Using the Delphi technique to identify the cancer education requirements of general practitioners

Continuing education for the general practitioner (GP) is in need of revision. Much of today's continuing education is based upon a traditional didactic approach, which is believed to be inappropriate and inefficient for the learning needs of the increasingly stretched GP. OBJECTIVE: To investigate the educational needs of a group of GPs, using the response to cancer to construct an appropriate model for the provision of care in general practice. METHOD: The Delphi technique was adopted to reach "expert" consensus. PARTICIPANTS: 49 GPs currently practising within two health authorities within the north-west region of England. DESIGN: Three waves of data collection were employed, with the same sample and the inclusion of an additional reference group. RESULTS: Many issues relating to the difficulties experienced by GPs regarding care of cancer patients were identified, along with associated training needs. Successive rounds of this Delphi survey enabled consensus to be reached about the level of importance to be assigned to these issues. This technique avoided some of the problems associated with a conventional committee approach (e.g. time, expense and potential bias in decision-making process). CONCLUSIONS: First, the Delphi technique provided a relatively quick means of gaining a consensus on the complex task set for participants. Second, continuing training for GPs would benefit from the adoption of a problem-based learning approach rather than traditional didactic methods.     

General practitioners’ perceptions of treatment of chronically ill patients managed in general practice: An interview study

BackgroundPatients with chronic conditions pose a major challenge to the Danish healthcare system. Since 2018, disease management programmes for patients with chronic obstructive pulmonary disease (COPD) and type 2 diabetes (T2D) were introduced in Denmark. Treatment in hospitals should be reserved for those patients who require specialised treatment. Hence, more patients with COPD and T2D fall within the general practitioners’ (GPs) responsibility.ObjectivesThis study explores GPs’ perceptions of their role as physicians responsible for the disease management programmes on COPD and T2D and their perceptions of the quality of care provided to these patient groups.MethodsBetween November 2019 and January 2020, we conducted semi-structured interviews with 14 GPs from the five regions of Denmark. We analysed the interviews using systematic text condensation inspired by Malterud’s thematic analysis.ResultsThe GPs stated that they have been managing the care of COPD and T2D patients for over a decade, and they considered the quality of care to be high. They believed that managing patient treatment pathways in general practice settings contributes to a heightened sense of security for the patient, mainly because of the long-standing and trusting relationship between the patient and GP.ConclusionAccording to the GPs, they continue to play an important role as treatment coordinators to ensure coherence and high quality in treating patients with COPD and type 2 diabetes.     

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.     

Shifting discourses of professionalism: a case study of general practitioners in the United Kingdom

This paper addresses shifting constructions of professional identity in the context of debates about reflexive modernisation and the changing role of professionals in the provision of primary healthcare. Data are drawn from interviews with 20 early-career general practitioners (GPs), who accounted for their orientations towards work in rather different ways from those typically reported in much primary care research. In particular, they reported high job satisfaction and success in achieving what they called 'nice work'. We argue that these GPs typify a shift in discourses of professionalism, characterised by respondents as the 'new general practice', which explicitly rejects many values attributed to 'traditional' general practice. Within the 'new general practice', professionalism has been de-coupled from some of the paradigmatic traits of traditional rhetorical accounts (such as vocation), and has significantly reframed others. Despite policy concerns that a retreat from 'vocational' professionalism will lead to reductions in service quality, we argue that this is not inevitable. The 'new general practice' resonates with the social values of reflexive modernisation, and has the potential to enable new, less paternalistic, forms of relationships with clients, although it remains to be seen whether this potential is realised in healthcare delivery.     

A Delphi study of occurring information in housing adaptation certificates

Background: Since 1993, the Housing Adaptation Act has provided disabled people the opportunity to receive grants for adapting their homes. A housing adaptation certificate certifying the necessity of adaptations must accompany any application and if information in housing adaptation certificates is not sufficient, the applicant is risking not having necessary housing adaptations.

Objective: The aim of this study was to identify and describe what information is missing, unnecessary or vague, in the housing adaptation certificates; to determine how often this occur, and how problematic this can be for the decision process.

Material and methods: 105 housing adaptation grant managers took part in a three-round Delphi survey.

