Developing a Fracture Risk Clinical Assessment Protocol for Long-Term Care: A Modified Delphi Consensus Process

ObjectivesTo develop a fracture risk Clinical Assessment Protocol (CAP) based on long-term care (LTC) fracture prevention recommendations and an embedded fracture risk assessment tool.DesignA modified Delphi consensus approach including 2 survey rounds and a face-to-face meeting was implemented to reach consensus on matching of LTC fracture prevention guideline statements to Fracture Risk Scale (FRS) risk levels.Setting and ParticipantsA national panel of recognized experts in osteoporosis, fractures, and long-term care, including an LTC resident and family members.MethodsRound 1 survey respondents (n = 24) were provided the LTC fracture prevention guidelines matched to FRS risk levels and were asked whether they agreed the guideline was appropriate for the risk level (yes, no, I don't know, I agree with some but not all of it) and to provide comments. In round 2, guideline statements that did not achieve consensus (≥80% agreement) were revised consistent with comments provided in round 1 and respondents were asked again if they agreed with the guideline statement. Statements that did not achieve consensus were to be discussed and resolved in an in-person meeting (n = 17).ResultsIn round 1 (75% response rate), consensus was achieved in 7/14 guideline statements. In round 2 (56% response rate), 5 statements were revised based on round 1 feedback and for 2 statements additional information was provided. Consensus was achieved in all but one statement related to the inappropriateness of pharmacologic therapy for residents with life expectancy less than 1 year. Following facilitated meeting discussions, consensus was obtained to revise the guideline statement to reflect that life expectancy was but one of several criteria that should be used to inform medication decisions.Conclusions and ImplicationsAn evidence-based fracture risk CAP was developed that will be embedded in international routine clinical assessment tools to guide fracture prevention in LTC.     

A Recommended Package of Long-Term Care Services to Promote Healthy Ageing Based on a WHO Global Expert Consensus Study

ObjectivesTo reach consensus on a minimum list of long-term care (LTC) interventions to be included in a service package delivered through universal health coverage (UHC).DesignA multistep expert consensus process.Setting and ParticipantsMultinational and multidisciplinary experts in LTC and ageing.MethodsThe consensus process was composed of 3 stages: (1) a preconsultation round that built on an initial list of LTC interventions generated by a previous scoping review; (2) 2-round surveys to reach consensus on important, acceptable, and feasible interventions for LTC; (3) a panel meeting to finalize the consensus.ResultsThe preconsultation round generated an initial list of 117 interventions. In round 1, 194 experts were contacted and 92 (47%) completed the survey. In round 2, the same experts contacted for round 1 were invited, and 115 (59%) completed the survey. Of the 115 respondents in round 2, 80 participated in round 1. Experts representing various disciplines (eg, geriatricians, family doctors, nurses, mental health, and rehabilitation professionals) participated in round 2, representing 42 countries. In round 1, 81 interventions achieved the predetermined threshold for importance, and in round 2, 41 interventions achieved the predetermined threshold for acceptability and feasibility. Nine conflicting interventions between rounds 1 and 2 were discussed in the panel meeting. The recommended list composed of 50 interventions were from 6 domains: unpaid and paid carers' support and training, person-centered assessment and care planning, prevention and management of intrinsic capacity decline, optimization of functional ability, interventions needing focused attention, and palliative care.Conclusions and ImplicationsAn international discussion and consensus process generated a minimum list of LTC interventions to be included in a service package for UHC. This package will enable actions toward a more robust framework for integrated services for older people in need of LTC across the continuum of care.     

Management of urinary stone disease in general practice: A French Delphi study

Background: Recommendations for the management of urolithiasis in primary care are lacking in France. The Delphi method was used to seek consensus from an expert panel regarding outpatient management of urolithiasis.

Methods: We gathered 25 French experts from five clinical specialties: general practice, urology, nephrology, emergency medicine and radiology. The first survey was formulated after an exhaustive literature review. At each of the three rounds, the experts were given the results of the previous round and were asked again to complete the survey. The threshold of 70% of the vote was taken as defining consensus. A final round of validation involving five additional general practitioners was conducted.

