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PubMed1998

Objectives of genetic counselling: differing views of purchasers, providers and users.

BACKGROUND: This study aimed to compare the views of purchasers, providers and users about the objectives of genetic counselling. METHODS: A modified Delphi technique was used, incorporating two postal questionnaires that were sent to six study groups with a three-month interval: purchasers (public health doctors (n = 37) and regional advisers in general practice (n = 35)); providers (clinical geneticists (n = 33) and genetic counsellors (n = 25)); and users (out-patients (n = 36) and members of genetic support groups (n = 32)). The response rate for the first questionnaire was 115/198 (58 per cent) and for the second, 102/198 (52 per cent). The first questionnaire asked an open-ended question about what the objectives of genetic counselling should be and asked respondents to rank order them. The second questionnaire summarized the views expressed in the first questionnaire and asked respondents to rank order the most frequently cited and most highly ranked five objectives. RESULTS: The five most frequently cited and highly ranked objectives from Questionnaire One were, in descending order: provide information, give support, facilitate decision-making, assess risk and achieve understanding. In response to Questionnaire Two, purchasers differed from providers and users in rating 'facilitate decision-making' more highly than did providers and users. By contrast, providers and users rated 'give information' more highly than did purchasers. CONCLUSIONS: Purchasers hold different views from providers and users about what the objectives of genetic counselling should be. This raises two questions: (1) Which views are or should be most influential in the future development of genetic counselling? (2) By what processes can more than one view on genetic counselling be integrated?

Attitude of Health Personnel↗

PubMed1998

Quality indicators for general practice: which ones can general practitioners and health authority managers agree are important and how useful are they?

BACKGROUND: The aim of the study was to assess the face validity of quality indicators being proposed for use in general practice by health authorities. METHOD: A national survey of health authorities was carried out to identify quality indicators being proposed for use in general practice. A two-stage Delphi process was used to establish general practitioners' (GPs') and health authority managers' views on the face validity of identified indicators. A total of 240 separate indicators identified by health authorities and the NHS Executive as potential markers of the quality of general practice care were assessed. Indicators related to access, organizational performance, preventive care, care for a small number of chronic diseases, prescribing and gatekeeping. The subjects were a purposive sample of 47 health authority managers and 57 general practice course organizers. RESULTS: Thirty-six indicators received median validity scores of 8 or 9 out of a maximum possible score of 9. Of this set, 83 per cent was rated identically by both groups of respondents. Prescribing and gatekeeping indicators generally received low validity scores. CONCLUSION: Acceptable face valid indicators were identified for all domains except gatekeeping. However, the indicators rated by the sample do not cover all aspects of care. No indicators were proposed for use by health authorities relating to effective communication, care of acute illness, health outcomes or patient evaluation. Although it is possible to develop indicators of general practice care which have face validity in the view of both GPs and managers, these will be very partial measures of quality. In the indicators used in this study, no explicit distinction was made between indicators designed to assess minimum standards with which all practices should comply, and indicators which could be used to reward higher levels of performance. Failure to separate these will result in antagonism from practitioners to quality improvement initiatives in the NHS, and a failure to engage the profession in improving quality of care.

Attitude of Health Personnel↗

PubMedDate not supplied

Comparing quality of care for sexually transmitted diseases in specialized and general clinics.

OBJECTIVE: The objective of this study was to compare quality of care for patients with sexually transmitted diseases (STDs) in specialized vs. general clinics. METHODS: The authors conducted a retrospective chart review evaluating compliance with a set of STD-related process of care quality indicators for adult patients seen in six Los Angeles County clinics (two STD specialized clinics and four general medical clinics). RESULTS: Thirty-two quality indicators were selected using a modified Delphi process. From March 1, 1996, to June 31, 1996, there were 205 STD-related visits to the two specialized STD clinics and 373 STD-related visits to the four general medical clinics. For patients with "classic" STDs (those for which sexual contact is the primary means of transmission), STD clinics achieved greater compliance than general medical clinics on 14 quality indicators, while general medical clinics achieved greater compliance on 4 indicators. CONCLUSION: STD clinics provide better overall STD care than general medical clinics. Possible explanations include differences in clinician experience with STD patients and greater use of standardized protocol sheets.

