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The RAND/UCLA modified Delphi panel method is a formal group consensus process that systematically and quantitatively combines expert opinion and evidence by asking panelists to rate, discuss, then re-rate items. The method has been used to develop medical society guidelines, other clinical practice guidelines, disease classification systems, research agendas, and quality improvement interventions. Traditionally, a group of experts meet in person to discuss results of a first-round survey. After the meeting, experts complete a second-round survey used to develop areas of consensus. During the COVID-19 pandemic, this aspect of the method was not possible. As such, we have adapted the method to conduct virtual RAND/UCLA modified Delphi panels. In this study, we present a targeted literature review to describe and summarize the existing evidence on the RAND/UCLA modified Delphi panel method and outline our adaptation for conducting these panels virtually. Transitioning from in-person to virtual meetings was not without challenges, but there have also been unexpected advantages. The method we describe here can be a cost-effective and efficient alternative for researchers and clinicians.

PurposeThe U.S. Food & Drug Administration has identified physical functioning (PF) as a core patient-reported outcome (PRO) in cancer clinical trials. The purpose of this study was to identify PF PRO measures (PROMs) in adult cancer populations and classify the PROMs by content covered (facets of PF) in each measure.MethodsAs part of the Patient Reports of Physical Functioning Study (PROPS) research program, we conducted a targeted literature review to identify PROMs that could be used in clinical trials to evaluate PF from the patient perspective. Next, we convened an advisory panel to conduct a modified, reactive, Delphi study to reach consensus on which PF facets are assessed by PROMs identified in the review. The panel engaged in a “card sort” activity to classify PROM items by PF facets. Consensus was reached when 80% of panel members agreed that at least one facet was being measured by each PROM item.ResultsThe literature review identified 13 PROMs that met inclusion criteria. Eight facets of PF were identified for classification in the Delphi study: ability, completion, difficulty, limitation, quality, frequency, bother, and satisfaction. Through two rounds, the panel documented and classified conceptual approaches for each PRO item presented. The most prevalent PF facets were ability, difficulty, and limitation.ConclusionClassifying PF PROMs by PF facets will promote more consistent communication regarding the aspects of PF represented in each PROM, helping researchers prioritize measures for inclusion in cancer clinical trials.

While the volume of virtual visits increased with the COVID-19 pandemic, little is still known regarding the quality of virtual visits. Furthermore, there is limited guidance on how best to evaluate the quality of virtual care initiatives. The objective of this study was to curate a balanced set of quality indicators grounded in the Quintuple Aim quality framework and the National Academy of Medicine domains of quality, including sustainability, to monitor the quality of virtual care in ambulatory environments. Phase 1 involved curating a list of ambulatory virtual care quality indicators from published and grey literature, along with knowledge user feedback generated through a pre-Delphi survey; these indicators were mapped and categorized to the Quintuple Aim and National Academy of Medicine (NAM) Quality Domains. In phase 2, a 19-member pan-Canadian panel was convened as part of a 3-round modified Delphi panel process to rate and rank the quality indicators. The panel included clinicians, individuals with lived experience with the health care system, policy makers, academics, and administrators. Panelists rated indicators using the Agency for Healthcare Research and Quality measure attributes on a 9-point Likert scale in round 1, followed by a virtual Delphi panel meeting to discuss indicators before round 2 of re-rating, then a final round 3 of ranking which assessed the importance of indicators within each quality domain and subdomain. To address gaps in the literature, novel quality indicators of virtual care were identified and discussed in panel discussions, patient group consultations, and a pre-Delphi survey. For indicator advancement during the rating exercises, 75% or more of the panelists' responses in the top tertile (scores of 7-9) with a median composite score of 7 or greater was required. There were 140 quality indicators identified in the literature which progressed through the 3 Delphi panel rounds. There was minimal attrition among Delphi panel members (17/19, 89% participated in all 3 rounds). After round 3, 25 indicators were included in the final scorecard. Aligned with the Quintuple Aim, there are 13 quality indicators on patient experience, 6 on provider experience, 2 on population health, 2 on health equity, and 2 on health system costs. A balanced set of 25 quality indicators of ambulatory virtual care was developed based on literature and consensus building from knowledge users across the health system. This curated set of indicators will support more comprehensive evaluations of virtual care. Organizations can use the set of indicators as part of a scorecard to compare across jurisdictions, identify priority areas, and ensure their virtual care initiatives are delivering high-quality care based on multiple domains of quality.

