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1.  Development of paediatric quality of inpatient care indicators for low-income countries - A Delphi study 
BMC Pediatrics  2010;10:90.
Background
Indicators of quality of care for children in hospitals in low-income countries have been proposed, but information on their perceived validity and acceptability is lacking.
Methods
Potential indicators representing structural and process aspects of care for six common conditions were selected from existing, largely qualitative WHO assessment tools and guidelines. We employed the Delphi technique, which combines expert opinion and existing scientific information, to assess their perceived validity and acceptability. Panels of experts, one representing an international panel and one a national (Kenyan) panel, were asked to rate the indicators over 3 rounds and 2 rounds respectively according to a variety of attributes.
Results
Based on a pre-specified consensus criteria most of the indicators presented to the experts were accepted: 112/137(82%) and 94/133(71%) for the international and local panels respectively. For the other indicators there was no consensus; none were rejected. Most indicators were rated highly on link to outcomes, reliability, relevance, actionability and priority but rated more poorly on feasibility of data collection under routine conditions. There was moderate to substantial agreement between the two panels of experts.
Conclusions
This Delphi study provided evidence for the perceived usefulness of most of a set of measures of quality of hospital care for children proposed for use in low-income countries. However, both international and local experts expressed concerns that data for many process-based indicators may not currently be available. The feasibility of widespread quality assessment and responsiveness of indicators to intervention should be examined as part of continued efforts to improve approaches to informative hospital quality assessment.
doi:10.1186/1471-2431-10-90
PMCID: PMC3022793  PMID: 21144065
2.  International recommendations for outpatient palliative care and prehospital palliative emergencies – a prospective questionnaire-based investigation 
BMC Palliative Care  2013;12:10.
Background
To determine the international recommendations and current practices for the treatment and prevention of palliative emergencies. The primary goal of the study was to gather information from experts on their nationally practised concepts.
Methods
One hundred and fifty self-report surveys were distributed by email to selected leading experts (palliative and emergency medical care) in Europe, North and South America, Africa, Asia, and Australia. An expert in this context was defined as an author of an article that was ranked by three reviewers as relevant to outpatient palliative and emergency medical .
Results
The total response rate was 61% (n = 92 experts). Survey responses were obtained from 35 different countries. The following standards in the treatment of palliative emergencies were recommended: (1) early integration of “Palliative Care Teams” (PCTs) and basic outpatient palliative care systems, (2) end-of-life discussions, (3) defined emergency medical documents, drug boxes, and “Do not attempt resuscitation” orders and (4) emergency medical training (physicians and paramedics).
Conclusions
This study detected structurally and nationally differences in outpatient palliative care regarding the treatment of palliative emergencies. Accordingly, these differences should be discussed and adapted to the respective specifications of individual single countries. A single established outpatient palliative emergency medical care concept may be the basis for an overall out-of-hospital palliative care system.
doi:10.1186/1472-684X-12-10
PMCID: PMC3602669  PMID: 23432905
Specialised palliative care services (SPCS); Emergency medical care; Palliative care; Palliative emergency; End-of-life care
3.  Developing targets for public health initiatives to improve palliative care 
BMC Public Health  2010;10:222.
Background
Palliative Care is an approach that improves quality of life for patients and their families facing the problems associated with incurable life-threatening illness. In many countries, due to the rapidly ageing population, increasingly more people are suffering from serious chronic disease towards the end of life, making further development in palliative care a major public health challenge. The aim of this study was to develop the first targets for public health initiatives to improve palliative care in Germany.
Methods
Based on the findings from pilot studies (qualitative interviews and surveys with different stakeholders in the health care system), we conducted a modified Delphi study with two rounds of questionnaires with experts in public health and palliative care. In the first round, the experts commented on the findings from the pilot studies. The answers were evaluated descriptively and with qualitative content analysis, resulting in the formulation of 25 targets. These were presented to the experts in the second Delphi round to assess each of them separately with regard to its importance and current implementation (7-point answer scales) and in relation to the other targets (defining the five most important of the 25 targets).