Adult↗

PubMed1997

Opinions of physical therapy education program directors on essential functions.

BACKGROUND AND PURPOSE: The purpose of this study was to determine the opinions of directors of physical therapy education programs concerning the essential functions physical therapist students must be able to complete, with or without reasonable accommodation. SUBJECTS: Fifty-eight physical therapy education program directors participated. METHODS: Participants completed surveys as part of a three-round Delphi technique. They had the opportunity to modify or make additions to the initial list in the first round and rate the items in the last two rounds using an ordinal scale. RESULTS: All participants rated communication skills and practicing in a safe, ethical, and legal manner as definitely essential functions. Nearly universal agreement (95%-99%) was present for determining physical therapy needs of patients with movement dysfunction and demonstrating the ability to apply universal precautions. Performance of treatment procedures and performance of assessment procedures were rated essential by 90% to 95% of the participants. The least agreement was found for participation in the process of scientific inquiry. CONCLUSION AND DISCUSSION: There is agreement among the physical therapy education program directors concerning the essential functions that should be required of students. The results of this study should serve as a reference for physical therapy education programs for developing the essential functions required of students.

Administrative Personnel↗

PubMed1999

Rating the appropriateness of coronary angiography, coronary angioplasty and coronary artery bypass grafting: the ACRE study. Appropriateness of Coronary Revascularisation study.

BACKGROUND: Previous studies investigating the appropriateness of invasive management of coronary disease had not reported the internal consistency of their ratings and may now be out of date. The aim of this study was to measure the influence of clinical factors on contemporary ratings of the appropriateness of coronary angiography, percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) in the Appropriateness of Coronary Revascularisation (ACRE) study. METHODS: The Delphi-RAND technique was used, in which an expert panel (four cardiologists, three cardiothoracic surgeons, a general physician and a general practitioner), meeting in 1995, rated mutually exclusive indications (n = 2178 for angiography, n = 995 for PTCA and n = 984 for CABG). The main outcome measures were the appropriateness category (inappropriate, uncertain or appropriate) for each of the three procedures and treatment preference. RESULTS: For revascularization, the strongest determinant of inappropriateness was coronary anatomy. The odds ratio (OR) for inappropriate PTCA was 10.6 (95 per cent confidence interval (CI) 4.8-23.5) for the effect of left main stem or three-vessel disease versus single-vessel disease, and for CABG it was 0.06 (95 per cent CI 0.03-0.15). The number of diseased vessels was strongly related to preference for medical, PTCA or CABG treatment (p for linear trend <0.001). Mild versus severe anginal symptoms were associated with inappropriate angiography (OR 2.0 (95 per cent CI 0.9-9.8), although this effect was stronger when only the cardiologists' ratings were considered (OR 10.1 (95 per cent CI 2.4-42.6)). CONCLUSION: These are the first UK ratings of appropriateness covering all three procedures. The associations with clinical factors provide evidence of the internal consistency of these ratings. Prospective validation of these ratings against clinical outcomes is under way in the ACRE study.

Aged↗

PubMed1994

A clinical grading scale to predict malignant hyperthermia susceptibility.