Background Ambulatory Care Sensitive Conditions (ACSCs) are health conditions for which adequate management, treatment and interventions delivered in the ambulatory care setting could potentially prevent hospitalization. Which conditions are sensitive to ambulatory care varies according to the scope of health care services and the context in which the indicator is used. The need for a country-specific validated list for Portugal has already been identified, but currently no national list exists. The objective of this study was to develop a list of Ambulatory Care Sensitive Conditions for Portugal. Methods A modified web-based Delphi panel approach was designed, in order to determine which conditions can be considered ACSCs in the Portuguese adult population. The selected experts were general practitioners and internal medicine physicians identified by the most relevant Portuguese scientific societies. Experts were presented with previously identified ACSC and asked to select which could be accepted in the Portuguese context. They were also asked to identify other conditions they considered relevant. We estimated the number and cost of ACSC hospitalizations in 2017 in Portugal according to the identified conditions. Results After three rounds the experts agreed on 34 of the 45 initially proposed items. Fourteen new conditions were proposed and four achieved consensus, namely uterine cervical cancer, colorectal cancer, thromboembolic venous disease and voluntary termination of pregnancy. In 2017 133,427 hospitalizations were for ACSC (15.7% of all hospitalizations). This represents a rate of 1685 per 100,000 adults. The most frequent diagnosis were pneumonia, heart failure, chronic obstructive pulmonary disease/chronic bronchitis, urinary tract infection, colorectal cancer, hypertensive disease atrial fibrillation and complications of diabetes mellitus. Conclusions New ACSC were identified. It is expected that this list could be used henceforward by epidemiologic studies, health services research and for healthcare management purposes. ACSC lists should be updated frequently. Further research is necessary to increase the specificity of ACSC hospitalizations as an indicator of healthcare performance.

ObjectiveTo identify priorities for improving healthcare organization management of patient access to primary care based on prior evidence and a stakeholder panel.BackgroundStudies on healthcare access show its importance for ensuring population health. Few studies show how healthcare organizations can improve access.MethodsWe conducted a modified Delphi stakeholder panel anchored by a systematic review. Panelists (N = 20) represented diverse stakeholder groups including patients, providers, policy makers, purchasers, and payers of healthcare services, predominantly from the Veterans Health Administration. A pre-panel survey addressed over 80 aspects of healthcare organization management of access, including defining access management. Panelists discussed survey-based ratings during a 2-day in-person meeting and re-voted afterward. A second panel process focused on each final priority and developed recommendations and suggestions for implementation.ResultsThe panel achieved consensus on definitions of optimal access and access management on eight urgent and important priorities for guiding access management improvement, and on 1–3 recommendations per priority. Each recommendation is supported by referenced, panel-approved suggestions for implementation. Priorities address two organizational structure targets (interdisciplinary primary care site leadership; clearly identified group practice management structure); four process improvements (patient telephone access management; contingency staffing; nurse management of demand through care coordination; proactive demand management by optimizing provider visit schedules), and two outcomes (quality of patients’ experiences of access; provider and staff morale). Recommendations and suggestions for implementation, including literature references, are summarized in a panelist-approved, ready-to-use tool.ConclusionsA stakeholder panel informed by a pre-panel systematic review identified eight action-oriented priorities for improving access and recommendations for implementing each priority. The resulting tool is suitable for guiding the VA and other integrated healthcare delivery organizations in assessing and initiating improvements in access management, and for supporting continued research.

