Rating the Appropriateness of Coronary Angiography — Do Practicing Physicians Agree with an Expert Panel and with Each Other?
Harvard University, Cambridge, Massachusetts, United States New England Journal of Medicine
(Impact Factor: 55.87).
07/1998; 338(26):1896-904. DOI: 10.1056/NEJM199806253382608
Evaluations of the appropriateness of medical care are important to monitor the quality of care and to contain costs and enhance safety by reducing inappropriate care. Experts' views are usually incorporated into evaluations of appropriateness. However, practicing physicians may not concur with these views, and physicians' clinical backgrounds may influence their beliefs.
We asked 1058 internists, family practitioners, and cardiologists in California, Florida, New York, Pennsylvania, and Texas to rate the appropriateness of coronary angiography after acute myocardial infarction for 20 common indications. Nine clinical experts also rated these indications using an established consensus method.
For 17 of the 20 indications, median ratings of surveyed physicians and the expert panel agreed within 1 unit on a 9-unit scale. Patients' older age had a negative effect on ratings by the expert panel but not on ratings by surveyed physicians. In multivariable analyses of surveyed physicians, cardiologists rated angiography as significantly more appropriate than did primary care physicians for complicated indications, and for uncomplicated indications cardiologists who performed invasive procedures gave higher appropriateness ratings for angiography than did cardiologists who did not perform such procedures and primary care physicians. For uncomplicated indications, physicians from hospitals providing coronary angioplasty and bypass surgery rated angiography as more appropriate than physicians from other hospitals. Physicians from New York and those employed by health maintenance organizations rated angiography as less appropriate than other physicians.
Surveyed physicians agreed with clinical experts about the appropriateness of coronary angiography after myocardial infarction for most indications, indicating that well-designed expert panels can closely reflect the views of practicing physicians. Variations in beliefs among practicing physicians suggest that evaluations of medical practice should incorporate the views of a range of relevant types of physicians.
Available from: Aaron Conway
- "Following development of a revised set of guidelines, a broader sample of CCL nurses (consensus panel) was sought to determine the degree of consensus on the recommendations. Only small improvements in reliability were expected from recruiting a larger sample size for the second round of the Delphi study (Ayanian et al. 1998). Yet, it was highly relevant in this study to try to maximise the potential for the guidelines to be representative of the views of practising CCL nurses because, due to limited research evidence, many of the recommendations needed to be made by consensus rather than from patient outcome data. "
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ABSTRACT: To develop clinical practice guidelines for nurse-administered procedural sedation and analgesia in the cardiac catheterization laboratory.
Numerous studies have reported that nurse-administered procedural sedation and analgesia is safe. However, the broad scope of existing guidelines for the administration and monitoring of patients who receive sedation during medical procedures without an anaesthetist present means there is a lack of specific guidance regarding optimal nursing practices for the unique circumstances where nurse-administered procedural sedation and analgesia is used in the cardiac catheterization laboratory.
A sequential mixed methods design was used. Initial recommendations were produced from three studies conducted by the authors: an integrative review; a qualitative study; and a cross-sectional survey. The recommendations were revised according to responses from a modified Delphi study. The first Delphi round was completed by nine senior cardiac catheterization laboratory nurses. All but one of the draft recommendations met the predetermined cut-off point for inclusion with 59 responses to the second round. Consensus was reached on all recommendations.
The guidelines that were derived from the Delphi study offer 24 recommendations within six domains of nursing practice: Pre-procedural assessment; Pre-procedural patient and family education; Pre-procedural patient comfort; Intra-procedural patient comfort; Intra-procedural patient assessment and monitoring; and Postprocedural patient assessment and monitoring.
These guidelines provide an important foundation towards the delivery of safe, consistent and evidence-based nursing care for the many patients who receive sedation in the cardiac catheterization laboratory setting.
Available from: ejcts.oxfordjournals.org
- "The main features of this technique include anonymity of participants to avoid individual dominance, an iterative process to allow changes of opinion in different rounds of questioning and controlled feedback for the participants by revealing group responses in the previous round of questioning. A number of studies have demonstrated the value of the Delphi method in areas of health care and epidemiology, particularly when robust forms of evidence such as randomized-controlled trials were unavailable   . "
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ABSTRACT: Video-assisted thoracoscopic surgery (VATS) lobectomy has been gradually accepted as an alternative surgical approach to open thoracotomy for selected patients with non-small-cell lung cancer (NSCLC) over the past 20 years. The aim of this project was to standardize the perioperative management of VATS lobectomy patients through expert consensus and to provide insightful guidance to clinical practice.
A panel of 55 experts on VATS lobectomy was identified by the Scientific Secretariat and the International Scientific Committee of the '20th Anniversary of VATS Lobectomy Conference-The Consensus Meeting'. The Delphi methodology consisting of two rounds of voting was implemented to facilitate the development of consensus. Results from the second-round voting formed the basis of the current Consensus Statement. Consensus was defined a priori as more than 50% agreement among the panel of experts. Clinical practice was deemed 'recommended' if 50-74% of the experts reached agreement and 'highly recommended' if 75% or more of the experts reached agreement.
Fifty VATS lobectomy experts (91%) from 16 countries completed both rounds of standardized questionnaires. No statistically significant differences in the responses between the two rounds of questioning were identified. Consensus was reached on 21 controversial points, outlining the current accepted definition of VATS lobectomy, its indications and contraindications, perioperative clinical management and recommendations for training and future research directions.
The present Consensus Statement represents a collective agreement among 50 international experts to establish a standardized practice of VATS lobectomy for the thoracic surgical community after 20 years of clinical experience.
Available from: PubMed Central
- "In this situation, we considered that the optimal methodology to examine the consensus was that developed by the RAND Corporation, as described above[7-12]. While this methodology is not perfect, we expect that it will provide the least biased set of quality indicators when appropriately performed, given previous findings that quality criteria developed using this methodology is reproducible[22,23] and agree with the opinions of practicing physicians and have predictive validity. "
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ABSTRACT: In Japan, attention has increasingly focused on ensuring the quality of care, particularly in the area of cancer care. The 2006 Basic Cancer Control Act reinforced efforts to ensure the quality of cancer care in a number of sectors, including the role of government in ensuring quality. We initiated a government-funded research project to develop quality indicators to measure the quality of care for five major cancers (breast, lung, stomach, colorectal, and liver cancer) in Japan, and palliative care for cancers in general. While we successfully developed a total of 206 quality indicators, a number of issues have been raised regarding the concepts and methodologies used to measure quality. Examples include the choice between measuring the process of care versus the outcome of care; the degree to which the process-outcome link should be confirmed in real-world measurement; handling of exceptional cases; interpretation of measurement results between quality of care versus quality of documentation; creation of summary scores; and the optimal number of quality indicators for measurement considering the trade-off between the measurement validity versus resource limitations. These and other issues must be carefully considered when attempting to measure quality of care, and although many appear to have no correct answer, continuation of the project requires that a decision nevertheless be made. Future activities in this project, which is still ongoing, should focus on the further exploration of these problems.
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