BACKGROUND: The diagnosis of an acute malignant hyperthermia reaction by clinical criteria can be difficult because of the nonspecific nature and variable incidence of many of the clinical signs and laboratory findings. Development of a standardized means for estimating the qualitative likelihood of malignant hyperthermia in a given patient without the use of specialized diagnostic testing would be useful for patient management and would promote research into improved means for diagnosing this disease. METHODS: Using the Delphi method and an international panel of 11 experts on malignant hyperthermia, a multifactor malignant hyperthermia clinical grading scale comprising standardized clinical diagnostic criteria was developed for classification of existing records and for application to new patients. RESULTS: This scale ranks the qualitative likelihood that an adverse anesthetic event represents malignant hyperthermia (malignant hyperthermia event rank) and that, with further investigation of family history, an individual patient will be diagnosed as malignant hyperthermia susceptible (malignant hyperthermia susceptibility rank). The assigned rank represents a lower bound on the likelihood of malignant hyperthermia. The clinical grading scale requires the anesthesiologist to judge whether specific clinical signs are appropriate for the patient's medical condition, anesthetic technique, and surgical procedure. CONCLUSIONS: The malignant hyperthermia clinical grading scale is recommended for use as an aid to the objective definition of this disease. It use may improve malignant hyperthermia research by allowing comparisons among well-defined groups of patients. This clinical grading system provides a new and comprehensive clinical case definition for the malignant hyperthermia syndrome.

Adult↗

PubMed2002

Overview of themes identified from African American discourse on quality of care.

The article reports on an exploratory descriptive study conducted to establish quality-of-care dimensions from African Americans' perspective, using a combined focus group interview and modified Delphi process. Descriptors of quality, which were identified using participants' vocabulary and thinking patterns, were used to establish quality-of-care dimensions; they were then examined in terms of an adapted quality-of-care framework. Themes and issues related to quality of care also were identified. The article analyzes the qualitative themes abstracted from that discourse and relates focus group interview guide questions to the emerging quality-of-care issues. An interpersonal processes-of-care framework is used to examine the quality-of-care themes, and the quality-of-care issues are discussed using a systems theoretical perspective.

Black or African American↗

PubMedDate not supplied

Quality of care: a comparison of perceptions of health professionals in clinical areas in the United Kingdom and the United States.

A tool was developed, using the nominal group and Delphi techniques, to explore healthcare staff's perceptions of the quality of hospital care provided in the United Kingdom compared with a tool from the United States. Similarities were identified in many core areas; however, there were several differences between the UK and US tools. This article identifies the process and findings and discusses possible reasons for similarities and differences between the tools.

Attitude of Health Personnel↗

PubMed1982

Guidelines for graduate medical education in geriatrics.

There has been a substantial increase in training programs in geriatrics over the past several years. In this paper the authors propose guidelines for geriatric training at the graduate medical educational level, both for specialized training (geriatric fellowship) and training in geriatrics as part of other specialty training (internal medicine, family practice, psychiatry, and neurology). Experts from relevant specialty boards and societies, an advisory group in geriatrics, and the faculty of the University of California-Los Angeles Multicampus Division of Geriatrics participated in a modified Delphi study which provided the information used to formulate the guidelines. Performance objectives, core content, training experiences, and clinical exposure and program evaluations are described for geriatric fellows and house staff members in internal medicine, family practice, neurology, and psychiatry. Recommendations included here may be of use to deans, faculty members, and educators responsible for the development of the many new geriatric training programs.

Aged↗

PubMed1983

Clinical instruction in medicine: a national survey.

In this paper the authors report on the medicine phase of three parallel studies undertaken to investigate clinical teaching skills in medicine, dentistry, and nursing. The intent of the overall study was to gather and assess broad-based information useful in the design and implementation of clinical teaching improvement programs in the health sciences. A 14-member consortium representing five schools each in medicine and dentistry and four in nursing collaborated by using a modified Delphi technique to resolve conflict and differences, through group judgments, in preferences to choices among educational goals and activities. Based upon an educational needs assessment, the design of the study and of the research methodology allows replication at individual institutions and provides a systematic approach for designing and implementing faculty development programs with specific skill emphasis at the clinical level.

Clinical Competence↗

PubMed1985

Self-evaluation by house officers in a primary care training program.

