Online modified-Delphi Panels Research Articles

Expert Panel Consensus on Management of Advanced Cancer-related Pain in Individuals with Opioid Use Disorder

Develop consensus on the appropriateness of cancer pain management strategies in individuals with co-occurring advanced cancer and OUD. Three-round modified-Delphi process with two cases: patient with advanced cancer, pain and OUD treated with buprenorphine/naloxone or methadone. Participants rated management strategies in Round 1, discussed results in Round 2, and provided final responses in Round 3 in an online modified-Delphi panel. Participants included experts in palliative care, addiction, or both, recruited by email from palliative care and addiction-focused professional groups, lists from prior studies, and snowball sampling. Of 120 experts, the majority of whom held MD or DO degrees (115, 96%), 70% participated in all rounds. For a patient with OUD on buprenorphine/naloxone, it was deemed appropriate to continue buprenorphine/naloxone with three-times-per-day dosing. Continuing buprenorphine/naloxone and adding a full-agonist opioid was deemed appropriate for patients with a prognosis of weeks-months, and of uncertain appropriateness for a prognosis of months-years. For a patient with OUD on methadone dispensed at a methadone clinic, it was deemed appropriate to take over prescribing and dose 2-3x/day. Continuing methadone daily while adding another full-agonist opioid was deemed appropriate for patients with a prognosis of weeks-months and of uncertain appropriateness for a prognosis of months-years. This qualitative study, urgently needed, consensus-based guidance for clinicians, and highlighted critical research and policy gaps needed to facilitate implementation. Findings underscore the importance of additional research to investigate optimal dosing of buprenorphine/naloxone and methadone in patients with advanced cancer pain and OUD, and factors influencing the preferred choice. Grant support from the Cambia Health Foundation.

Improving Mental Health Guardianship: From Prevention to Treatment.

The authors sought to identify the most promising strategies for improving the mental health guardianship process in Los Angeles County for adults with mental illness who are gravely disabled. In May and June 2019, 56 experts, working in hospitals or outpatient facilities or representing legal, advocacy, policy, or forensic organizations, participated in an online modified-Delphi panel, rating the ethical appropriateness, impact on care quality, efficiency, and feasibility of nine strategies for improvement of mental health guardianship. Agreement was determined with the RAND/UCLA appropriateness method, and comments were thematically analyzed. The strategy ranked highest by the participating experts was improving the administrative functioning and judicial processes of entities involved in mental health guardianship proceedings-it was the only strategy that achieved agreement among panelists and was rated highly on all four criteria. Other preferred strategies were enhancing the ability of assertive outpatient mental health teams to serve individuals before they experience a crisis and expanding the continuum of unlocked residential treatment settings. Opportunities exist to improve all stages of the mental health guardianship process. Experts favored strategies that streamline administrative processes, facilitate community integration into treatment, and ensure fidelity to best practices. Improving the mental health guardianship process has the potential to speed up delivery of services, better manage resources, and increase access to treatment for individuals with mental illness who are gravely disabled.

Informing the Development of a Standardized Clinical Definition of Neonatal Abstinence Syndrome: Protocol for a Modified-Delphi Expert Panel.

BackgroundNeonatal abstinence syndrome (NAS) is a postnatal withdrawal syndrome that most commonly results from prenatal opioid exposure. Every 15 minutes, an infant is born in the United States with signs of NAS. The field lacks a standardized clinical definition of NAS, complicating discussions on programmatic and policy development to support opioid-exposed mothers and infants.ObjectiveThe goal of this paper is to describe a protocol for a systematic expert panel process to inform the development of a clinical definition of NAS.MethodsWe will conduct two three-round online modified-Delphi panels using the ExpertLens system and will follow the recommendations for Conducting and REporting of DElphi Studies (CREDES). One panel will focus on developing key components of a clinical definition of NAS, and the second panel will focus on neonatal opioid withdrawal syndrome (NOWS), which is a term that has come into use to differentiate opioid-exposed infants from infants exposed to other substances in utero. However, there is lack of agreement on the precise clinical definition of NOWS and how it is distinct from or overlaps with NAS. Each panel will complete two rating rounds and a discussion round using a similar protocol. We will analyze all rating data descriptively and determine the presence of agreement within and between the two panels. We will also perform thematic analysis of the qualitative comments to contextualize the panel findings.ResultsThe panels were convened between October 29 and December 17, 2020. Their results were disseminated and discussed at a national conference on NAS that took place on March 17-18, 2021.ConclusionsA standardized clinical definition of NAS will help to better characterize NAS incidence and to design effective clinical, public health, and policy interventions to support opioid-exposed mother-infant dyads.International Registered Report Identifier (IRRID)DERR1-10.2196/25387