Results: Twenty experts participated in the study (five urologists, four nephrologists, four general practitioners, four emergency physicians, and three radiologists, participation rate = 80%). According to the survey results, most patients could be treated as outpatients (70.5% of the votes) but a biological (urine dipstick and culture, serum creatinine?±?serum β-hcg) and imaging (renal ultrasound?+?Kidney-Ureters-Bladder X-ray or low-dose CT san) work-up is recommended within 24?hours. Non-steroidal anti-inflammatory drugs are the analgesics of choice. An aetiological work-up should be performed after the second episode of renal colic. A follow-up imaging should be carried out yearly in urolithiasis patients.

Conclusion: With the use of the Delphi method, we propose a multidisciplinary recommendation for the management of urolithiasis patients in primary care.     

Perceptions of a multidisciplinary team regarding a pediatric rehabilitation modified needs assessment

Background: Efficient service delivery models that optimize processes and human resources are required in the current health care climate. A family-centered care approach is recognized as a model that can improve the effectiveness and efficiency of pediatric rehabilitation. The objective of this study was to explore the perceptions of a multidisciplinary health care team regarding the use of the Préparation au plan d’intervention (PAPI), a modified needs assessment tool designed to facilitate a family-centered care approach among children with cerebral motor deficits (CMD) and their families.

Methods: One focus group was conducted with the multidisciplinary team (n?=?10) of the CMD program at a pediatric rehabilitation center. It was audio recorded and transcribed verbatim for content analysis.

Results: Three overarching themes were identified from the analyzes: (1) a facilitator of open communication, (2) a way to gain the unique sense of the child and family and (3) parents as the experts of their child.

Conclusions: Health care professionals value the use of the PAPI as a way of facilitating a family-centered care plan process, specifically with children with cerebral motor deficits.     

Recommendations for Welcoming Back Nursing Home Visitors During the COVID-19 Pandemic: Results of a Delphi Panel

ObjectivesNursing homes became epicenters of COVID-19 in the spring of 2020. Due to the substantial case fatality rates within congregate settings, federal agencies recommended restrictions to family visits. Six months into the COVID-19 pandemic, these largely remain in place. The objective of this study was to generate consensus guidance statements focusing on essential family caregivers and visitors.DesignA modified 2-step Delphi process was used to generate consensus statements.Setting and ParticipantsThe Delphi panel consisted of 21 US and Canadian post-acute and long-term care experts in clinical medicine, administration, and patient care advocacy.MethodsState and federal reopening statements were collected in June 2020 and the panel voted on these using a 3-point Likert scale with consensus defined as ≥80% of panel members voting “Agree.” The consensus statements then informed development of the visitor guidance statements.ResultsThe Delphi process yielded 77 consensus statements. Regarding visitor guidance, the panel made 5 strong recommendations: (1) maintain strong infection prevention and control precautions, (2) facilitate indoor and outdoor visits, (3) allow limited physical contact with appropriate precautions, (4) assess individual residents' care preferences and level of risk tolerance, and (5) dedicate an essential caregiver and extend the definition of compassionate care visits to include care that promotes psychosocial well-being of residents.Conclusions and ImplicationsThe COVID-19 pandemic has seen substantial regulatory changes without strong consideration of the impact on residents. In the absence of timely and rigorous research, the involvement of clinicians and patient care advocates is important to help create the balance between individual resident preferences and the health of the collective. The results of this evidence-based Delphi process will help guide policy decisions as well as inform future research.     

Identification and expert panel rating of key structural approaches applied in health economic obesity models

