Delphi methodology in healthcare research: How to decide its appropriateness

Practice recommendations for culturally sensitive communication at the end of life in intensive care: A modified eDelphi study

BACKGROUND

Clinicians need specific knowledge and skills to effectively communicate with patients and their family when a patient is dying in the ICU. End-of-life communication is compounded by language differences and diverse cultural and religious beliefs.

AIM

The aim was to develop and evaluate practice recommendations for culturally sensitive communication at the end of life.

METHOD

Modified two-round eDelphi study. An Australian national sample of 58 expert ICU clinicians of nursing and medical backgrounds participated in an online survey to rate the relevance of 13 practice recommendations. Ten clinicians participated in a subsequent expert panel interview to provide face validity and comprehensive details about the practical context of the recommendations. Survey data were analysed using descriptive statistics, interview data using deductive content analysis.

RESULTS

All 13 practice recommendations achieved item content validity index (I-CVI) above 0.8, and scale content validity index (S-CVI) of 0.95, indicating sufficient consensus. Recommendations prioritising use of professional interpreters and nurse involvement in family meetings achieved near perfect agreement amongst participants. Recommendations to facilitate family in undertaking cultural, spiritual and religious rituals and customs, advocate for family participation in treatment limitation discussions, and clinician access to professional development opportunities about culturally sensitive communication also achieved high level consensus.

CONCLUSION

These practice recommendations provide guidance for ICU clinicians in their communication with patients and families from culturally diverse backgrounds.

IMPLICATIONS FOR CLINICAL PRACTICE

Clinicians want practice recommendations that are understandable and broadly applicable across diverse ICU contexts. The high consensus scores confirm these practice recommendations are relevant and feasible to clinicians who provide end-of-life care for patients and their family members. The recommendations also provide clear guidance for ICU leaders, managers and organisational policy makers.

Global emergency medicine research priorities: a mapping review

Recognizing and prioritizing research areas in emergency care is crucial for generating evidence and advancing research programs, aiming to enhance health outcomes for both individuals and populations. The objective of this review is to document global clinical and nonclinical research priorities. The Emergency Medicine Education and Research by Global Experts network, consisting of 22 sites across six continents, conducted a mapping review of publications on emergency medicine research priorities (2000-2022) across seven databases. We included studies with replicable methodologies for determining research priorities, excluding those limited to individual diseases. Three reviewers independently screened, selected, and categorized results into clinical and nonclinical topics. Discrepancies were resolved by an independent investigator and consensus. Outcomes measures and analysis include descriptive analysis of research priorities grouped into clinical and nonclinical topics, characteristics of publications including countries represented in the author list, target audience (such as researchers or policy makers), participants (e.g. patients), and methods (e.g. Delphi) of priority setting. Among 968 screened papers, 57 publications from all WHO regions were included. Most (36, 63%) had authors from only a single country, primarily in North America and Europe. Patient representatives were included in only 10 (18%). Clinical research priorities clustered into resuscitation, cardiology, central nervous system, emergency medical services, infectious disease, mental health, respiratory disease, and trauma. Distribution was broad in North America and Europe but focused on infectious diseases and resuscitation in Africa and Asia. Eleven nonclinical topics included access to care, health policy, screening/triage, social determinants of health, staffing, technology/simulation, shared decision making, cross-sectoral collaboration, education, patient-centered care, and research networks. Nonclinical topics were broad in Europe and America, focused on access to care and health screening in Africa, and mostly absent in other WHO regions. Published research priorities in emergency medicine are heterogeneous and geographically limited, mostly containing groups of authors from the same country. The majority of publications in global research priority setting stem from Western countries, covering a broad spectrum of clinical and nonclinical topics. Research priorities from Africa and Asia tend to focus on specific issues more prevalent in those regions of the world.

Sleep for infants after discharge from a neonatal ward: Expert- and parent endorsed strategies

BACKGROUND

This study aims to outline sleep strategies grounded in scientific research and endorsed by sleep experts, integrating parental input into the evaluation process, to assist parents in supporting infant sleep after discharge from a neonatal ward.

METHODS

A Delphi method, consisting of three rounds, was employed. Sleep strategies based on scientific literature were presented to sleep experts and parents of infants discharged from a neonatal ward.