Background Treatment of schizophrenia has traditionally aimed for symptomatic remission without addressing many daily problems patients face. Although no standard definition of functional recovery in patients with first-episode psychosis (FEP) and early-phase (EP) schizophrenia exists in the literature, most clinicians consider it a useful concept in daily practice. We conducted a Delphi panel to develop expert consensus on assessing functional recovery in FEP and EP schizophrenia patients and defining its domains, which we compared with currently available patient- and clinician-reported outcome measures (PROMs, CROMs). Methods The three-stage modified Delphi panel consisted of a 1:1 interview round and two online survey rounds involving five expert steering committee and 16 panel members. We conducted a narrative review of the literature in PubMed to identify instruments assessing functioning in people with schizophrenia. Results Panelists were presented with 38 statements about functional recovery (definition, domains, and assessment) and approaches to achieving it. Panelists defined functional recovery for FEP and EP schizophrenia patients as a multidimensional state closely related to quality of life. When evaluating functional recovery, panelists agreed that assessing (1) depression, (2) aggressive behavior, (3) social interaction, (4) family functioning, (5) education and/or employment, (6) leisure activities, (7) self-care, and (8) sexual functioning was important. Panelists also agreed that asking patients about self-care and sexual functioning was less critical at every encounter. It was agreed that patients may be said to have reached partial functional recovery if they recovered in some but not all domains. There was consensus that long-acting injectable antipsychotics can facilitate functional recovery by increasing treatment adherence, lessening disease and treatment burden, and reducing functional decline. The literature review identified eight PROMs and CROMs that assess functioning in schizophrenia. However, none evaluated all eight domains of functional recovery. Conclusions Functional recovery is an important treatment goal in FEP and EP patients. PROMs and CROMs do not evaluate all eight domains of functional recovery agreed by the Delphi panel. Further research is needed to better understand and improve how functional recovery is assessed in clinical practice.

Background Fabry disease is a rare, X-linked inherited lysosomal storage disorder, that manifests as a heterogeneous disease with renal, cardiac and nervous system involvement. The most common pain experienced by people with Fabry disease are episodes of neuropathic pain reported in up to 80% of classical hemizygous male patients and up to 65% of heterozygous female patients. No clear consensus exists within UK clinical practice for the assessment and management of pain in Fabry disease based on agreed clinical practice and clinical experience. Here we describe a modified Delphi initiative to establish expert consensus on management of pain in Fabry disease in the UK clinical setting. Methods Delphi panel members were identified based on their demonstrated expertise in managing adult or paediatric patients with Fabry disease in the UK and recruited by an independent third-party administrator. Ten expert panellists agreed to participate in two survey rounds, during which they remained anonymous to each other. Circulation of the questionnaires, and collection and processing of the panel’s responses were conducted between September 2021 and December 2021. All questions required an answer. Results The Delphi panel reached a consensus on 21 out of 41 aspects of pain assessment and management of pain in Fabry disease. These encompassed steps in the care pathway from the goals of therapy through to holistic support, including the use of gabapentin and carbamazepine as first-line analgesic medications for the treatment of neuropathic pain in Fabry disease, as well as the proactive management of symptoms of anxiety and/or depression associated with Fabry pain. Conclusions The consensus panel outcomes reported here have highlighted strengths in current UK clinical practice, along with unmet needs for further research and agreement. This consensus is intended to prompt the next steps towards developing clinical guidelines.