Expertise in ambulatory care requires a broad range of knowledge and skills. A modified Delphi survey technique was used to delineate diagnoses, management techniques, and procedural skills in seven subspecialty areas necessary for house officers in a primary care internal medicine training program. Self-evaluation instruments were developed, and residents were asked to rate their abilities in the seven areas. At entry, the house officers generally had more confidence in their diagnostic abilities than in their management techniques and procedural skills. Progression through the training program was accompanied by increases in confidence in all areas except the behavioral sciences. The self-evaluation approach provided a longitudinal assessment of changes in the confidence of house officers throughout their training and an indication of the effectiveness of the educational program.

Ambulatory Care↗

PubMed1992

Geriatrics fellows' perceptions of the quality of their research training.

In the last quarter of 1987-88, 95 second- and third-year geriatrics fellows were surveyed to examine their perceptions of the quality of research training available through their programs. A three-phase Delphi survey method was used, with the numbers of individuals responding per phase ranging from 58 (61%) to 68 (72%). The responses were clustered in five areas by means of factor analysis using a varimax rotation procedure. The fellows perceived their research training to be inadequate, primarily due to insufficient time for research activities and to inadequate exposure to research-qualified scientists. The authors conclude that although the fellows strongly supported the notion of a research-focused third fellowship year, implementing such a plan may be futile if new resources are not made available.

Delphi Technique↗

PubMed2000

A pilot survey study to define quality in residency education.

PURPOSE: To begin to define indicators of quality in internal medicine residency training. METHOD: In 1995, through a modified Delphi process, the Association of Program Directors in Internal Medicine's Research Committee developed a questionnaire containing 44 items (34 process and ten outcome indicators). The survey was mailed to all 418 internal medicine program directors and a convenience sample of medical residents. RESULTS: Responding at a rate of 78% (326), program directors rated several indicators as important. These included such faculty characteristics as stability, completeness, supervision, clinical skills, and teaching commitment; institutional support; amount of resident evaluation and feedback; encouragement of lifelong learning; and ability to meet its program goals. There was strong agreement between faculty and residents (r = 0.91). Items rated less important included graduates' selecting academic or generalist careers, residents' caring for elective cardiac catheterization patients, resident community service, training minorities and women, and faculty research. CONCLUSION: These results demonstrate the diversity of opinion of what defines quality in residency education and the emphasis placed on process rather than outcome indicators. To be valid, future endeavors must include all those with a stake in graduate medical education, including accrediting bodies, future employers, and patients.

Attitude of Health Personnel↗

PubMed2004

Guidelines for preclerkship bioterrorism curricula.

PURPOSE: To develop medical school curriculum guidelines related to bioterrorism to ensure that future medical graduates are armed with the critical knowledge, skills, and attitudes to face this emerging threat. METHOD: An Internet-based Delphi survey was performed in 2002 under the auspices of the Association of Medical School Microbiology and Immunology Chairs involving 64 medical educators in microbiology, immunology, and infectious diseases representing 54 U.S. medical schools. A 12-member bioterrorism expert reference panel participated in the final phase of the survey. RESULTS: Study participants identified the top educational objectives for the following bioterrorism-related curriculum categories: general issues, biodefense, public health, infection control, infectious diseases, and toxins. CONCLUSION: The study focused on preparedness training through the development of curricular guidelines in predominantly preclerkship medical education by identifying basic science and clinical laboratory aspects of putative biologic weapons organisms and toxins, clinical manifestations of bioterrorist attacks, treatment strategies, epidemiology, and prophylaxis.

Allergy and Immunology↗

PubMed2001

Stroke care: a method for measuring compliance with AHCPR guidelines.

