Identification of features of electronic prescribing systems to support quality and safety in primary care using a modified Delphi process

Background  

Electronic prescribing is increasingly being used in primary care and in hospitals. Studies on the effects of e-prescribing systems have found evidence for both benefit and harm. The aim of this study was to identify features of e-prescribing software systems that support patient safety and quality of care and that are useful to the clinician and the patient, with a focus on improving the quality use of medicines.     

Priority-setting and feasibility of health information exchange for primary care patients with intellectual disabilities: A modified Delphi study

ObjectiveAccurate health information exchange (HIE) is fragile in healthcare for patients with intellectual disabilities (ID), threatening the health outcomes for this patient group. In conjunction with a group of experts, we aimed to identify the principal actions and organisational factors facilitating HIE for primary care patients with ID and to assess their perceived feasibility in daily practice.MethodsWe conducted a two-round modified Delphi study with Dutch GPs (n = 22), support workers (n = 18) and ID physicians (n = 20). In an extensive set of 61 items covering actions and organisational factors, experts ranked items in order of importance and rated their feasibility.ResultsAgreement was reached on the importance of 22 actions and eight organisational factors, of which 82% were deemed (very) feasible in daily practice. Experts stressed the importance of listed actions and factors being implemented simultaneously and remarked that further priority should be based on contextual demands.Conclusion and practice implicationsThis study indicates the principal actions and organisational factors for HIE regarding primary care patients with ID. The set can be used as a practical guide to optimise inter-professional cooperation and arrange the distribution of HIE roles and responsibilities in relation to this patient group.     

Development of a food allergy education resource for primary care physicians

Background  

Food allergy is estimated to affect 3–4% of adults in the US, but there are limited educational resources for primary care physicians. The goal of this study was to develop and pilot a food allergy educational resource based upon a needs survey of non-allergist healthcare providers.     

Increasing the options for reducing adverse events: Results from a modified Delphi technique

Background

The aim of this paper is to illustrate a simple method for increasing the range of possible options for reducing adverse events in Australian hospitals, which could have been, but was not, adopted in the wake of the landmark 1995 'Quality in Australian Health Care' study, and to report the suggestions and the estimated lapse time before they would impact upon mortality and morbidity.

Method

The study used a modified Delphi technique that first elicited options for reducing adverse events from an invited panel selected on the basis of their knowledge of the area of adverse events and quality assurance. Initial suggestions were collated and returned to them for re-consideration and comment.

Results

Completed responses from both stages were obtained from 20 of those initially approached. Forty-one options for reducing AEs were identified with an average lapse time of 3.5 years. Hospital regulation had the least delay (2.4 years) and out of hospital information the greatest (6.4 years).

Conclusion

Following identification of the magnitude of the problem of adverse events in the 'Quality in Australian Health Care' study a more rapid and broad ranging response was possible than occurred. Apparently viable options for reducing adverse events and associated mortality and morbidity remain unexploited.

     

Recommendations for the allergy management in the primary care

The majority of patients seeking medical advice for allergic diseases are first seen in a primary care setting. Correct diagnosis with identification of all offending allergens is an absolute prerequisite for appropriate management of allergic disease by the general practitioner. Allergy diagnostic tests recommended for use in primary care are critically reviewed in accordance with the significant workload in a primary care setting. Simplified pathways for recognition and diagnosis of allergic diseases are proposed, that should be further adapted to local (national) conditions.     

Results of an allergy educational needs questionnaire for primary care

It is well recognized that knowledge of allergic conditions is suboptimal in primary care. The Primary Care Interest Group of the European Academy of Allergy and Clinical Immunology undertook an educational needs survey to better understand what they were and how best to meet them, in the primary care environment. An electronic questionnaire was devised and distributed as widely as possible. A total of 2226 people from 63 countries opened the e‐questionnaire of which 692 provided evaluable responses. In total, 81% were medical doctors with 299 possessing additional qualifications. Self‐declared gaps in knowledge were expressed for most manifestations of allergy with a correspondingly high self‐expressed educational need. The preferred learning modalities were online guidelines (69.6%) and courses (68.8%) followed closely by workshops (68%), structured online modules (63.9%) and small local working groups (59.75%). Podcasts and webinars scored poorly with only 25% expressing these as preferred learning modes although there was an age gradient. The preferred electronic platform was the personal computer (82.6%). A better understanding of the needs of primary care should help guide the design of educational initiatives to meet those needs.     