ObjectivesThis study aims to assess the key structural modelling approaches applied in published obesity models, and to provide an expert consensus to improve the methodology and consistency of the application of decision-analytic modelling in obesity research.MethodsUsing a previously published systematic literature search as basis, ten individual interviews, and a face-to-face expert panel meeting were conducted. Within the expert panel meeting, the interview findings were presented and discussed, rated and where possible consensus statements were obtained. In particular, five topics of interest were assessed: time horizon, model type, obesity-related clinical events simulated, event simulation approaches and external event validation.ResultsIn addition to generic modelling standards, several obesity-specific recommendations were generated: Simulating a lifetime horizon was regarded as optimal (100% agreement); Ideally, both short and long-term results should be presented (100%); Using a risk equation approach for simulating the clinical events was the most preferred approach (60%) followed by applying a body mass index (BMI) related relative risk to a base risk estimate (30%); Continuous BMI approaches were preferred (100%); An individual patient/microsimulation state transition model was regarded as preferred modelling approach (90%); Discrete event simulation (DES) was regarded as the most flexible approach for building an obesity model but it was recognised as complex, and more difficult to build, populate and to disseminate; Performing an external validation was rated as important (100%).ConclusionsThe obtained insights, discussion and consensus can provide valuable information for developing decision-analytic models to generate high-quality and transparent economic evidence for obesity interventions.     

Quality indicators for primary care mental health services

Objectives: To identify a generic set of face valid quality indicators for primary care mental health services which reflect a multi-stakeholder perspective and can be used for facilitating quality improvement.

Design: Modified two-round postal Delphi questionnaire.

Setting: Geographical spread across Great Britain.

Participants: One hundred and fifteen panellists representing 11 different stakeholder groups within primary care mental health services (clinical psychologist, health and social care commissioner, community psychiatric nurse, counsellor, general practitioner, practice nurse/district nurse/health visitor, psychiatrist, social worker, carer, patient and voluntary organisations).

Main outcome measures: Face validity (median rating of 8 or 9 on a nine point scale with agreement by all panels) for assessing quality of care.

Results: A maximum of 334 indicators were rated by panels in the second round; 26% were rated valid by all panels. These indicators were categorised into 21 aspects of care, 11 relating to general practices and 10 relating to health authorities or primary care groups/trusts. There was variation in the total number of indicators rated valid across the different panels. Overall, GPs rated the lowest number of indicators as valid (41%, n=138) and carers rated the highest number valid (91%, n=304).

Conclusions: The quality indicators represent consensus among key stakeholder groups in defining quality of care within primary care mental health services. These indicators could provide a guide for primary care organisations embarking on quality improvement initiatives in mental health care when addressing national targets and standards relating to primary care set out in the National Service Framework for Mental Health for England. Although many of the indicators relate to parochial issues in UK service delivery, the methodology used in the development of the indicators could be applied in other settings to produce locally relevant indicators.

     

Effects of the reform of the Dutch healthcare into managed competition: Results of a Delphi study among experts

BackgroundIn 2006 a major healthcare reform was introduced in the Netherlands, implying managed competition. This study explored the level of consensus on the outcomes and desired changes of this new system, and differences between stakeholder groups.MethodsA three-round Delphi-study was conducted among Dutch healthcare insurers, health economists, and professionals in general practice (GP) care and mental health (MH) care. In the first round, 20 experts indicated the most important advantages and disadvantages of the Dutch managed competition, and desired changes. Experts in the second (n = 106) and third round (N = 88) rated the importance of the 88 factors identified in the first round.ResultsOnly healthcare insurers reached consensus on important advantages (i.e. improved efficiency; room for choice). Health economists reached almost no consensus on any factors. GP and MH-care professionals reached most consensus on disadvantages (i.e. focus on price over quality, increased bureaucracy) and desired changes (i.e. reduce bargaining power of healthcare insurers; increase attention for care of complex patients); half of them suggested abolishment of managed competition.ConclusionGP and MH-care professionals were most dissatisfied and suggested several changes or even abolishment of the 2006 reform; healthcare insurers mentioned some benefits. This level of dissatisfaction among health care professionals indicates that there is room for improvement, preferably developed in conjunction with stakeholders.     

