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PubMed2004

A qualitative study of post-settlement influences on State tobacco control funding.

State settlements with the tobacco industry increased the availability of funds that might be used for improving health outcomes and increased scrutiny of tobacco control funding overall. This research identified potential explanatory factors for state tobacco control funding and developed a conceptual framework to guide further exploration. Key informant interviews with 14 tobacco policy professionals were conducted to augment the information available in the scientific literature on funding influences. Interviews yielded a comprehensive list of 26 factors that were returned to key informants for ratings of importance using a modified Delphi process. Results indicate that the top funding influences are budgetary constraints, lobbying, advocacy, tobacco economy, legislative priorities, public opinion, and leadership by the governor or state legislators. A conceptual diagram is presented of all factors clustered into three categories. Further research is planned to quantify these factors and assess their explanatory value

Delphi Technique↗

PubMed1995

Financial consequences of reducing treatment availability in a publicly-funded orthodontic service. A decision analysis problem.

When a third party is responsible for funding a component of the health service, cost/benefit assessments become important. Such assessments become urgent when the budget is reduced. In this paper decision analysis has been applied to evaluate potential savings by reducing the proportion of children offered free orthodontic treatment through the National Health Service in Denmark. Data for the development of the decision tree was acquired using the Delphi technique. The results suggest that a reduction in the proportion of children offered early treatment might ultimately lead to an increased consumption of resources. Further investigation of the issue is needed before definitive recommendations can be made.

Budgets↗

PubMed2005

Cost-effectiveness in Italy of preventive treatment with ramipril in patients at high risk of cardiovascular events.

OBJECTIVES: A cost-effectiveness analysis was conducted in Italy of preventive treatment with ramipril (an angiotensin converting enzyme [ACE] inhibitor) compared to no treatment in patients at high risk of cardiovascular death. The analysis was based on data extracted from the HOPE trial. METHODS: The current life table method was used in order to model a lifetime time horizon for outcomes and costs. The cohorts used were 1000 subjects on ramipril, and 1000 subjects on placebo enrolled in the HOPE trial. Kaplan-Meier curves at 5 years of the clinical study were fitted using an exponential model over a lifetime horizon, the outcome variables being myocardial infarction, stroke, revascularization and death. Total direct medical costs have been considered from a third-party payer's perspective--the Italian National Health Service. Resources involved in each event/activity were estimated using the modified Delphi technique with a panel of six clinicians. Types of resources reported included drug therapies, laboratory and imaging tests, physician visits, outpatient and inpatient rehabilitation, as well as medical and surgical hospital admissions. The incremental cost per life year gained was the main measure of the analysis. RESULTS: ICER (incremental cost-effectiveness ratio) decreases with the length of the treatment period. After the first year the ICER is 55,062 euros and subsequently decreases to about 12,770 euros at 5 years, 5945 euros at 10 years and 3726 euros at 20 years. The two ways sensitivity analysis showed that at 5 years ICERs range from a saving of 4059 euros to a cost of 22,929 euros (at 20 years they are 1814 euros and 4434 euros), mainly depending on the cost of drug and cost of events. Previous analyses in other countries based on the HOPE study obtained ICER values which are comparable with our results, when taking into account the different cost structure of the health care systems. CONCLUSIONS: On the basis of these results, the use of ramipril is likely to represent an efficient use of public health expenditure in the Italian healthcare system.

Angiotensin-Converting Enzyme Inhibitors↗

PubMed2004

Essential elements of an early intervention service for psychosis: the opinions of expert clinicians.

BACKGROUND: Early intervention teams attempt to improve outcome in schizophrenia through earlier detection and the provision of phase-specific treatments. Whilst the number of early intervention teams is growing, there is a lack of clarity over their essential structural and functional elements. METHODS: A 'Delphi' exercise was carried out to identify how far there was consensus on the essential elements of early intervention teams in a group of 21 UK expert clinicians. Using published guidelines, an initial list was constructed containing 151 elements from ten categories of team structure and function. RESULTS: Overall there was expert consensus on the importance of 136 (90%) of these elements. Of the items on which there was consensus, 106 (70.2%) were rated essential, meaning that in their absence the functioning of the team would be severely impaired. CONCLUSION: This degree of consensus over essential elements suggests that it is reasonable to define a model for UK early intervention teams, from which a measure of fidelity could be derived.