Results
Six most relevant targets for public health initiatives to improve palliative care in Germany were worked out: Supporting palliative care as a basic attitude for the care of people in the last phase of life; coordinating healthcare for people in the last phase of life; establishing cooperation among health professions and disciplines; establishing education in palliative care for all professional groups with contact to people in the last phase of life; reviewing the evidence of palliative care measures; offering support to family members who are caring for someone in the last phase of life.
Conclusions
To systematically develop palliative care, it makes sense to define fields of action with individual targets. For Germany, it can be recommended to give priority to the targets that were highlighted as the most relevant in this study. The next step will be to develop, implement and evaluate tangible measures to achieve these targets.
doi:10.1186/1471-2458-10-222
PMCID: PMC2874778  PMID: 20429901
4.  Developing a web-based information resource for palliative care: an action-research inspired approach 
Background
General Practitioners and community nurses rely on easily accessible, evidence-based online information to guide practice. To date, the methods that underpin the scoping of user-identified online information needs in palliative care have remained under-explored. This paper describes the benefits and challenges of a collaborative approach involving users and experts that informed the first stage of the development of a palliative care website [1].
Method
The action research-inspired methodology included a panel assessment of an existing palliative care website based in Victoria, Australia; a pre-development survey (n = 197) scoping potential audiences and palliative care information needs; working parties conducting a needs analysis about necessary information content for a redeveloped website targeting health professionals and caregivers/patients; an iterative evaluation process involving users and experts; as well as a final evaluation survey (n = 166).
Results
Involving users in the identification of content and links for a palliative care website is time-consuming and requires initial resources, strong networking skills and commitment. However, user participation provided crucial information that led to the widened the scope of the website audience and guided the development and testing of the website. The needs analysis underpinning the project suggests that palliative care peak bodies need to address three distinct audiences (clinicians, allied health professionals as well as patients and their caregivers).
Conclusion
Web developers should pay close attention to the content, language, and accessibility needs of these groups. Given the substantial cost associated with the maintenance of authoritative health information sites, the paper proposes a more collaborative development in which users can be engaged in the definition of content to ensure relevance and responsiveness, and to eliminate unnecessary detail. Access to volunteer networks forms an integral part of such an approach.
doi:10.1186/1472-6947-7-26
PMCID: PMC2194759  PMID: 17854509
5.  Family meetings in palliative care: Multidisciplinary clinical practice guidelines 
BMC Palliative Care  2008;7:12.
Background
Support for family carers is a core function of palliative care. Family meetings are commonly recommended as a useful way for health care professionals to convey information, discuss goals of care and plan care strategies with patients and family carers. Yet it seems there is insufficient research to demonstrate the utlility of family meetings or the best way to conduct them. This study sought to develop multidisciplinary clinical practice guidelines for conducting family meetings in the specialist palliative care setting based on available evidence and consensus based expert opinion.
Methods
The guidelines were developed via the following methods: (1) A literature review; (2) Conceptual framework; (3) Refinement of the guidelines based on feedback from an expert panel and focus groups with multidisciplinary specialists from three palliative care units and three major teaching hospitals in Melbourne, Australia.
Results
The literature review revealed that no comprehensive exploration of the conduct and utility of family meetings in the specialist palliative care setting has occurred. Preliminary clinical guidelines were developed by the research team, based on relevant literature and a conceptual framework informed by: single session therapy, principles of therapeutic communication and models of coping and family consultation. A multidisciplinary expert panel refined the content of the guidelines and the applicability of the guidelines was then assessed via two focus groups of multidisciplinary palliative care specialists. The complete version of the guidelines is presented.
Conclusion
Family meetings provide an opportunity to enhance the quality of care provided to palliative care patients and their family carers. The clinical guidelines developed from this study offer a framework for preparing, conducting and evaluating family meetings. Future research and clinical implications are outlined.
doi:10.1186/1472-684X-7-12
PMCID: PMC2542352  PMID: 18710576
6.  Palliative care in Germany from a public health perspective: qualitative expert interviews 
BMC Research Notes  2009;2:116.