RESULTS

A literature search identified 11 sleep strategies. These strategies were incorporated in Delphi round 1. Out of 17 sleep experts, 13 reviewed and revised these 11 sleep strategies, resulting in a list of 8 sleep strategies. In round 2, these strategies were ranked by 14 out of 17 sleep experts, with "knowledge gathering" being ranked the most important sleep strategy. In round 3, the same list of 8 sleep strategies was ranked by 35 parents. They found "sleep hygiene" and "swaddling" the most important strategies.

CONCLUSION

This study offers 8 sleep strategies that are grounded in scientific research, supported by experts, and evaluated by parents. Experts and parents prioritize sleep strategies differently. Therefore, healthcare professionals should offer practical and customized sleep strategies that align with the unique needs of each family.

IMPACT

Experts and parents prioritize sleep strategies differently. This study offers a summary of sleep strategies that are grounded in scientific research, supported by experts, and include parental feedback in the evaluation process. Healthcare professionals can use these strategies to offer practical and customized sleep advise that aligns with the unique needs of each family.

UK Defence Rehabilitation consensus agreement for the conservative management of Achilles and patellar tendinopathy: a modified Delphi approach

Achilles and patellar tendinopathy are common in military personnel due to the repetitive high loads and challenging extrinsic risk factors associated with the demands of their role. Sports medicine is rapidly evolving. Up-to-date evidence-based research is essential, alongside clinical reasoning, to deliver best-practice treatment to service personnel, underpinned by the duty of care to their long-term career.The aim of this research was to develop recommendations on conservative management of Achilles and patellar tendinopathy in relation to the military population. A systematic review was conducted by a multidisciplinary clinical panel from across Defence Rehabilitation. The panel was split into four subgroups (diagnosis and outcome measures, medical, exercise and adjuncts). Each subgroup proposed recommendations for voting across the wider authorship in a modified Delphi process. 28 recommendations achieved substantial agreement following a chaired meeting attended by all authors. A summary infographic was produced to highlight themes relevant to the military patient population.Diagnosis of Achilles and patellar tendinopathy remains clinical. The consensus panel strongly advocates exercise rehabilitation as the primary management of Achilles and patellar tendinopathy. Medical interventions should respect the long-term occupational needs of the military population. Education is advised, but further adjunctive interventions should only be considered on a case-by-case basis. This consensus agreement provides a framework for the development of local guidelines for the management of Achilles and patellar tendinopathy in the UK military population.

How Delphi studies in the health sciences find consensus: a scoping review

BACKGROUND

Delphi studies are primarily used in the health sciences to find consensus. They inform clinical practice and influence structures, processes, and framework conditions of healthcare. The practical research-how Delphi studies are conducted-has seldom been discussed methodologically or documented systematically. The aim of this scoping review is to fill this research gap and to identify shortcomings in the methodological presentation in the literature. On the basis of the analysis, we derive recommendations for the quality-assured implementation of Delphi studies.

METHODS

Forming the basis of this scoping review are publications on consensus Delphi studies in the health sciences between January 1, 2018, and April 21, 2021, in the databases Scopus, MEDLINE via PubMed, CINAHL, and Epistemonikos. Included were publications in German and English containing the words "Delphi" in the title and "health" and "consensus" in the title or abstract. The practical research was analyzed for the qualitative content of the publications according to three deductive main categories, to which an influence on the result of Delphi studies can be imputed (expert panel, questionnaire design, process and feedback design).

RESULTS

A total of 287 consensus Delphi studies were included in the review, whereby 43% reported having carried out a modified Delphi. In most cases, heterogeneous expert groups from research, clinical practice, health economics, and health policy were surveyed. In about a quarter of the Delphi studies, affected parties, such as patients, were part of the expert panel. In the Delphi questionnaires it was most common for standardized Likert scales to be combined with open-ended questions. Which method was used to analyze the open-ended responses was not reported in 62% of the Delphi studies. Consensus is largely (81%) defined as percentage agreement.

CONCLUSIONS

The results show considerable differences in how Delphi studies are carried out, making assessments and comparisons between them difficult. Sometimes an approach points to unintended effects, or biases in the individual judgments of the respondents and, thus, in the overall results of Delphi studies. For this reason, we extrapolate suggestions for how certain comparability and quality assurance can be achieved for Delphi studies.