Adult↗

PubMed2006

Health Research Profile to assess the capacity of low and middle income countries for equity-oriented research.

BACKGROUND: The Commission on Health Research for Development concluded that "for the most vulnerable people, the benefits of research offer a potential for change that has gone largely untapped." This project was designed to assess low and middle income country capacity and commitment for equity-oriented research. METHODS: A multi-disciplinary team with coordinators from each of four regions (Asia, Latin America, Africa and Central and Eastern Europe) developed a questionnaire through consensus meetings using a mini-Delphi technique. Indicators were selected based on their quality, validity, comprehensiveness, feasibility and relevance to equity. Indicators represented five categories that form the Health Research Profile (HRP): 1) Research priorities; 2) Resources (amount spent on research); 3) Production of knowledge (capacity); 4) Packaging of knowledge and 5) Evidence of research impact on policy and equity. We surveyed three countries from each region. RESULTS: Most countries reported explicit national health research priorities. Of these, half included specific research priorities to address inequities in health. Data on financing were lacking for most countries due to inadequate centralized collection of this information. The five main components of HRP showed a gradient where countries scoring lower on the Human Development Index (HDI) had a lower capacity to conduct research to meet local health research needs. Packaging such as peer-reviewed journals and policy forums were reported by two thirds of the countries. Seven out of 12 countries demonstrated impact of health research on policies and reported engagement of stakeholders in this process. CONCLUSION: Only one out of 12 countries indicated there was research on all fronts of the equity debate. Knowledge sharing and management is needed to strengthen within-country capacity for research and implementation to reduce inequities in health. We recommend that all countries (and external agencies) should invest more in building a certain minimum level of national capacity for equity-oriented research.

Africa↗

PubMed2005

An ethical framework for cardiac report cards: a qualitative study.

BACKGROUND: The recent proliferation of health care report cards, especially in cardiac care, has occurred in the absence of an ethical framework to guide in their development and implementation. An ethical framework is a consistent and comprehensive theoretical foundation in ethics, and is formed by integrating ethical theories, relevant literature, and other critical information (such as the views of stakeholders). An ethical framework in the context of cardiac care provides guidance for developing cardiac report cards (CRCs) that are relevant and legitimate to all stakeholders. The purpose of this study is to develop an ethical framework for CRCs. METHODS: Delphi technique - 13 panelists: 2 administrators, 2 cardiac nurses, 5 cardiac patients, 2 cardiologists, 1 member of the media, and 1 outcomes researcher. Panelists' views regarding the ethics of CRCs were analyzed and organized into themes. RESULTS: We have organized panelists' views into ten principles that emerged from the data: 1) improving quality of care, 2) informed understanding, 3) public accountability, 4) transparency, 5) equity, 6) access to information 7) quality of information, 8) multi-stakeholder collaboration, 9) legitimacy, and 10) evaluation and continuous quality improvement. CONCLUSION: We have developed a framework to guide the development and dissemination of CRCs. This ethical framework can provide necessary guidance for those generating CRCs and may help them avoid a number of difficult issues associated with existing ones.

Access to Information↗

PubMed2006

Assessing the level of healthcare information technology adoption in the United States: a snapshot.