What Clinical Activities Do Advanced-Practice Registered Dietitian Nutritionists Perform? Results of a Delphi Study

Activities performed by advanced-practice registered dietitian nutritionists (RDNs) have yet to be clearly elucidated. The study aimed to gain consensus on the practice activities of advanced-practice RDNs who provide direct clinical nutrition care. A three-round Delphi study was conducted. Purposive sampling identified 117 RDN experts working as clinicians and/or managers in direct care settings that met inclusion criteria for advanced-level practice. In Round 1, 85 experts provided open-ended advanced-level practice activities linked to the Nutrition Care Process sections. Using content analysis, the responses were coded into activity statements. In Round 2, experts rated the essentiality of these activities. In Round 3, experts re-rated statements not reaching consensus while viewing their previous rating, the group median, and comments. Median ratings of 1.0 to 3.0 were defined as essential, 4.0 were neither essential nor nonessential, and 5.0 to 7.0 were nonessential. Consensus was reached when the interquartile range of responses to each question was <2.0. Seventy-six (89.4%) experts completed all rounds. From 770 comments, 129 activity statements were generated. All statements reached consensus: 97.7% as essential; 0.8% as nonessential; and 1.5% as neither. Of essential activities, 67.5% were highly essential with limited variability (median=1.0; interquartile range≤2.0). Advanced-practice RDNs' tasks are patient-centered and reflect complex care; involve a comprehensive and discriminating approach; are grounded in advanced knowledge and expertise in clinical nutrition; include use of advanced interviewing, education, and counseling strategies; and require communication with patient, families, and the health care team. The high-level of consensus from experts suggest advanced-level clinical nutrition practice exists and can be defined.     

Proposals for person‐centred care in the COVID‐19 era. Delphi study

BackgroundIn this COVID‐19 era, we need to rethink the criteria used to measure the results of person‐centred care strategies.ObjectiveTo identify priorities, and criteria that health services can use to pursue actually the goal of achieving person‐centred care.DesignThree‐phase online qualitative study performed during May–July of 2020 using the Delphi technique.Setting and ParticipantsAn online platform was used for a consensus meeting of 114 participants, including health planning experts, health‐care institution managers, clinicians and patients.Main Outcome MeasuresCriteria and indicators for the achievement of person‐centred care.Main ResultsThe first round began with 125 proposals and 11 dimensions. After the second round, 28 ideas reached a high level of consensus among the participants. Ultimately, the workgroup agreed on 20 criteria for goals in the implementation of person‐centred care during the COVID‐19 era and 21 related indicators to measure goal achievement.DiscussionNine dimensions and 28 priorities were identified. These priorities are also in accordance with the quadruple aim approach, which emphasizes the need for care for health‐care professionals, without whom it is impossible to achieve a better quality of care.ConclusionsPerson‐centred care continues to be a key objective. However, new metrics are needed to ensure its continued development during the restoration of public health services beyond the control of COVID‐19.Patient or Public ContributionTwelve professionals and patient representatives participated voluntarily in the construction of the baseline questionnaire and in the selection of the criteria and indicators using an online platform for consensus meetings.     

Identifying components of advanced-level clinical nutrition practice: a Delphi study

The dietetics profession lacks a comprehensive definition of advanced-level practice. Using a three-round Delphi study with mailed surveys, expert consensus on four dimensions of advanced-level practice that define advanced practice registered dietitians (RDs) in clinical nutrition was explored. Purposive sampling identified 117 RDs who met advanced-level practice criteria. In round 1, experts rated the essentiality of statements on a 7-point ordinal scale and generated open-ended practice activity statements regarding the following four dimensions of advanced-level practice: professional knowledge, abilities and skills, approaches to practice, roles and relationships, and practice behaviors. Median ratings of 1.0 to 3.0 were defined as essential, 4.0 was neutral, and 5.0 to 7.0 were nonessential. In rounds 2 and 3, experts re-rated statements not reaching consensus by evaluating their previous responses, group median rating, and comments. Consensus was reached when the interquartile range of responses to a statement was ≤2.0. Eighty-five experts enrolled (72.6%); 76 (89.4%) completed all rounds. In total, 233 statements were rated, with 100% achieving consensus; 211 (90.6%) were essential to advanced practice RD clinical practice. Having a master's degree; completing an advanced practice residency; research coursework; and advanced continuing education were essential, as were having 8 years of experience; clinical nutrition knowledge/expertise; specialization; participation in research activities; and skills in technology and communication. Highly essential approaches to practice were systematic yet adaptable and used critical thinking and intuition and highly essential values encompassed professional growth and service to patients. Roles emphasized patient care and leadership. Essential practice activities within the nutrition care process included provision of complex patient-centered nutrition care using application of advanced knowledge/expertise and interviewing and counseling strategies approached in a comprehensive yet discriminating manner. Communication with patients and the health care team is a priority. An advanced-level practice model in clinical nutrition was proposed depicting the requisite attributes and activities within four dimensions of professional practice.     