Development of a heat-illness screening instrument using the Delphi panel technique

Context:

Exertional heat illness (EHI) is the third leading cause of death among athletes, but with preparticipation screening, risk factors can be identified, and some EHIs can be prevented.

Objective:

To establish content validity of the Heat Illness Index Score (HIIS), a 10-item screening instrument designed to identify athletes at risk for EHI during a preparticipation examination.

Design:

Delphi study.

Setting:

The Delphi technique included semistructured face-to-face or telephone interviews and included electronic questionnaires administered via e-mail.

Patients or Other Participants:

Six individuals with extensive research experience and/or clinical expertise in EHI participated as expert panelists.

Main Outcome Measure(s):

We used a Delphi panel technique (3 rounds) to evaluate the HIIS with the consensus of expert opinions. For round 1, we conducted face-to-face interviews with the panelists. For round 2, we solicited panelists'' feedback of the transcribed data to ensure trustworthiness, then provided the participants with the revised HIIS and a questionnaire eliciting their levels of agreement for each revision from the previous round on a visual analog scale (11.4 cm) with extreme indicators of strongly disagree and strongly agree. We calculated the mean and SD for each revision and accepted when the mean was greater than 7.6 cm (agree) and the SD still permitted a positive response (>5.7 cm), suggesting consensus. For round 3, we instructed participants to indicate their levels of agreement with each final, revised item and their levels of agreement with the entire instrument on a 4-point Likert scale (1 = strongly disagree, 4 = strongly agree).

Results:

In round 1, panelists supported all 10 items but requested various revisions. In round 2, 16.3% (7 of 43) revisions were rejected, and 2 revisions were modified. In round 3, 100% of panelists reported agreeing (n = 3 of 6) or strongly agreeing (n = 3 of 6) with the final instrument.

Conclusions:

Panelists were able to achieve consensus and validated the content of the HIIS, as well as the instrument itself. Implementation and further analysis are necessary to effectively identify the diagnostic accuracy of the HIIS.     

Priorities for understanding and managing occupational allergy: a Delphi Consensus*

Limiting factors in the understanding, clinical management, and prevention of occupationally related allergic disease should be identified, since these dictate the tasks that need to be undertaken and/or important research questions that warrant an answer. Through an adaptation of the Delphi technique, a working group of the Special Interest Group on Occupational Allergy of the British Society of Allergy and Clinical Immunology addressed these issues. The consensus categorized and ranked the limiting factors and tasks needed in relation to epidemiology and natural history, mechanisms, clinical diagnosis, statute and education, and the workplace environment. This report should help focus the debate regarding which issues are perceived to be most relevant and timely for research and good practice in the field of occupational allergy.     

Pediatric appointment keeping: improving adherence in a primary care allergy clinic

We evaluated the effects of introducing and discontinuing an intervention designed to improve adherence with scheduled appointments in a pediatric allergy clinic. Five nonadherent and three adherent patients received reminders and incentives for keeping their scheduled appointments. Adherence with appointments increased for three of the five nonadherent children, who had an average increase of 13%, and adherent patients continued to keep appointments during the intervention condition. After 10 scheduled allergy clinic appointments had been kept, incentives were discontinued while reminders continued. Improvements in adherence were not maintained after incentives were discontinued and two children showed reductions in adherence to below-baseline levels. Incentive programs increase appointment keeping, but discontinuing incentives abruptly may result in the return of nonadherence, even when reminders are provided as a maintenance strategy. Future pediatric psychology research and practice should investigate both the benefits and limitations of strategies designed to improve adherence.     

Critical items for assessing risk of lung and colorectal cancer in primary care: a Delphi study

Background

Patients with lung or colorectal cancer often present late and have a poor prognosis. Identifying diagnostic indicators to optimally assess the risk of these cancers in primary care would support early identification and timely referral for patients at increased risk.

Aim

To obtain consensus regarding potential diagnostic indicators that are important for assessing the risk of lung or colorectal cancer in primary care consulters presenting with lung or abdominal symptoms.