SummaryA panel of European experts was convened to establish consensus on a treat-to-target strategy in osteoporosis. Panellists agreed that the ultimate goals of treating osteoporosis are recovering pre-fracture functional level and reducing subsequent fracture risk; there was consensus that total hip bone mineral density is currently the most appropriate treatment target in clinical practice.IntroductionA modified Delphi approach was convened to establish consensus among European experts on best practice management for patients with fragility fractures and whether a treat-to-target (T2T) strategy is applicable in osteoporosis.MethodsA panel of 12 clinical experts (from eight European countries) voted on 13 final statements relating to a T2T strategy for osteoporosis across three rounds of blinded, remotely conducted electronic surveys (Likert scale: ‘strongly disagree’, ‘disagree’, ‘unable to answer’, ‘agree’, ‘strongly agree’). When panellists disagreed, they were asked how the statement could be adjusted to allow for a positive response, which was used to refine the statement for the following round. Consensus was defined as ≥ 75% agreement with a statement. Panellists were selected by UCB Pharma, which provided financial and logistical support.ResultsConsensus was reached for 13/13 statements. Panellists agreed that the most important goals for fragility fracture patients are recovery of pre-fracture functional level and reduction of subsequent fracture risk. There was also consensus that a T2T strategy is applicable to osteoporosis and that bone mineral density (BMD) is currently the most clinically appropriate target. With regard to the definition of a specific BMD treatment target and timeframes applicable to T2T in osteoporosis, no clear consensus was reached; panellists emphasised that these would need to be individually determined.ConclusionsAccording to a panel of European experts, the main goals of fracture management are to recover pre-fracture functional level and reduce fracture risk. Total hip BMD seems to be the most clinically appropriate treatment target within a T2T strategy.

Substantial evidence supports the effectiveness of implanted Vagus Nerve Stimulation (VNS) in the management of unipolar difficult-to-treat depression (DTD). While the treatment is included in several national and international guidelines, there is limited information to guide clinicians regarding patient selection and use of VNS in clinical practice. A group of 32 experts in the use of VNS were identified from the main countries currently providing the treatment globally. A modified Delphi technique was used to document views on 55 statements regarding the goals, patient selection, and use of VNS treatment in routine clinical practice. Statements were rated on a 9-point Likert scale from \"strongly disagree\" to \"strongly agree\". Over the course of three rounds of voting, with statements modified based on anonymous comments from panelists, consensus agreement or disagreement was deemed if at least 75% of panel members scored a statement between 7 and 9, or 1 and 3, respectively. Consensus was reached by the panel on 75% of the statements covering a wide range of issues. There was agreement that the main goals for VNS are long-term management of symptoms and improvement in quality of life, that the treatment is appropriate for all ages of patients and that there are few contraindications. A set of expert recommendations for the use of VNS for DTD was generated. These should be of value to clinicians to ensure current best practices are followed when considering this treatment.

Energy transition debates have been characterized by a strong emphasis on the technical implications of shifting away from fossil fuels to renewable energy sources, with little consideration of social contexts. This is now changing, with a growing emphasis on reconfiguring the social aspects of energy, particularly in terms of introducing more democratic processes into behavior change and energy practice engagements. This article situates itself within these debates and demonstrates the transformative potential of combining participatory action research (PAR) approaches with a modified Delphi method for understanding energy transition issues, particularly beyond forecasting instruments. There remains a dearth in literature combining the Delphi method with PAR; its application in the field of energy transitions is very innovative. PAR draws from grassroots and local-based knowledge, Delphi panels typically focus on the insights from a panel of professional experts. In combining these two approaches, to develop principles for an inclusive and just energy transition, a reflexive form of dialogue emerges that gives voice to what are often considered dissonant or mismatched perspectives. Furthermore, the experimental use of a modified Delphi panel, combined with PAR, offers a strategy to promote knowledge sharing between different groups and to counter potential communication barriers among different actors in society. This article shows how a modified Delphi panel approach is considerably enhanced by combining elements of PAR, raising the potential of Delphi panels beyond forecasting instruments, which often seek to determine the way the future “will be,” toward an envisioning tool that collaboratively seeks to explore the way a low-carbon system “could be,” or perhaps “should be.” The development of energy transition principles, endorsed through the modified Delphi panel, offers a concrete way to enact practices of energy justice within a more democratized energy system.