BACKGROUND: Comprehensive knowledge about the level of healthcare information technology (HIT) adoption in the United States remains limited. We therefore performed a baseline assessment to address this knowledge gap. METHODS: We segmented HIT into eight major stakeholder groups and identified major functionalities that should ideally exist for each, focusing on applications most likely to improve patient safety, quality of care and organizational efficiency. We then conducted a multi-site qualitative study in Boston and Denver by interviewing key informants from each stakeholder group. Interview transcripts were analyzed to assess the level of adoption and to document the major barriers to further adoption. Findings for Boston and Denver were then presented to an expert panel, which was then asked to estimate the national level of adoption using the modified Delphi approach. We measured adoption level in Boston and Denver was graded on Rogers' technology adoption curve by co-investigators. National estimates from our expert panel were expressed as percentages. RESULTS: Adoption of functionalities with financial benefits far exceeds adoption of those with safety and quality benefits. Despite growing interest to adopt HIT to improve safety and quality, adoption remains limited, especially in the area of ambulatory electronic health records and physician-patient communication. Organizations, particularly physicians' practices, face enormous financial challenges in adopting HIT, and concerns remain about its impact on productivity. CONCLUSION: Adoption of HIT is limited and will likely remain slow unless significant financial resources are made available. Policy changes, such as financial incentivesto clinicians to use HIT or pay-for-performance reimbursement, may help health care providers defray upfront investment costs and initial productivity loss.

Attitude of Health Personnel↗

PubMed2006

Development of appropriateness explicit criteria for cataract extraction by phacoemulsification.

BACKGROUND: Consensus development techniques were used in the late 1980s to create explicit criteria for the appropriateness of cataract extraction. We developed a new appropriateness of indications tool for cataract following the RAND method. We tested the validity of our panel results. METHODS: Criteria were developed using a modified Delphi panel judgment process. A panel of 12 ophthalmologists was assembled. Ratings were analyzed regarding the level of agreement among panelists. We studied the influence of all variables on the final panel score using linear and logistic regression models. The explicit criteria developed were summarized by classification and regression tree analysis. RESULTS: Of the 765 indications evaluated by the main panel in the second round, 32.9% were found appropriate, 30.1% uncertain, and 37% inappropriate. Agreement was found in 53% of the indications and disagreement in 0.9%. Seven variables were considered to create the indications and divided into three groups: simple cataract, with diabetic retinopathy, or with other ocular pathologies. The preoperative visual acuity in the cataractous eye and visual function were the variables that best explained the panel scoring. The panel results were synthesized and presented in three decision trees. Misclassification error in the decision trees, as compared with the panel original criteria, was 5.3%. CONCLUSION: The parameters tested showed acceptable validity for an evaluation tool. These results support the use of this indication algorithm as a screening tool for assessing the appropriateness of cataract extraction in field studies and for the development of practice guidelines.

Activities of Daily Living↗

PubMed2006

Explicit criteria for prioritization of cataract surgery.

BACKGROUND: Consensus techniques have been used previously to create explicit criteria to prioritize cataract extraction; however, the appropriateness of the intervention was not included explicitly in previous studies. We developed a prioritization tool for cataract extraction according to the RAND method. METHODS: Criteria were developed using a modified Delphi panel judgment process. A panel of 11 ophthalmologists was assembled. Ratings were analyzed regarding the level of agreement among panelists. We studied the effect of all variables on the final panel score using general linear and logistic regression models. Priority scoring systems were developed by means of optimal scaling and general linear models. The explicit criteria developed were summarized by means of regression tree analysis. RESULTS: Eight variables were considered to create the indications. Of the 310 indications that the panel evaluated, 22.6% were considered high priority, 52.3% intermediate priority, and 25.2% low priority. Agreement was reached for 31.9% of the indications and disagreement for 0.3%. Logistic regression and general linear models showed that the preoperative visual acuity of the cataractous eye, visual function, and anticipated visual acuity postoperatively were the most influential variables. Alternative and simple scoring systems were obtained by optimal scaling and general linear models where the previous variables were also the most important. The decision tree also shows the importance of the previous variables and the appropriateness of the intervention. CONCLUSION: Our results showed acceptable validity as an evaluation and management tool for prioritizing cataract extraction. It also provides easy algorithms for use in clinical practice.