Background
Improving palliative care is a public health priority. However, little is known about the views of public health experts regarding the state of palliative care in Germany and the challenges facing it. The main aim of this pilot study was to gather information on the views of internationally experienced public health experts with regard to selected palliative care issues, with the focus on Germany, and to compare their views with those of specialist palliative care experts. Qualitative guided interviews were performed with ten experts (five from palliative care, five from public health). The interviews were analysed using qualitative content analysis.
Findings
Older people and non-cancer patients were identified as target groups with a particular priority for palliative care. By contrast to the public health experts, the palliative care experts emphasized the need for rehabilitative measures for palliative patients and the possibilities of providing these. Significant barriers to the further establishment of palliative care were seen, amongst other things, in the powerful lobby groups and the federalism of the German health system.
Conclusion
The findings suggest that from the experts' point of view (1) palliative care should focus on the needs of older people particularly in view of the demographic changes; (2) more attention should be paid to rehabilitative measures in palliative care; (3) rivalries among different stakeholders regarding their responsibilities and the allocation of financial resources have to be overcome in Germany.
doi:10.1186/1756-0500-2-116
PMCID: PMC2715412  PMID: 19566946
7.  A Delphi clinical practice protocol for the management of very long chain acyl-CoA dehydrogenase deficiency 
Introduction
Very long chain acyl-CoA dehydrogenase (VLCAD) deficiency is a disorder of oxidation of long chain fat, and can present as cardiomyopathy or fasting intolerance in the first months to years of life, or as myopathy in later childhood to adulthood. Expanded newborn screening has identified a relatively high incidence of this disorder (1:31,500), but there is a dearth of evidence-based outcomes data to guide the development of clinical practice protocols. This consensus protocol is intended to assist clinicians in the diagnosis and management of screen-positive newborns for VLCAD deficiency until evidence-based guidelines are available.
Method
The Oxford Centre for Evidence-based Medicine system was used to grade the literature review and create recommendations graded from A (evidence level of randomized clinical trials) to D (expert opinion). Delphi was used as the consensus tool. A panel of 14 experts (including clinicians, diagnostic laboratory directors and researchers) completed three rounds of survey questions and had a face-to-face meeting.
Result
Panelists reviewed the initial evaluation of the screen-positive infant, diagnostic testing and management of diagnosed patients. Grade C and D consensus recommendations were made in each of these three areas. The panel did not reach consensus on all issues, particularly in the dietary management of asymptomatic infants diagnosed by newborn screening.
doi:10.1016/j.ymgme.2008.09.008
PMCID: PMC3219055  PMID: 19157942
Very long chain acyl-CoA dehydrogenase; deficiency (VLCAD); Fatty acid oxidation; Delphi; Clinical practice protocol; Newborn screening
8.  Terminology, Taxonomy, and Facilitation of Motor Learning in Clinical Practice: Protocol of a Delphi Study 
JMIR Research Protocols  2013;2(1):e18.
Background
Facilitating motor learning in patients during clinical practice is complex, especially in people with cognitive impairments. General principles of motor learning are available for therapists to use in their practice. However, the translation of evidence from the different fields of motor learning for use in clinical practice is problematic due to lack of uniformity in definition and taxonomy of terms related to motor learning.
Objective
The objective of this paper was to describe the design of a Delphi technique to reach consensus on definitions, descriptions, and taxonomy used within motor learning and to explore experts’ opinions and experiences on the application of motor learning in practice.
Methods
A heterogeneous sample of at least 30 international experts on motor learning will be recruited. Their opinions regarding several central topics on motor learning using a Delphi technique will be collected in 3 sequential rounds. The questionnaires in the 3 rounds will be developed based on the literature and answers of experts from earlier rounds. Consensus will be reached when at least 70% of the experts agree on a certain topic. Free text comments and answers from open questions on opinions and experiences will be described and clustered into themes.