Nature and Predictors of Response Changes in Modified-Delphi Panels.

To describe the extent and nature of changes in participants' responses after exposure to group feedback and discussion in modified-Delphi panels and to identify factors affecting those changes. We analyzed data from 2 online modified-Delphi panels, each consisting of 2 rating rounds and an online discussion round. We included responses from 55 participants who answered 38 questions in both rating rounds. Because not all participants answered each question twice, our sample consisted of 1846 cases (response changes). We used mixed-effect logistic and multinomial logistic regression to identify factors predicting response changes and their direction relative to group median-our consensus measure. Participants changed, on average, 49% of their responses. A response was changed in 47% of the 1846 cases: 28% of responses were changed toward consensus and 19% away from it. Although some measures of subjective participation experiences had a marginally significant impact on the propensity and direction of response changes, several objective measures of discussion engagement were statistically significant predictors of both the presence and direction of response changes. Our results illustrate the nature of response changes and highlight the importance of exposing participants to alternative perspectives and encouraging them to explain their perspectives.

Practical Considerations in Using Online Modified-Delphi Approaches to Engage Patients and Other Stakeholders in Clinical Practice Guideline Development.

Patients and caregivers are increasingly recognized as key stakeholders in developing clinical practice guidelines (CPGs). Online engagement approaches offer the promise of a rigorous, scalable, and convenient engagement method. This paper illustrates how an online modified-Delphi approach could be used to engage patients, caregivers, and other stakeholder in CPG development. It provides practical guidance for conducting online modified-Delphi panels that covers (1) joint development of the engagement approach with relevant stakeholders, (2) adaptation of methods used by experts in guideline development, (3) pilot testing, (4) participant recruitment, (5) determining panel size and composition, (6) building participant capacity, (7) facilitation of two-way interaction, (8) continuous engagement and retention of participants, (9) rigorous data analysis, (10) evaluation of engagement activities, and (11) result dissemination. The paper is based on a recently completed study about engaging individuals with Duchenne muscular dystrophy (DMD) and their caregivers in determining the patient-centeredness of DMD care guidelines.

Patient and caregiver perspectives on guideline adherence: the case of endocrine and bone health recommendations for Duchenne muscular dystrophy

BackgroundClinical care guidelines are typically developed by clinicians and researchers. Including patient and caregiver voices in guideline development may help create guidelines that are more useful for patients and consequently improve their guideline adherence. Although there is substantial research on the factors that affect providers’ adherence to guidelines, there is less research on the factors that affect patients’ compliance with guideline recommendations, especially among those with rare disorders.The purpose of this study is to explore factors that are likely to affect patient/caregiver adherence to endocrine and bone health recommendations for Duchenne Muscular Dystrophy (DMD). To do so, we used qualitative data collected as part of the study designed to develop, implement, and evaluate a new online, modified-Delphi approach to engaging patients with rare diseases and their caregivers in guideline development, using care guidelines for DMD as a case study.MethodsWe thematically analyzed qualitative data collected from 95 adults with DMD and their caregivers who participated in at least one round of our online modified-Delphi panel process. Participants rated and commented on the patient-centeredness of 19 recommendations about vertical growth, weight management, bone health, and delayed puberty included in the 2018 DMD care considerations. Patient-centeredness was operationalized as the importance and acceptability of care recommendations.ResultsThematic analyses revealed six factors that affect guideline adherence from the patient/caregiver perspective: content and format of recommendations, patient and provider characteristics, and social and financial factors.ConclusionsThis study used a novel approach to exploring patient and caregiver perspectives on factors that may affect guideline adherence. The six factors identified by DMD patients and caregivers are similar to the factors affecting provider adherence and are not limited to DMD. Understanding consistency between provider- and patient/caregiver-identified barriers to following guideline recommendations can lead to developing more successful interventions for increasing guideline adherence.