Charting the path to the implementation of universal health coverage policy in Nigeria through the lens of Delphi methodology

BACKGROUND

Expanding access to equitable health insurance is an important lever towards the overall strategy for achieving universal health coverage. In Nigeria, health insurance coverage is low with a renewed government action on increasing access to and coverage of high-quality healthcare services to citizens, particularly for the vulnerable and poor population. Therefore, our study co-creates the priorities for expanding health insurance in Nigeria, focusing on key policy reforms, public advocacy, and innovative financing strategies to ensure broader and more equitable coverage for the population.

METHODOLOGY

We employed a Delphi approach methodology through strategic health insurance meetings with a diverse multidisciplinary panel of 125 stakeholders including representatives of accredited Health Insurance Maintenance Organizations, Heads of States Social Health Insurance Agencies, Development Partners representatives, academics, government officials, national health insurance authority expanded management team and experts in health insurance across all the states of Nigeria to recommend specific actions towards health insurance expansion and universal health coverage in Nigeria.

RESULTS

The participants/panels were able to come up with a consensus on 66 priorities for health insurance expansion in Nigeria working with stakeholders within the Nigerian health insurance ecosystem across the 36 states and Nigeria's FCT. From these priorities, seven priority areas and 17 themes were derived that should be considered by the government, policymakers, regulators, and practitioners to deepen health insurance penetration in Nigeria. These seven priority areas that have been identified include enrolment, equity, organizational health and structure, data and technology, quality, market efficiency, and citizen engagement.

CONCLUSION

The priorities identified for health insurance expansion in Nigeria will go a long way in shaping health insurance. We hope that government, policymakers, regulators, and practitioners in the health ecosystem will use these social policy actions to set priorities for increasing health insurance coverage and address inadequacies to accelerate the drive towards the attainment of UHC by 2030.

Expert Consensus on Developing Information and Communication Technology-Based Patient Education Guidelines for Rheumatic Diseases in the Korea

BACKGROUND

This study aimed to identify key priorities for the development of guidelines for information and communication technology (ICT)-based patient education tailored to the needs of patients with rheumatic diseases (RDs) in the Republic of Korea, based on expert consensus.

METHODS

A two-round modified Delphi study was conducted with 20 rheumatology, patient education, and digital health literacy experts. A total of 35 items covering 7 domains and 18 subdomains were evaluated. Each item was evaluated for its level of importance, and the responses were rated on a 4-point Likert scale. Consensus levels were defined as "high" (interquartile range [IQR] ≤ 1, agreement ≥ 80%, content validity ratio [CVR] ≥ 0.7), "Moderate" (IQR ≥ 1, agreement 50-79%, CVR 0.5-0.7), and "Low" (IQR > 1, agreement < 50%, CVR < 0.5).

RESULTS

Strong consensus was reached for key priorities for developing guidelines in areas such as health literacy, digital health literacy, medical terminology, user interface, and user experience design for mobile apps. Chatbot use and video (e.g., YouTube) also achieved high consensus, whereas AI-powered platforms such as ChatGPT showed moderate-to-high agreement. Telemedicine was excluded because of insufficient consensus.

CONCLUSION

The key priorities identified in this study provide a foundation for the development of ICT-based patient education guidelines for RDs in the Republic of Korea. Future efforts should focus on integrating digital tools into clinical practice to enhance patient engagement and improve clinical outcomes.

Changing the trajectories of mental health difficulties in Norfolk and Suffolk: a research-priority-setting project with patients, the public, clinicians, policymakers and other stakeholders-study protocol

INTRODUCTION

Mental health problems are the most significant cause of disability and have high annual economic costs; hence, they are a priority for the government, service providers and policymakers. Consisting of largely coastal and rural communities, the populations of Norfolk and Suffolk, UK, have elevated burdens of mental health problems, areas with high levels of deprivation and an increasing migrant population. However, these communities are underserved by research and areas with the greatest mental health needs are not represented or engaged in research. This National Institute of Health and Care Research-funded project aims to bring together key stakeholders to conduct extensive scoping work to identify mental health needs and priorities as a basis for conducting larger research to address the identified priorities over the next 5 years.