Results
This study is currently ongoing. It is financially supported by Stichting Alliantie Innovatie (Innovation Alliance Foundation), RAAK-international (Registration number: 2011-3-33int).
Conclusions
The results of this study will enable us to summarize and categorize expert knowledge and experiences in a format that should be more accessible for therapists to use in support of their clinical practice. Unresolved aspects will direct future research.
doi:10.2196/resprot.2604
PMCID: PMC3668605  PMID: 23685621
motor learning; Delphi technique; clinical practice; consensus; definitions
9.  Early identification of and proactive palliative care for patients in general practice, incentive and methods of a randomized controlled trial 
BMC Family Practice  2011;12:123.
Background
According to the Word Health Organization, patients who can benefit from palliative care should be identified earlier to enable proactive palliative care. Up to now, this is not common practice and has hardly been addressed in scientific literature. Still, palliative care is limited to the terminal phase and restricted to patients with cancer. Therefore, we trained general practitioners (GPs) in identifying palliative patients in an earlier phase of their disease trajectory and in delivering structured proactive palliative care. The aim of our study is to determine if this training, in combination with consulting an expert in palliative care regarding each palliative patient's tailored care plan, can improve different aspects of the quality of the remaining life of patients with severe chronic diseases such as chronic obstructive pulmonary disease, congestive heart failure and cancer.
Methods/Design
A two-armed randomized controlled trial was performed. As outcome variables we studied: place of death, number of hospital admissions and number of GP out of hours contacts.
Discussion
We expect that this study will increase the number of identified palliative care patients and improve different aspects of quality of palliative care. This is of importance to improve palliative care for patients with COPD, CHF and cancer and their informal caregivers, and to empower the GP. The study protocol is described and possible strengths and weaknesses and possible consequences have been outlined.
Trial Registration
The Netherlands National Trial Register: NTR2815
doi:10.1186/1471-2296-12-123
PMCID: PMC3228678  PMID: 22050863
10.  For which glaucoma suspects is it appropriate to initiate treatment? Article Type: AAO Meeting Paper Section/Category 
Ophthalmology  2009;116(4):710-71782.
Objective
Because uncertainty exists about which glaucoma suspects should be treated, we sought to identify glaucoma suspects whom an expert panel could agree would be appropriate or inappropriate to treat.
Design
RAND/UCLA appropriateness method, a well-established procedure to synthesize the scientific literature with expert opinion to resolve uncertainty on a health topic.
Participants
Eleven-member panel composed of recognized international leaders in the field of glaucoma.
Methods
Based on a systematic review of the literature on potentially important factors to consider when deciding to initiate treatment, we initially created over 1000 scenarios of glaucoma suspects. The panel formally rated the appropriateness of initiating treatment for glaucoma suspects through a two-round modified Delphi method, a technique that preserves the confidentiality of individual panelists’ ratings but allows panelists to compare their own ratings to those of the entire panel.
Main Outcome Measures
Final ratings for scenarios were categorized as appropriate, uncertain, or inappropriate to treat according to typical pre-specified statistical criteria previously used in projects using the RAND/UCLA appropriateness method. Tools were developed to help clinicians approximate the panel ratings of glaucoma suspects.
Results
The panel chose age, life expectancy, intraocular pressure (IOP), central corneal thickness, cup/disc ratio, disc size, and family history as the variables to consider when deciding whether to treat glaucoma suspects. Permutations of these variables created 1800 unique scenarios. The panel rated 587 (33%) scenarios as appropriate, 585 (33%) as uncertain, and 628 (35%) as inappropriate for treatment initiation. Analysis of variance determined that IOP had greater impact than any other variable on panel ratings. We created a point system with 96% sensitivity and 93% specificity for predicting panel ratings of appropriateness for a glaucoma suspect.
Conclusions
An expert panel can reach agreement on the appropriateness and inappropriateness of treatment for glaucoma suspects.
doi:10.1016/j.ophtha.2008.12.065
PMCID: PMC2722433  PMID: 19344823
11.  Factors influencing the adoption, implementation, and continuation of physical activity interventions in primary health care: a Delphi study 
BMC Family Practice  2013;14:142.