Activities of Daily Living↗

PubMed2007

Exploring the effects of telehealth on medical human resources supply: a qualitative case study in remote regions.

BACKGROUND: The availability of medical human resource supply is a growing concern for rural and remote communities in many countries. In the last decade, various telehealth experiences in Canada have highlighted the potential impact of this technology on professional practice. The purpose of this study was to explore physicians' and managers' perceptions regarding the potential of telehealth to support recruitment and retention of physicians in remote and rural regions. METHODS: A case study in Eastern Quebec was performed to explore this complex phenomenon. The analytical framework was based on two literature reviews and a Delphi study. Data were collected from semi-structured interviews with 41 physicians and 22 managers. Transcripts were produced and interview content was coded independently by two judges and validated by an expert panel. RESULTS: Interviews have highlighted the potential impact of telehealth on several factors influencing the recruitment and retention of physicians in rural and remote regions. The potential effects of telehealth on physicians' choice of practice location could be seen at the professional, organizational, educational and individual levels. For instance, telehealth could improve work satisfaction by allowing a regional on-call duty system and a better follow-up of patients. However, there are also certain limits related to telehealth, such as the fear that it would eventually replace all continuing medical education activities and onsite specialists in remoteregions. CONCLUSION: Telehealth is likely to have an impact on several factors related to medical workforce supply in remote and rural regions. However, the expected benefits will materialize if and only if this technology is properly integrated into organizations as a support to professional practice.

Administrative Personnel↗

PubMed2002

Core competencies in cancer genetics for advanced practice oncology nurses.

PURPOSE/OBJECTIVES: To determine core competencies in cancer genetics for advanced practice nurses (APNs) in oncology. DESIGN: Survey. SAMPLE: Expert panel of 9 nursing educators or researchers, 9 general genetics experts, 9 genetics experts with specialties in oncology, and 10 oncology APN nurse consumers (N = 37). METHODS: Utilizing the Delphi Technique, two rounds of surveys were conducted. Round 1's survey required open-ended responses to identify skills, attitudes, and competencies specific to cancer genetics. Round 2 requested ranking of the importance of identified competencies. MAIN RESEARCH VARIABLES: Skills, attitudes, and competencies specific to cancer genetics. FINDINGS: Recommended genetics competencies and knowledge for oncology APNs were identified for the categories of direct caregiver (6 items), coordinator (6 items), consultant (7 items), educator (6 items), researcher (8 items), and professional attitudes (16 items). CONCLUSIONS: Identified competencies provide a foundation and direction for development of the education curriculum recommended for all practicing oncology APNs. IMPLICATIONS FOR NURSING: Integrating genetic concepts into clinical practice is essential. Oncology APNs must have an expanded knowledge base in genetics to enable them to incorporate advances in genetics into practice to ensure quality outcomes. Development of genetics education is crucial to ensure future competency. Research that determines the impact of such education is warranted

Adult↗

PubMed2003

Cancer pain management in Lanarkshire: a community-based audit.

BACKGROUND: A prospective, longitudinal audit of pain management in patients with cancer was conducted in an unselected community population in Lanarkshire, Scotland. METHODS: Using a modified Delphi technique, a recording form was developed and a dedicated project manager was appointed to oversee the development and implementation of the audit. Community staff recorded pain level and analgesic prescribing on consecutive home visits to patients with cancer-related pain. Areas of good and poor prescribing were assessed using standards previously developed for the Scottish Cancer Pain Audit. These results were fed back to prescribers in a variety of ways and used as a focus for a programme of primary care-based education. RESULTS: Five hundred and forty-one patients have been entered in the audit between May 1999 and end October 2002. A total of 3259 visits have been recorded and 88% of general practices in Lanarkshire submitted forms during this period. Pain scores were recorded in 90% of visits. Specific gaps in prescribing practice were identified. CONCLUSION: The audit demonstrated that it is possible to engage primary care teams in a continuing audit of cancer pain management, which is achievable within the context of normal care. It provided a means to collect and analyse serial data on pain level and pain management and to identify areas of prescribing in need of improvement. Concerted efforts to establish the legitimacy and relevance of the project in the eyes of key stakeholders proved fundamental to encouraging longer-term behavioural change in the management of cancer pain.