Design and setting

A Delphi study was conducted with 28 participants from primary and secondary care and academic settings in the UK and Europe.

Method

Indicators were obtained from systematic reviews, recent primary studies and consultation with experts prior to the Delphi study being conducted. Over three rounds, participants rated each diagnostic indicator in terms of its importance, ranked them in order of importance, and rated each item as crucial or not crucial to assess during a GP consultation.

Results

The final round resulted in 25 items remaining for each type of cancer, including established cancer symptoms such as rectal bleeding for colorectal cancer and haemoptysis for lung cancer, but also less frequently used indicators such as patients’ concerns about cancer.

Conclusion

This study highlights the items clinicians feel would be most crucial to include in the clinical assessment of primary care patients, a number of which have rarely been noted in the previous literature. Their importance in assessing the risk of lung or colorectal cancer will be tested as part of a large prospective cohort study (CANDID).     

CAM therapies among primary care patients using opioid therapy for chronic pain

Background  

Complementary and alternative medicine (CAM) is an increasingly common therapy used to treat chronic pain syndromes. However; there is limited information on the utilization and efficacy of CAM therapy in primary care patients receiving long-term opioid therapy.     

Advance care planning for cancer patients in primary care: a feasibility study

Background

Advance care planning is being promoted as a central component of end-of-life policies in many developed countries, but there is concern that professionals find its implementation challenging.

Aim

To assess the feasibility of implementing advance care planning in UK primary care.

Design of study

Mixed methods evaluation of a pilot educational intervention.

Setting

Four general practices in south-east Scotland.

Method

Interviews with 20 GPs and eight community nurses before and after a practice-based workshop; this was followed by telephone interviews with nine other GPs with a special interest in palliative care from across the UK.

Results

End-of-life care planning for patients typically starts as an urgent response to clear evidence of a short prognosis, and aims to achieve a ‘good death’. Findings suggest that there were multiple barriers to earlier planning: prognostic uncertainty; limited collaboration with secondary care; a desire to maintain hope; and resistance to any kind of ‘tick-box’ approach. Following the workshop, participants'' knowledge and skills were enhanced but there was little evidence of more proactive planning. GPs from other parts of the UK described confusion over terminology and were concerned about the difficulties of implementing inflexible, policy-driven care.

Conclusion

A clear divide was found between UK policy directives and delivery of end-of-life care in the community that educational interventions targeting primary care professionals are unlikely to address. Advance care planning has the potential to promote autonomy and shared decision making about end-of-life care, but this will require a significant shift in attitudes.     

Clinical subtypes of core premenstrual disorders: a Delphi survey

The purpose of this study was to classify the clinical subtypes of core premenstrual disorders during the International Society for Premenstrual Disorders’ second consensus meeting. Multiple iterations were used to achieve consensus between a group of experts; these iterations included a two-generational Delphi technique that was preceded and followed by open group discussions. The first round was to generate a list of all potential clinical subtypes, which were subsequently prioritized using a Delphi methodology and then finalised in a final round of open discussion. On a six-point scale, 4 of the 12 potential clinical subtypes had a mean score of ≥5.0 following the second iteration and only 3 of the 4 still had a mean score of ≥5.0 after the third iteration. The final list consisted of these three subtypes and an additional subtype, which was introduced and agreed upon, in the final iteration. There is consensus amongst experts that core premenstrual disorder is divided into three symptom-based subtypes: predominantly physical, predominantly psychological and mixed. A proportion of psychological and mixed subtypes may meet the DSM-IV diagnostic criteria for premenstrual dysphoric disorder.     

Evaluating primary practice: proposals for a modified model suited to chiropractic care.

Although chiropractic care is not yet considered to have achieved scientific validity, it enjoys widespread public acceptance. It is hypothesised that one of the barriers to chiropractic establishing scientific validity is the propensity of researchers to frame their randomized controlled clinical trials according to a biomedical rather than a biopsychosocial model. It is proposed that while chiropractic care should be required to establish a cause--effect relationship between spinal manipulation and clinical response, subjective patient--valued outcomes should also be monitored. For chiropractic care to be adequately assessed recognition needs to be given to the usefulness of qualitative measurements in health care. Interventions selected solely upon the basis of statistical significance run the risk of overlooking clinically meaningful outcomes.     