The purpose of this article is to describe a method for converting practice guidelines to measurement criteria. To evaluate the processes of care received by patients with stroke at 11 Veteran's Administration hospital sites, we developed a measurement system based on Agency for Health Care Policy and Research (AHCPR) Post-Stroke Rehabilitation Clinical Practice Guidelines. Guideline recommendations were used as the framework for identifying important dimensions of care, and for developing chart abstraction instruments for both the acute and postacute settings. Using a modified Delphi technique to solicit opinions from an expert panel, a method was developed for aggregation of item-level chart abstraction components to overall guideline compliance scores. The measurement system was shown to have good-to-excellent intrarater and interrater reliability at the item, dimension, and overall compliance score levels. Abstraction of a sample of 100 medical records demonstrated the ability of the instruments to detect variability in processes of post-stroke care. This study provides the foundation for future research, which will evaluate associations between processes of post-stroke care, as measured by this medical chart abstraction system, and patient outcomes. (All abstraction instruments, criteria, and scoring algorithms described in this article are available for download at http://www2.kumc.edu/coa.)

Aged↗

PubMed1996

Improving self-efficacy in nursing research.

THE PURPOSE OF this project was to increase research activities of practicing nurses at one large healthcare facility. The members of the nursing research committee at this institution planned a participatory learning experience with the goal of increasing the nurses' self-efficacy toward conducting research. Increased self-efficacy was the impetus for stimulating increased research activities by the nurses. Measurable outcomes of this project included a significant increase in the participants' self-efficacy and implementation of a number of research projects. The Delphi technique proved useful in identifying nursing research priorities as well as in stimulating nurses to initiate and conduct clinical research. Project implementation and evaluation are described to help practicing nurses and their employers in pursuit of the same goal.

Clinical Competence↗

PubMed1998

Assessing nursing problems of importance for the development of nursing care in a radiation therapy department.

The challenges to nurses working in the rapidly changing milieu of radiotherapy in cancer care are great. New treatment regimens continually require reexamination of old assumptions about patients' needs and communication between colleagues. In order to continue the development of the nursing care in the radiation therapy department, the purpose of this study was to assess the nursing problems experienced in the care of the cancer patients and the nursing problems experienced in work with other professionals from the nurse's perspective. Eighteen of the 38 nurses in the radiation therapy department were invited to participate in the study. The mean age of the nurses was 39 years (range 25-57 years). The study was carried out by using a three-phase, structured, communication-process method according to the Delphi technique. The nurses reported "poor follow-up of patients who have completed radiation therapy," closely followed by "finding time to document the nursing care" and "finding time to treat the scheduled patients" as the most problematic areas of importance for the development of nursing care. The nursing problems considered to be the most difficult in the work with other professionals were "lack of communication," "lack of knowledge of our work and competence," and "lack of comprehension of each other's professions." With the present trend in the health care system toward smaller financial resources, it is necessary to find new ways of organizing nursing care in order to find time to take care of the patient's problems during and after the radiation therapy. This study constituted the base for organizing a nursing care clinic in the department with sufficient time to assess and monitor side effects, patient education, sexual counselling, and coping assistance.

Adult↗

PubMed1998

Ensuring the success of women in academic orthopaedics.

In spring of 1995, the Academic Orthopaedic Society convened a panel of 21 female academic orthopaedists and 24 senior members of the society to discuss the challenges facing female orthopaedic residents and women in academic orthopaedics. Participants began by reviewing results of a 200 item mail survey of fulltime and parttime female academic orthopaedic surgeons. The survey had been conducted in early 1995. Using the Delphi technique, the panelists identified challenges facing women and ranked them in priority order. Although the challenges identified by survey respondents and panelists were similar, the priority assigned to them varied. Panel and survey findings pointed to a need for action in six areas: increasing mentoring; overcoming gender bias; reducing women's social and professional isolation; increasing attention to promotion and salary equity; providing greater accommodation for family responsibilities; and expanding recruitment efforts. This paper suggests actions that department chairpersons and the Academic Orthopaedic Society may take to attract more women to academic orthopaedics. Because many of the issues emerging from the survey and panel were not gender specific, implementation of the recommendations may benefit male and female orthopaedic residents and academic surgeons in general.

Career Choice↗