosis. Some of the expert opinion presented herein is the only data related to acoustic tumor diagnosis available to clinicians. These data are a first step in elevation of decision-making for tumor diagnosis above the level of speculation. However, the experts' responses displayed a pattern of inaccuracy that limits the clinical application of their opinion. Exposing this pattern was instructive for identifying desirable features of protocols for diagnosing tumors. We recommend that protocols not depend on clinicians estimating probability of tumor. Instead, protocols may list specific findings, such as unilateral distortion on the telephone, to indicate, when present, that the risk of tumor is sufficient to order a diagnostic test.

Adult↗

PubMed2006

[Identification of items for creating a questionnaire for the assessment of instrumental activities of daily living (IADL) in elderly patients].

OBJECTIVE: To identify items to design a questionnaire to assess IADL in the elderly in the community. DESIGN: Delphi study. LOCATION: Community setting, primary health care. PARTICIPANTS: Fifty seven multidisciplinary experts (family doctors, geriatricians, physiotherapists, social workers, male nurses) who are members of the Spanish Society of Family and Community Medicine or the Spanish Geriatrics and Gerontology Society. METHODS: Three consecutive questions sent via e-mail or fax. First: what items you would take into account in a questionnaire to assess IADL in the elderly? Second: out of the groupings select 10 you consider to be of special relevance? Third: among the 14 more most selected items, select, by scoring from 1 to 10, the ones you consider more important? In the end we obtained the 10 items to include in the questionnaire according to their scores. RESULTS: Thirty experts answered the 3 mailings. The 53 initial proposals were grouped into 24 items. In the end we obtained the following selection (from higher to lower score): dealing with medication, use of the telephone, housework, handling money, walking outside the home, security measures and risk avoidance, shopping, dealing with doors and keys, transport use, and means of social contact. CONCLUSIONS: Only 2 items could have gender influence (in contrast to other questionnaires), as "shopping" does not refer only to the household ones and "housework" also includes activities carried out by males. The most important items are "dealing with medication" (due to the high prevalence of problems and clinical outcomes) and "the use of the telephone" (survival item).

Activities of Daily Living↗

PubMedDate not supplied

[Opinion on health priorities in the community of Valencia].

In this study we have used a qualitative approach partially based on the Delphi technique to establish the ten priorities for health in the Valencian Community for the next five years. Two rounds of mail surveys were made sending questionnaires to 1834 people including Health Councillors of the Town Halls, nurses and doctors of the three valencian provinces. The overall response rate was 28.3%. The priorities which were perceived as most important by the respondents were the development of primary care, improvements in the management of health services and the development of preventive medicine. The fourth and fifth places of the ranking were: improvements of emergency services and increasing the budget devoted to hospital care. The 6th priority was preventive measures in cardiovascular diseases, the 7th actions against drug abuse, the 8th special attention to childhood and ageing populations and the last two priorities were protection of the environment and infectious diseases prevention. We consider this approach as useful to obtain additional valuable information complementary to the information obtained from traditional statistics or health surveys specially in the areas of management, diseases prevention and actions towards special groups of population.

Delphi Technique↗

PubMedDate not supplied

[Consensus doesn't always mean agreement: limitations of consensus methods in health services].

Taking decisions in uncertain situations has led to a high use of the consensus methods (Nominal Group Technique, Delphi Method, and Consensus Conferences) in the health services. The review made in this article shows that the appropriate use of these techniques requires a high degree of methodologic precision, especially in relation to the financer's declaration of objectives, the appropriate selection of the participants, previous realization of a synthesis of the preexistent information, the definition of the agreement degree which leads to the consensus and in the evaluation of its impact.

Centers for Disease Control and Prevention, U.S.↗