Cell mediated lympholysis; a modified technique using indium-oxine-labelled targets

The isotope ⁵¹Cr generally used in the cell mediated lympholysis (CML) assay suffers from the disadvantage of low specific activity, poor incorporation and high spontaneous release, limiting the CML assay to 4–6 h. We have labelled PHA derived human lymphoblasts with the isotope ¹¹¹indium (using ¹¹¹indium-oxine) and evaluated these cells as targets in CML. The level of ¹¹¹In-oxine incorporation decreased rapidly in the presence of serum; in the absence of serum approximately 85% of the available isotope in the supernatant was incorporated into the blasts. Under the labelling conditions used, spontaneous release was 1.6–2%/h on average allowing an effector phase of 18 h. About 5–8% of the released isotope was reutilized by the effector cells during an 18 h incubation period. Extending the CML assay from 6 to 18 h greatly increased the cytotoxicity. At an effector to target ratio of 25:1, the average per cent specific release increased from 15 to 50%. The use of ¹¹¹In-oxine labelled targets in the CML therefore increases the sensitivity of the test and allows fewer effector and target cells to be used as compared with ⁵¹Cr techniques.     

Improving allergy management in the primary care network – a holistic approach

The incidence, prevalence and costs of allergy have increased substantially in recent decades in many parts of Europe. The dominant model of allergy care within Europe is at the moment specialist‐based. This model will become unsustainable and undeliverable with increasing disease prevalence. One solution to increase provision of allergy services is to diversify the providers. A new model for the provision of allergy care in the community with the general practitioner at the forefront is proposed. Pre‐ and postgraduate allergy education and training, implementation of pathways of care, allergy specialization and political will to generate resources and support are essential to achieve this new model. In parallel the holistic view of allergic diseases should be maintained, including assessment of severity and risk, psychological factors and health‐care related costs in the context of the patient‐centered decision making process.     

Clinical features of kidney cancer in primary care: a case-control study using primary care records

Background

Kidney cancer accounts for over 4000 UK deaths annually, and is one of the cancer sites with a poor mortality record compared with Europe.

Aim

To identify and quantify all clinical features of kidney cancer in primary care.

Design

Case-control study, using General Practice Research Database records.

Method

A total of 3149 patients aged ≥40 years, diagnosed with kidney cancer between 2000 and 2009, and 14 091 age, sex and practice-matched controls, were selected. Clinical features associated with kidney cancer were identified, and analysed using conditional logistic regression. Positive predictive values for features of kidney cancer were estimated.

Results

Cases consulted more frequently than controls in the year before diagnosis: median 16 consultations (interquartile range 10–25) versus 8 (4–15): P<0.001. Fifteen features were independently associated with kidney cancer: visible haematuria, odds ratio 37 (95% confidence interval [CI] = 28 to 49), abdominal pain 2.8 (95% CI = 2.4 to 3.4), microcytosis 2.6 (95% CI = 1.9 to 3.4), raised inflammatory markers 2.4 (95% CI = 2.1 to 2.8), thrombocytosis 2.2 (95% CI = 1.7 to 2.7), low haemoglobin 1.9 (95% CI = 1.6 to 2.2), urinary tract infection 1.8 (95% CI = 1.5 to 2.1), nausea 1.8 (95% CI = 1.4 to 2.3), raised creatinine 1.7 (95% CI = 1.5 to 2.0), leukocytosis 1.5 (95% CI = 1.2 to 1.9), fatigue 1.5 (95% CI = 1.2 to 1.9), constipation 1.4 (95% CI = 1.1 to 1.7), back pain 1.4 (95% CI = 1.2 to 1.7), abnormal liver function 1.3 (95% CI = 1.2 to 1.5), and raised blood sugar 1.2 (95% CI = 1.1 to 1.4). The positive predictive value for visible haematuria in patients aged ≥60 years was 1.0% (95% CI = 0.8 to 1.3).

Conclusion

Visible haematuria is the commonest and most powerful single predictor of kidney cancer, and the risk rises when additional symptoms are present. When considered alongside the risk of bladder cancer, the overall risk of urinary tract cancer from haematuria warrants referral.