The P.O.S.T Guidelines for Nutrition Blogs: A Modified e-Delphi Study

BackgroundBlogs are being used increasingly to disseminate nutrition information to consumers, including by registered dietitians (RDs). Guidelines in authoring blogs are important for dietetics professionals so that they effectively communicate evidence-based nutrition information in this format.ObjectiveThe aim of this study was to obtain consensus from experts comprising RDs with active blog-writing experience on a set of guidelines for use by RDs when authoring a healthy eating or nutrition information blog.DesignA modified e-Delphi technique with a consensus-based approach was used in this study undertaken between June and October 2019. The purpose-built, pilot-tested e-Delphi survey was informed by a literature review and included statements from 3 domains comprising blog readers and communication; purpose and healthy eating messages; and structure, voice, and tone. Expert participants were identified purposively and via snowballing. In each survey round, statements that achieved 80% consensus were accepted.Participants/settingA total of 19 experts consented to participate. Experts resided in the United States, Australia, and United Kingdom. Experts were mainly women aged between 30 and 49 years and working in private practice and/or research or teaching areas of nutrition and dietetics.ResultsAcross 3 domains, a total of 33 statements were accepted, comprising a final set of guidelines named the P.O.S.T (purpose, community, structure, and tone) Guidelines for Nutrition Blogs.ConclusionsConsensus from a panel of dietetics experts resulted in the P.O.S.T Guidelines for Nutrition Blogs, which can support RDs in authoring healthy eating blogs. This will ensure that evidence-based nutrition messages provided to consumers are engaging and effective.     

Promoting behaviour change in patients with coronary heart disease

Background: Secondary prevention is an effective strat-egy for reducing coronary heart disease morbidity and mortality. Secondary prevention in primary care has been shown to be suboptimal. Evidence on approaches to behaviour change, suitable for implementation in primary care, is needed.

Objective: To identify approaches to behaviour change in patients with coronary heart disease that are rele-vant to primary care and compare the views of health professionals in two different healthcare systems (United Kingdom and the Republic of Ireland).

Methods: Two nominal groups were conducted in Northeast Scotland and the West of Ireland with expert panels representing core and extended primary care teams. Participants were asked to generate ideas, rank them, and then discuss areas of disagreement before a second round of ranking.

Results: In both groups, there was good consensus on items relating to individual patient assessment (including motivation and understanding), addressing the practitioner's willingness to change, using established principles of behaviour change, and having adequate resources, staff and time. Priorities were, however, different. Emphasis on items relating to resources, staff and organisation was particularly strong in the Irish group; there was more emphasis on approaches to behaviour change in the Scottish group.

Conclusions: When attempting to promote behaviour change and secondary prevention, there are different priorities in different healthcare systems. These should be taken into account in the design of any intervention.     

Home visits by family physicians in Poland: Patients’ perspective

Abstract

Background: General Practitioners (GPs) sometimes base their clinical decisions on ‘gut feelings.’ Research into the significance of this phenomenon with focus groups and a Delphi consensus procedure in the Netherlands provided a concept of ‘gut feelings:’ a sense of alarm, a sense of reassurance and several determinants. The transculturality of ‘gut feelings’ has been examined briefly until now as the issue is complex.

Objective: To determine whether a consensus on ‘gut feelings’ in general practice in France could be obtained. Using a similar Delphi consensus procedure and the same six initial statements as in the Netherlands, and compare the French results with the seven final Dutch consensual statements.

Method: Qualitative research, including a Delphi consensus procedure after a forward-backward translation (FBT) of the initial Dutch statements of ‘gut feelings.’ A heterogeneous sample of 34 French expert GPs participated. FBT of the final French statements was undertaken for a content comparison with the Dutch.

Results: After three Delphi rounds, French GPs reached agreement on nine statements. Many similarities have been found between the Dutch and the French defining statements, with reservations concerning the ‘sense of reassurance,’ which French GPs seemed to feel more cautious about.