Analgesics↗

PubMed2006

ICF core sets: how to specify impairment and function in systemic lupus erythematosus.

The World Health Organization's International Classification of Function (ICF) is a tool to characterize and illuminate better the full of array of problems a patient faces when affected by disease. Specifying these problems is a particular challenge in a disease like systemic lupus erythematosus (SLE) because of the wide variety in organ systems involved, its variable activity and severity, and considerable ethnic and local differences. The authors of this manuscript believe, however, that a broader understanding will prove essential for optimal patient care, and that there is sufficient experience now in defining ICF Core Sets to successfully complete core sets for SLE. Therefore, we will embark on an international project for developing ICF Core Sets for SLE, which we here delineate. This development will include two versions: 1) The Brief ICF Core Set for SLE will be a very focused list of categories essential for SLE clinical trials; and 2) The Comprehensive ICF Core Set will be much broader and useful for guiding multidisciplinary assessment in patients with SLE. Both Core Sets will be developed in a formal decision-making and consensus process of health professionals integrating evidence gathered from preliminary studies. The final definition of the Core Sets will occur at a consensus conference which will integrate: i) a systematic review of the literature regarding the outcome measures used in clinical trials and selected observational studies; ii) focus groups or semi-structured interviews with SLE patients; iii) a Delphi exercise with world wide involvement of experts; and iv) the evidence from empirical studies. The development of these SLE ICF Core Sets is designed to be an inclusive, open, worldwide process. We therefore invite both SLE clinical experts and SLE patients to participate actively.

Consensus Statements as Topic↗

PubMed2005

Precise formulation and evidence-based application of resource-constrained triage.

OBJECTIVES: To develop a precise mathematical formulation of resource-constrained triage, denoted the Sacco triage method (STM), to develop an evidence-based application to blunt trauma, and to compare the STM with the simple triage and rapid treatment (START) method. METHODS: Resource-constrained triage is modeled mathematically as a classic resource allocation problem. The objective is to maximize expected survivors given constraints on the timing and availability of resources. The model incorporates estimates of time-dependent victim survival probabilities based on an initial assessment and expected deterioration. For application to blunt trauma, an "RPM" score, based on respiratory rate, pulse rate, and motor response, was used to predict survivability. Logistic function-generated survival probability estimates for scene values of RPM were determined from 76,459 blunt-injured patients from the Pennsylvania Trauma Outcome Study (PTOS). The Delphi method provided expert consensus on victim deterioration rates, and the model was solved using linear programming. STM was compared with START across various criteria of process and outcome. Outcome was measured by expected number of survivors in simulated resource-constrained casualty incidents. RESULTS: In this mathematical simulation, RPM was a more accurate predictor of survivability from blunt trauma than the Injury Severity Score and the Revised Trauma Score, as measured by calibration and discrimination statistics. STM resulted in greater expected survivorship than START in all simulations. CONCLUSIONS: Resource-constrained triage is modeled precisely as an evidence-based, outcome-driven method that maximizes expected survivors in consideration of resources. The lifesaving potential and operational advantages over current methods warrant scrutiny and further research.

Delphi Technique↗

PubMed2006

Emergency medicine practitioner knowledge and use of decision rules for the evaluation of patients with suspected pulmonary embolism: variations by practice setting and training level.