Results: At least 65% consensus was reached regarding the following six statements: missing information about disability duration, possession of relevant assistive devices, consequences of the disability in housing, prognosis of consequences, who the informant is, or contains preferences for specific solutions. Missing, unnecessary or vague information pose serious or less serious problems and 38–72% of the participants reported that this often or always occur.

Conclusion: Housing adaptation certificates need to be improved.

Significance: The results of this study are used to design a checklist for use by housing adaptation certificate writers.     

Evaluating a primary care psychology service in Ireland: a survey of stakeholders and psychologists

Primary care psychology services (PCPS) represent an important resource in meeting the various health needs of our communities. This study evaluated the PCPS in a two‐county area within the Republic of Ireland. The objectives were to (i) examine the viewpoints of the service for both psychologists and stakeholders (healthcare professionals only) and (ii) examine the enactment of the stepped care model of service provision. Separate surveys were sent to primary care psychologists (n = 8), general practitioners (GPs; n = 69) and other stakeholders in the two counties. GPs and stakeholders were required to rate the current PCPS. The GP survey specifically examined referrals to the PCPS and service configuration, while the stakeholder survey also requested suggestions for future service provision. Psychologists were required to provide information regarding their workload, time spent on certain tasks and productivity ideas. Referral numbers, waiting lists and waiting times were also obtained. All 8 psychologists, 23 GPs (33% response rate) and 37 stakeholders (unknown response rate) responded. GPs and stakeholders reported access to the PCPS as a primary concern, with waiting times of up to 80 weeks in some areas. Service provision to children and adults was uneven between counties. A stepped care model of service provision was not observed. Access can be improved by further implementation of a stepped care service, developing a high‐throughput service for adults (based on a stepped care model), and employing a single waiting list for each county to ensure equal access.     

Delivering end-of-life care for patients with cancer at home: Interviews exploring the views and experiences of general practitioners

Many patients with terminal cancer wish to die at home and general practitioners in the United Kingdom have a critical role in providing this care. However, it has been suggested general practitioners lack confidence in end-of-life care. It is important to explore with general practitioners their experience and perspectives including feelings of confidence delivering end-of-life care to people with cancer. The aim of this study was to explore general practitioners experiences of providing end-of-life care for people with cancer in the home setting and their perceptions of confidence in this role as well as understanding implications this has on policy design. A qualitative study design was employed using semi-structured interviews and analysed using thematic analysis. Nineteen general practitioners from London were purposively sampled from eight general practices and a primary care university department in 2018–2019, supplemented with snowballing methods. Five main themes were constructed: (a) the subjective nature of defining palliative and end-of-life care; (b) importance of communication and managing expectations; (c) complexity in prescribing; (d) challenging nature of delivering end-of-life care; (e) the unclear role of primary care in palliative care. General practitioners viewed end-of-life care as challenging; specific difficulties surrounded communication and prescribing. These challenges coupled with a poorly defined role created a spread in perceived confidence. Experience and exposure were seen as enabling confidence. Specialist palliative care service expansion had important implications on deskilling of essential competencies and reducing confidence levels in general practitioners. This feeds into a complex cycle of causation, leading to further delegation of care.     

英国初级卫生保健制度及其信息化建设初探

重点介绍英国在卫生服务提供、卫生筹资、资源调配、制度建设等方面的基本做法和工作特点,以及英国卫生信息化管理建设的机构与投入情况,分析信息化在支撑医疗保健服务绩效管理、全科医生服务质量控制、全科医生均质化培养、信息便民服务等方面发挥的重要作用,为了解、借鉴英国卫生制度提供有益的参考.     

Delphi法在筛选眼科手术准入评价指标中的应用

目的 建立眼科手术准入评价指标体系,为规范眼科手术准人提供依据.方法 采用Delphi法对14名眼科专家进行两轮问卷调查,听取专家的意见和建议,筛选评价指标.结果 专家的平均年龄为42岁,全部具有副高以上职称,平均工作年限为20.8年;两轮咨句问卷回收率为93.33%,专家平均权威系数为0.78;确立了9项眼科手术准入指标体系;两轮咨询后,专家协调系数为0.521,差异具有显著意义（P＜0.01）.结论 眼科手术准入评价指标体系可信程度较高,具有从多方面对眼科手术准入实施量化评价、对眼科手术准入的医生要求更高、患者参与对眼科手术准入的评价等特点,可为科学合理评价眼科手术准入提供辅助决策支持.     