Lack of preregistered analysis plans allows unacceptable data mining for and selective reporting of consensus in Delphi studies

ObjectivesTo empirically demonstrate how undisclosed analytic flexibility provides substantial latitude for data mining and selective reporting of consensus in Delphi processes. Study Design and SettingPooling data across eight online modified-Delphi panels, we first calculated the percentage of items reaching consensus according to descriptive analysis procedures commonly used in health research but selected post hoc in this article. We then examined the variability of items reaching consensus across panels. ResultsPooling all panel data, the percentage of items reaching consensus ranged from 0% to 84%, depending on the analysis procedure. Comparing data across panels, variability in the percentage of items reaching consensus for each analysis procedure ranged from 0 (i.e., all panels had the same percentage of items reaching consensus for a given analysis procedure) to 83 (i.e., panels had a range of 11% to 94% of items reaching consensus for a given analysis procedure). Of 200 total panel-by-analysis-procedure configurations, four configurations (2%) had all items and 64 (32%) had no items reaching consensus. ConclusionUndisclosed analytic flexibility makes it unacceptably easy to data mine for and selectively report consensus in Delphi processes. As a solution, we recommend prospective, complete registration of preanalysis plans for consensus-oriented Delphi processes in health research.

Ethics and Science in the Participatory Era: A Vignette-Based Delphi Study.

Participatory researchers rely on relationship-based ethical considerations to address ethical challenges, but little is known about how these considerations shape day-to-day decision-making. We presented vignettes describing ethical dilemmas to health researchers with varying degrees of experience in participatory research in an online modified-Delphi panel. Panelists rated potential solutions to dilemmas and provided rationales for choosing solutions in text boxes and discussion boards. Panelists agreed on a preferred solution for three of five vignettes. Panelists indicated that ethical research decision-making should be inclusive of diverse perspectives. Panelists prioritized scientific goals above participatory ones and viewed tenets of scientific validity as value-free. Panelists indicated that participatory research ethics would be difficult to codify, but that vignette-based learning could support didactic objectives.

Development of Cardiovascular Quality Indicators for Rheumatoid Arthritis: Results from an International Expert Panel Using a Novel Online Process

Patients with rheumatoid arthritis (RA) have a high risk of premature cardiovascular disease (CVD). We developed CVD quality indicators (QI) for screening and use in rheumatology clinics. A systematic review was conducted of the literature on CVD risk reduction in RA and the general population. Based on the best practices identified from this review, a draft set of 12 candidate QI were presented to a Canadian panel of rheumatologists and cardiologists (n = 6) from 3 academic centers to achieve consensus on the QI specifications. The resulting 11 QI were then evaluated by an online modified-Delphi panel of multidisciplinary health professionals and patients (n = 43) to determine their relevance, validity, and feasibility in 3 rounds of online voting and threaded discussion using a modified RAND/University of California, Los Angeles Appropriateness Methodology. Response rates for the online panel were 86%. All 11 QI were rated as highly relevant, valid, and feasible (median rating ≥ 7 on a 1-9 scale), with no significant disagreement. The final QI set addresses the following themes: communication to primary care about increased CV risk in RA; CV risk assessment; defining smoking status and providing cessation counseling; screening and addressing hypertension, dyslipidemia, and diabetes; exercise recommendations; body mass index screening and lifestyle counseling; minimizing corticosteroid use; and communicating to patients at high risk of CVD about the risks/benefits of nonsteroidal antiinflammatory drugs. Eleven QI for CVD care in patients with RA have been developed and are rated as highly relevant, valid, and feasible by an international multidisciplinary panel.