BACKGROUND: Several clinical decision rules (CDRs) have been validated for pretest probability assessment of pulmonary embolism (PE), but the authors are unaware of any data quantifying and characterizing their use in emergency departments. OBJECTIVES: To characterize clinicians' knowledge of and attitudes toward two commonly used CDRs for PE. METHODS: By using a modified Delphi approach, the authors developed a two-page paper survey including 15 multiple-choice questions. The questions were designed to determine the respondents' familiarity, frequency of use, and comprehension of the Canadian and Charlotte rules. The survey also queried the frequency of use of unstructured (gestalt) pretest probability assessment and reasons why physicians choose not to use decision rules. The surveys were sent to physicians, physician assistants, and medical students at 32 academic and community hospitals in the United States and the United Kingdom. RESULTS: Respondents included 555 clinicians; 443 (80%) work in academic practice, and 112 (20%) are community based. Significantly more academic practitioners (73%) than community practitioners (49%) indicated familiarity with at least one of the two decision rules. Among all respondents familiar with a rule, 50% reported using it in more than half of applicable cases. A significant number of these respondents could not correctly identify a key component of the rule (23% for the Charlotte rule and 43% for the Canadian rule). Fifty-seven percent of all respondents indicated use of gestalt rather than a decision rule in more than half of cases. CONCLUSIONS: Academic clinicians were more likely to report familiarity with either of these two specific decision rules. Only one half of all clinicians reporting familiarity with the rules use them in more than 50% of applicable cases. Spontaneous recall of the specific elements of the rules was low to moderate. Future work should consider clinical gestalt in the evaluation of patients with possible PE.

Adult↗

PubMed2003

Identifying potential indicators of the quality of end-of-life cancer care from administrative data.

PURPOSE: To explore potential indicators of the quality of end-of-life services for cancer patients that could be monitored using existing administrative data. METHODS: Quality indicators were identified and assessed by literature review for proposed indicators, focus groups with cancer patients and family members to assess candidate indicators and generate new ideas, and an expert panel ranking the meaningfulness and importance of each potential indicator using a modified Delphi approach. RESULTS: There were three major concepts of poor quality of end-of-life cancer care that could be examined using currently-available administrative data (such as Medicare claims): institution of new anticancer therapies or continuation of ongoing treatments very near death; a high number of emergency room visits, inpatient hospital admissions, or intensive care unit days near the end of life; and a high proportion of patients never enrolled in hospice, only admitted in the last few days of life, or dying in an acute-care setting. Concepts such as access to psychosocial and other multidisciplinary services and pain and symptom control are important and may eventually be feasible, but they cannot currently be applied in most data systems. Indicators based on limiting the use of treatments with low probability of benefit or indicators based on economic efficiency were not acceptable to patients, family members, or physicians. CONCLUSION: Several promising claims-based quality indicators were identified that, if found to be valid and reliable within data systems, could be useful in identifying health-care systems in need of improving end-of-life services.

Cancer Care Facilities↗

PubMed1990

Future issues in children's health care: addressing psychosocial concerns.

A panel of experts, participating in a Delphi poll, identified significant issues facing psychosocial aspects of health care for children in the future. In three rounds of feedback and evaluation, ten top future issues were composited in rank order: chronic illness and complex health care needs; sociogenic problems; unequal access to health care; lack of financial resources for psychosocial services; increased focus on prevention; children without primary caregivers; complex ethical questions; family-centered care; training of health care professionals; and interdisciplinary integration. Implications of these issues are discussed.

Child↗

PubMedDate not supplied

A model for making project funding decisions at the National Cancer Institute.

This paper describes the development of a model for making project funding decisions at The National Cancer Institute (NCI). The American Stop Smoking Intervention Study (ASSIST) is a multiple-year, multiple-site demonstration project, aimed at reducing smoking prevalence. The initial request for ASSIST proposals was answered by about twice as many states as could be funded. Scientific peer review of the proposals was the primary criterion used for funding decisions. However, a modified Delphi process made explicit several criteria of secondary importance. A structured questionnaire identified the relative importance of these secondary criteria, some of which we incorporated into a composite preference function. We modeled the proposal funding decision as a zero-one program, and adjusted the preference function and available budget parametrically to generate many suitable outcomes. The actual funding decision, identified by our model, offers significant advantages over manually generated solutions found by experts at NCI.

Competitive Bidding↗