Consensus views on advance care planning for dementia: a Delphi study

The uptake of advance care planning (ACP) is particularly low among people with dementia. This may reflect barriers to communication between professionals, patients and families in the face of lack of consensus about the process. This study aimed to methodically investigate consensus views of how ACP should be explained and carried out with people with dementia. A three‐round Delphi study explored views of how and when ACP should be addressed, what should be covered, who should be involved and why rates of ACP are low. Seventeen participants took part comprising family members, old age psychiatrists and policy makers. Thirty‐two items reached consensus. The panel agreed on 11 different areas for discussion. They concurred that ACP was best addressed after the person has come to terms with the diagnosis when the individual feels ready to do so. There was a consensus view that the process should be couched in terms of ‘certain possibilities’. Consensus items emphasised personal choice and autonomy, while also prioritising the need to discuss financial aspects and to include spouses. There was no consensus that professionals should be involved, although the panel viewed them as carrying some responsibility for low uptake. It is suggested that ACP should include general discussion of values as well as coverage of specific points. Professionals need to offer discussion and information on ACP, but also make clear that the patient has the right to choose whether to pursue ACP or not.     

More than technology and access: primary care patients' views on the use and non-use of health information in the Internet age

Over the past decade, there has been considerable interest in the transmission of health information made available though the Internet with increasing confidence being placed in the potential power of the Internet to transform communication, clinical practice and relationships with patients. Subsequent to the failure of a primary‐care‐based initiative designed to provide free assistance and access to health information via the Internet, a survey was conducted. Findings from this survey suggested that facilitating access to e‐information is necessary, but not in itself sufficient, to encourage current non‐users to start exploring the Internet. The qualitative study reported here was aimed at exploring the way in which people use and perceive the utility of Internet information for managing health and illness and engaging with the health service system. Data was gathered from two sources. Interviews and observations of a sample who had used a free primary‐care‐based Internet service (n = 5) and interviews with a sample drawn from a survey of patient attitudes to using the Internet for health information (n = 12). The less‐considered aspects of access and the use of e‐information for health matters related to the varied existing relationships respondents had to computers, health information and health professionals. One of the main reasons why some respondents do not use the Internet to access health information is related to a lack of perceived utility and pertinence of such information for managing their healthcare. The optimal and equitable use of the Internet as a means of complimenting health‐service utilisation will not emerge merely from increasing access to e‐information. The potential for narrowing or increasing inequality between the information rich and poor needs to be viewed in a broader psychosocial context. The latter includes the nature of existing relationships which people have with the health service and the value that people place on their own capacity to make use of information in managing their healthcare.     

Development of a pediatric Lyme meningitis symptom measurement instrument using a Delphi technique

Published Lyme meningitis treatment studies are limited by outcome measures that cannot capture day-to-day differences in clinical improvement. Our goal was to use expert consensus to develop a daily measurement instrument for assessing clinical improvement in children with Lyme meningitis. We assembled a panel of 24 nationally recognized Lyme disease experts to develop a pediatric daily symptom measurement instrument. Experts responded to four rounds of surveys, receiving feedback about the previous round prior to each subsequent round with anonymity for participants and responses. Using modified Delphi methods, we established a novel Lyme meningitis outcome instrument. The final Pediatric Lyme Meningitis Symptom Measurement instrument includes five items: headache (Likert scale), neck pain/stiffness (Likert scale), fever (yes/no), light sensitivity (yes/no) and vision problems (yes/no). We defined three consecutive days with a symptom score of zero as the minimum to define clinical improvement. Using expert consensus, we developed a novel Pediatric Lyme Meningitis Symptom Measurement instrument to measure treatment response daily for children with Lyme meningitis enrolled in clinical studies.     