Conclusion: ‘Gut feelings’ are a well-defined concept in France too. The Dutch and the French consensual statements seem very close. The transculturality of the concept is confirmed, which is a new indicator that ‘gut feelings’ are a self-contained concept.     

Patient-Centered Care for Women: Delphi Consensus on Evidence-Derived Recommendations

ObjectivePatient-centered care (PCC) could reduce gender inequities in quality of care. Little is known about how to implement patient-centered care for women (PCCW). We aimed to generate consensus recommendations for achieving PCCW.MethodsWe used a 2-round Delphi technique. Panelists included 21 women of varied age, ethnicity, education, and urban/rural residence; and 21 health professionals with PCC or women’s health expertise. Panelists rated recommendations, derived from prior research and organized by a 6-domain PCC framework, on a 7-point Likert scale in an online survey. We used summary statistics to report response frequencies and defined consensus as when ≥85% panelists chose 5 to 7.ResultsThe response rate was 100%. In round 1, women and professionals retained 46 (97.9%) and 42 (89.4%) of 47 initial recommendations, respectively. The round 2 survey included 6 recommendations for women and 5 recommendations for professionals (did not achieve consensus in round 1 or were newly suggested). In round 2, women retained 2 of 6 recommendations and professionals retained 3 of 5 recommendations. Overall, 49 recommendations were generated. Both groups agreed on 44 (94.0%) recommendations (13 retained by 100% of both women and clinicians): fostering patient-physician relationship (n = 11), exchanging information (n = 10), responding to emotions (n = 4), managing uncertainty (n = 5), making decisions (n = 8), and enabling patient self-management (n = 6).ConclusionThe recommendations represent the range of PCC domains, are based on evidence from primary research, and reflect high concordance between women and professional panelists. They can inform the development of policies, guidelines, programs, and performance measures that foster PCCW.     

An International Consensus List of Potentially Clinically Significant Drug-Drug Interactions in Older People

ObjectivesWe aimed to establish an explicit list of potentially clinically significant drug-drug interactions (DDIs) in people aged ≥65 years.DesignA preliminary list of potentially clinically significant DDIs was compiled, based on 154 DDIs identified from literature review. Subsequently, a 2-round online Delphi survey was undertaken with a multidisciplinary expert panel. A consensus meeting and a final round were conducted to validate the final DDI list and the scope of information provided.Setting and ParticipantsTwenty nine experts, including geriatricians and clinical pharmacists from 8 European countries.MeasuresFor each DDI, in the first 2 rounds, experts were asked to score the severity of potential harm on a 5-point Likert-type scale. DDIs were directly included on the final list if the median score was 4 (major) or 5 (catastrophic). DDIs with a median score of 3 (moderate) were discussed at a consensus meeting and included if ≥75% of participants voted for inclusion in the final round.ResultsConsensus was achieved on 66 potentially clinically significant DDIs (28 had a median score of 4/5 and 48 of 3 in the Delphi survey). Most concerned cardiovascular, antithrombotic, and central nervous system drugs. The final list includes information on the mechanism of interaction, harm, and management. Treatment modification is recommended for three-quarters of DDIs.Conclusion and ImplicationsWe validated a list of potentially clinically significant DDIs in older people, which can be used in clinical practice and education to support identification and management of DDIs or to assess prevalence in epidemiologic and intervention studies.     

Developing quality indicators for older adults: transfer from the USA to the UK is feasible

Background: Measurement of the quality of health care is essential for quality improvement, and patients are an underused source of data about quality of care. We describe the adaptation of a set of USA quality indicators for use in patient interview surveys in England, to measure the extent to which older patients receive a broad range of effective healthcare interventions in both primary and secondary care.

Method: One hundred and nineteen quality indicators covering 16 clinical areas, based on a set of indicators for the care of vulnerable elderly patients in the USA, were reviewed by a panel of 10 clinical experts in England. A modified version of the RAND/UCLA appropriateness method was used and panel members were supplied with literature reviews summarising the evidence base for each quality indicator. The indicators were sent for comment before the panel meeting to UK charitable organisations for older people.