METHODS AND ANALYSIS

This 12-month mixed-methods research-priority-setting project consists of five phases. It is being conducted in Norfolk and Suffolk counties in the East of England, UK. Underpinned by Delphi methodology, it will adopt the James Lind Alliance approach to identify priorities for mental health research for the populations of Norfolk and Suffolk. The project will use multiple methods, including mapping and identification of stakeholders, online questionnaires, face-to-face focus groups and interviews, and consensus meetings with experts and mental health stakeholders. Key evidence-informed priorities will be collaboratively ranked and documented, and a final top 10 research priorities will be identified to inform future research, policy and service provision.

ETHICS AND DISSEMINATION

This study was approved by the University of East Anglia's Faculty of Medicine and Health Research Ethics Committee (reference: ETH2324-2542), Norwich, UK. Research findings will be disseminated through workshops with stakeholders and collaborators and via peer-reviewed scientific publications, presentations at academic societies, blogs and social media.

Development of decision-aid of goal-setting for patients with distal radius fracture: Aid for decision-making in occupation choice for distal radius fracture

BACKGROUND

Patients with distal radius fractures (DRFs) encounter significant difficulties and challenges in their daily lives due to their medical condition and a lack of strategies for modifying activities. Occupation-based interventions have emerged as promising strategies to improve occupational performance and participation outcomes, addressing these challenges.

PURPOSE

This study aims to develop the aid for decision-making in occupation choice for distal radius fracture (ADOC-DRF), a novel decision-aid tool designed to facilitate patient-centered and occupation-based goal-setting by offering illustrations tailored to the postsurgical recovery period and prescribed activity loads.

STUDY DESIGN

We utilized consensus development methods, including the nominal group technique and a web-based Delphi survey.

METHODS

Through the nominal group technique with three experts, we established the development concept, items, and illustrations for the ADOC-DRF prototype. Subsequently, a Delphi web survey was conducted to gather expert opinions using a five-point Likert scale (1 = disagree and 5 = agree) and achieve consensus among 22 experts, aiming for a consensus point of 3.75 (75%) or higher.

RESULTS

Three rounds of Delphi web surveys were conducted, involving a variety of items and comments, ultimately achieving the required consensus rate. This process identified 52 items, which were categorized into four distinct post-DRF progression phases: phase 1: immobilization, phase 2 early: immobilization removal (start of active motion), phase 2 late: immobilization removal (callus formation), and phase 3: resistance period (bone healing).

CONCLUSIONS

The ADOC-DRF shows promise as an innovative tool for facilitating occupation-based intervention in hand therapy for DRF patients. However, its generalizability is currently limited to Japan. To ensure broader applicability and utility, it is essential to validate the tool in diverse cultural contexts through international multicenter studies, thereby enhancing its global relevance.

Generation of Indicators to Assess Quality of Health Care in Hospital at Home Through e-Delphi

BACKGROUND AND OBJECTIVES

The quality of health care in hospital at home (HaH) has been measured in different countries using simple indicators and clinical results that only contribute to some dimensions of the quality of health care. We sought to generate indicators to comprehensively evaluate the quality of health care provided to HaH users through the e-Delphi technique.

METHODS

The e-Delphi technique was performed with the participation of 17 HaH experts. The methodological strategy applied in this study was divided into the following 3 phases: a preparatory phase; consultation phase; and consensus phase. Three rounds of consultations were conducted with experts. In round 1, they were asked to identify which aspects of HaH they believed should be evaluated using an indicator for each of the following 6 dimensions of health care quality: effectiveness; efficiency; timeliness; patient-centered care; equity; and safety. In round 2, they were asked to rate each indicator using a 5-point Likert-type scale with the following values: (1) Totally disagree; (2) Disagree; (3) Moderately agree; (4) Agree; and (5) Totally agree. The criteria for evaluating each indicator were as follows: (1) The indicator is a useful measure for assessing the quality of health care provided to HaH users. (2) The indicator is clearly and specifically written and does not require modification. (3) The indicator is essential and incorporates information that can be extracted from HaH program records. An indicator was considered approved if it received at least 65% approval from the expert panel for each evaluation criterion. In round 3, experts were asked to reassess their ratings, taking into account the opinions of the other experts. The reliability of this technique was ensured through credibility, reliability, and confirmability. We obtained ethical approval of the corresponding institutions and informed consent from the participating experts.