GPs' perceptions of the role of DEXA scanning: an exploratory study

BACKGROUND: Current recommendation are that women with clinical indicators of low bone mineral density should be offered a DEXA (dual energy X-ray absorptiometer) scan to help assess the need for treatment, but little is known about GPs' attitudes towards DEXA scans. OBJECTIVE: Our aim was to explore GPs' beliefs about diagnosis and management of osteoporosis, including the role that DEXA scanning can play. METHODS: Semi-structured interviews with five GPs in the North Staffordshire area were used to explore how GPs make decisions about diagnosis and treatment of osteoporosis, including the use of scans and the application of potential clinical risk factors to decisions about screening and treatment. RESULTS: The decision-making process about whether and who to scan is complex and was influenced by a range of factors including issues of diagnosis, treatment, patient pressure and 'external' factors such as practice protocol and the perceived local availability of scans. CONCLUSIONS: GPs found it difficult to decide who and when to scan despite guidelines for primary care. Perceived local availability of DEXA scans is important and has implications for raising awareness.     

应用德尔菲法构建健康学校评价指标体系

应用德尔菲法构建健康学校建设评价指标体系,为采用有效手段推动健康学校建设提供参考依据.方法 通过头脑风暴法和专题讨论,形成指标体系框架;通过2轮专家咨询、层次分析法计算评估体系中各级指标权重,确定健康学校建设评价指标体系.结果 15名专家参与德尔菲咨询,2轮均收回15份有效资料.专家权威系数为0.825,2轮指标的变异系数均<0.30;一级指标和二级指标的专家协调系数分别为0.540和0.597,专家协调系数均有统计学意义(P值均<0.01).初步确定的健康学校建设评价指标体系由4个一级指标,8个二级指标和35个三级指标组成.结论 初步建立较完备的健康学校建设评价指标体系.该体系结构稳定,专家意见比较协调,涵盖健康学校建设的主要因素.     

To support and not to cure: general practitioner management of loneliness

Loneliness is associated with numerous detrimental effects on physical health, mental health, cognition and lifestyle. Older adults are one of the groups at highest risk of loneliness, and indeed about 46% of older adults in England feel lonely. Those experiencing loneliness visit their general practitioner (GP) more frequently than those who are not, which has the capacity to put a strain on GPs and primary care waiting lists and costs. This study's aim was to explore GPs' views and experiences of loneliness within their older adult patients, and to understand GPs' awareness and feelings of agency within this. Nineteen UK GPs were recruited using purposive sampling and snowballing techniques. Individual semi‐structured interviews were conducted either in person or over the telephone. Data were analysed using thematic analysis. Four overarching themes were identified from the data: Whose responsibility is it anyway?, Pandora's box of shame; Keeping distance; and Community responsibility. Themes emphasise that GPs tend to hold a medicalised and individualistic view of loneliness. This intensifies stigma which in turn creates barriers to raising the topic. GPs felt powerless in their ability to fix the ‘problem’ and tended to believe that the solution had to lie in the community, the individual or in social care rather than in primary care. The findings are discussed in the context of literature on GP management of other social problems which give rise to similar issues concerning the restrictions of the medical model and the need for joined‐up approaches in which the GP is one part of a wider social support structure. It is suggested that it might be useful for training and support for GPs to address management of social problems jointly rather than training specific to loneliness which GPs tend to see as peripheral to their core remit.     

Delphi法在全人全程传染病电子健康档案设计中的应用

目的应用Delphi法筛选全人全程传染病电子健康档案的主要指标。方法采用Delphi法对30名专家进行问卷调查。选择的专家涉及公共卫生、全科医学、健康教育和社区卫生管理等方面。结果专家权威系数为o．85,问卷回收率90．00％,咨询的可靠性高。指标的重要性协调系数分别为0．426、0．538和0．625,必需性协调系数分别为0,442、0．574和0．592,可获得性协调系数分别为0．558、0．551和0．620,统计学检验P值均〈0．0l,专家意见协调性较好,预测结果可取。根据指标的均数、变异系数和协调系数结合研究小组讨论意见,共筛选出呼吸道传染病（流感,）档案42个一级指标,20个二级指标,6个三级指标。结论应用Delphi法筛选全人全程传染病电子健康档案内容是科学有效的。