Results: The panel rated 102 of the 119 indicators (86%) as valid for use in England; 17 (14%) were rejected as invalid. All 58 indicators about treatment or continuity and follow up were rated as valid compared with just over half (13 of 24) of the indicators about screening.

Conclusions: These 102 indicators are suitable for use in patient interview surveys, including the English Longitudinal Study of Ageing (ELSA). The systematic measurement of quality of care at the population level and identification of gaps in quality is essential for quality improvement. There is potential for transfer of quality indicators between countries, at least for the health care of older people.

     

Identifying subgroups of persons with multimorbidity based on their needs for care and support

Background

Health care-related harm is an internationally recognized threat to public health. The United Kingdom’s national health services demonstrate that upwards of 90% of health care encounters can be delivered in ambulatory settings. Other countries are transitioning to more family practice-based health care systems, and efforts to understand avoidable harm in these settings is needed.

Methods

We developed 100 scenarios reflecting a range of diseases and informed by the World Health Organization definition of ‘significant harm’. Scenarios included different types of patient safety incidents occurring by commission and omission, demonstrated variation in timeliness of intervention, and conditions where evidence-based guidelines are available or absent. We conducted a two-round RAND / UCLA Appropriateness Method consensus study with a panel of family practitioners in England to define “avoidable harm” within family practice. Panelists rated their perceptions of avoidability for each scenario. We ran a k-means cluster analysis of avoidability ratings.

Results

Panelists reached consensus for 95 out of 100 scenarios. The panel agreed avoidable harm occurs when a patient safety incident could have been probably, or totally, avoided by the timely intervention of a health care professional in family practice (e.g. investigations, treatment) and / or an administrative process (e.g. referrals, alerts in electronic health records, procedures for following up results) in accordance with accepted evidence-based practice and clinical governance. Fifty-four scenarios were deemed avoidable, whilst 31 scenarios were rated unavoidable and reflected outcomes deemed inevitable regardless of family practice intervention. Scenarios with low avoidability ratings (1 s or 2 s) were not represented by the categories that were used to generate scenarios, whereas scenarios with high avoidability ratings (7 s 8 s or 9 s) were represented by these a priori categories.

Discussion

The findings from this RAND/UCLA Appropriateness Method study define the characteristics and conditions that can be used to standardize measurement of outcomes for primary care patient safety.

Conclusion

We have developed a definition of avoidable harm that has potential for researchers and practitioners to apply across primary care settings, and bolster international efforts to design interventions to target avoidable patient safety incidents that cause the most significant harm to patients.

     

Quality standards for child and adolescent mental health in primary care

ABSTRACT: BACKGROUND: Child and adolescent mental health problems are common in primary healthcare settings. However, few parents of children with mental health problems express concerns about these problems during consultations. Based on parental views, we aimed to create quality of care measures for child and adolescent mental health in primary care and develop consensus about the importance of these quality standards within primary care. METHODS: Quality Standards were developed using an iterative approach involving four phases: 1) 34 parents with concerns about their child's emotional health or behaviour were recruited from a range of community settings including primary care practices to participate in focus group discussions, followed by validation groups or interviews. 2) Preliminary Quality Standards were generated that fully represented the parents' experiences and were refined following feedback from an expert parent nominal group. 3) 55 experts, including parents and representatives from voluntary organisations, across five panels participated in a modified two-stage Delphi study to develop consensus on the importance of the Quality Standards. The panels comprised general practitioners, other community-based professionals, child and adolescent psychiatrists, other child and adolescent mental health professionals and public health and policy specialists. 4) The final set of Quality Standards was piloted with 52 parents in primary care. RESULTS: In the Delphi process, all five panels agreed that 10 of 31 Quality Standards were important. Although four panels rated 25-27 statements as important, the general practitioner panel rated 12 as important. The final 10 Quality Standards reflected healthcare domains involving access, confidentiality for young people, practitioner knowledge, communication, continuity of care, and referral to other services. Parents in primary care agreed that all 10 statements were important. CONCLUSIONS: It is feasible to develop a set of Quality Standards to assess mental healthcare provision for children and adolescents seen within primary healthcare services. Primary care practitioners should be aware of parental perspectives about quality of care as these may influence helpseeking behaviours.