RESULTS

Nine unpublished and reliable indicators were generated. In addition, 13 indicators were incorporated that evaluate aspects previously analyzed by other authors and/or national and international institutions, which were adapted to be used in HaH. The total indicators generated (n = 22) represented all dimensions of the quality of health care: safety; opportunity; effectiveness; efficiency; equity; and patient-centered care.

CONCLUSIONS

The 22 indicators generated through the e-Delphi technique permit a comprehensive evaluation of the quality of health care provided to HaH users.

Nutcracker syndrome (a Delphi consensus)

BACKGROUND

Nutcracker syndrome (NCS) describes the symptomatic compression of the left renal vein between the aorta and superior mesenteric artery. Whereas asymptomatic compression is a common radiological finding, patients with NCS can report a range of symptoms. There are no specific diagnostic criteria and interventions include a range of open surgical and endovascular procedures. Therefore, we wished to develop an international consensus document covering aspects of diagnosis, management, and follow-up for patients with NCS.

METHODS

A three-stage modified Delphi consensus was performed. A steering committee developed 37 statements covering 3 categories for patients with NCS: diagnosis, management, and follow-up. These statements were reported individually by 20 international experts in the management of venous disease, using a 5-point Likert scale. Consensus was defined if ≥70% of respondents rated the statement between 1 and 2 (agreement) and between 4 and 5 (disagreement). Those statements without consensus were recirculated in a second round of voting. A third round of the questionnaire was performed with 14 additional statements to clarify diagnostic values of NCS.

RESULTS

Responses were returned by 20 of 20 experts (100%) in round one and 17 of 20 (85%) in round two. Initial consensus was reached in 24 of 37 statements (65%) spread over all categories. Round two achieved a further consensus on 5 out of 10 statements (50%). No categories reported consensus on all statements. In round two consensus was reached in the category of follow-up (4/5 statements [80%]). The final round reached consensus on 5 out of 14 statements (36%). Experts agreed that imaging is obligated to confirm NCS. Experts did not agree on specific diagnostic cut-off values. There was a consensus that the first choice of operative treatment is left renal vein transposition and that the risk of stent migration outweighs the advantages of a percutaneous procedure.

CONCLUSIONS

Consensus was achieved on most statements concerning the assessment and management of NCS. This Delphi consensus identified those areas in which further research is needed, such as antiplatelet therapy, endovascular treatment, and renal autotransplantation. A rare disease registry to improve data and reports of patient outcomes is warranted.

Essential Elements in Synoptic Operative Reports for Hepato-Pancreato-Biliary Cancer Surgery: An HPB/CGSO Training Program Survey

BACKGROUND

Synoptic operative reports (SORs) are checklists or templates that contain standardized elements of an operation. These elements are associated with standardized inclusion of critical elements of the operative report that translate into numerous potential benefits. Whereas SORs for melanoma, breast, and colorectal cancer surgery have already been widely implemented, similar templates for hepato-pancreato-biliary (HPB) cancer surgery are currently lacking.

METHODS

An anonymous voluntary online survey was distributed to HPB attendings and fellows at HPB and complex general surgical oncology (CGSO) fellowship programs.

RESULTS

The 54 participants in this study comprised 31 (57%) HPB surgery attendings, 15 (28%) HPB surgery fellows, and 8 (15%) CGSO fellows. Notably, only six (11%) participants reported consistent use of an HPB SOR. The most commonly reported barriers to SOR uptake were the "lack of a readily available template" (55%) and the "lack of consensus/guidelines" (49%). Despite these limiting factors, a majority of respondents indicated a strong willingness to use a standardized and readily available HPB SOR (mean, 4.13/5 ± 1.23). This interest did not differ between attendings and fellows (p = 0.52) or between the participants stratified by surgical experience (p = 0.58). Finally, the participants were provided a comprehensive list of possible elements to incorporate into a standardized pancreatic and hepatobiliary SOR. After the exclusion of elements with less than 75% agreement, the pancreatic SORs included 17 (57%) of 30 possible elements, and the hepatobiliary SORs included 19 (76%) of 25 possible elements.

CONCLUSION

Broad consensus on several elements of the HPB SOR suggests that uptake should be accelerated in HPB surgery.