Background
The introduction of efficacious physical activity interventions in primary health care is a complex process. Understanding factors influencing the process can enhance the development of effective introduction strategies. This Delphi study aimed to identify factors most relevant for the adoption, implementation, and continuation of physical activity interventions in primary health care by examining experts’ opinions on the importance and changeability of factors previously identified as potentially relevant for the process.
Methods
In the first round, 44 experts scored factors on their importance for each stage of the introduction process, as well as on their changeability. In the second round, the same experts received a questionnaire containing a reduced list of factors, based on the first-round results. They were asked to indicate their top-10 most important factors for each stage, and to re-rate factors’ changeability. Thirty-seven experts completed this round.
Results
Most important factors could be identified for each stage. Some factors were found important for a specific stage, e.g., the presence of intervention champions within the organization (adoption), provider knowledge (implementation), and the intervention’s sustainability (continuation), while others were perceived important for all stages, i.e., the intervention’s financial feasibility, the intervention’s accessibility to the target group, and time to deliver the intervention. The majority of most important factors was perceived changeable. However, for some factors no consensus could be reached regarding their changeability.
Conclusions
This study identified general and stage-specific factors relevant for the introduction of physical activity interventions in primary health care. It emphasizes the importance of taking these factors into account when designing introduction strategies, and of giving special attention to the distinct stages of the process. Due to lack of consensus on the changeability of most important factors, the extent to which these factors can be influenced by introduction strategies remains unclear.
doi:10.1186/1471-2296-14-142
PMCID: PMC3848920  PMID: 24070166
Physical activity; Interventions; Primary health care; Introduction; Adoption; Implementation; Continuation; Delphi; Importance; Changeability
12.  Ensuring competency in end-of-life care: controlling symptoms 
Background
Palliative medicine is assuming an increasingly important role in patient care. The Education for Physicians in End-of-life Care (EPEC) Project is an ambitious program to increase core palliative care skills for all physicians. It is not intended to transmit specialty level competencies in palliative care.
Method
The EPEC Curriculum was developed to be a comprehensive syllabus including trainer notes, multiple approaches to teaching the material, slides, and videos of clinical encounters to trigger discussion are provided. The content was developed through a combination of expert opinion, participant feedback and selected literature review. Content development was guided by the goal of teaching core competencies not included in the training of generalist and non-palliative medicine specialist physicians.
Results
Whole patient assessment forms the basis for good symptom control. Approaches to the medical management of pain, depression, anxiety, breathlessness (dyspnea), nausea/vomiting, constipation, fatigue/weakness and the symptoms common during the last hours of life are described.
Conclusion
While some physicians will have specialist palliative care services upon which to call, most in the world will need to provide the initial approaches to symptom control at the end-of-life.
doi:10.1186/1472-684X-1-5
PMCID: PMC126248  PMID: 12149128
13.  What is case management in palliative care? An expert panel study 
Background
Case management is a heterogeneous concept of care that consists of assessment, planning, implementing, coordinating, monitoring, and evaluating the options and services required to meet the client's health and service needs. This paper describes the result of an expert panel procedure to gain insight into the aims and characteristics of case management in palliative care in the Netherlands.
Methods
A modified version of the RAND®/University of California at Los Angeles (UCLA) appropriateness method was used to formulate and rate a list of aims and characteristics of case management in palliative care. A total of 76 health care professionals, researchers and policy makers were invited to join the expert panel, of which 61% participated in at least one round.
Results
Nine out of ten aims of case management were met with agreement. The most important areas of disagreement with regard to characteristics of case management were hands-on nursing care by the case manager, target group of case management, performance of other tasks besides case management and accessibility of the case manager.
Conclusions
Although aims are agreed upon, case management in palliative care shows a high level of variability in implementation choices. Case management should aim at maintaining continuity of care to ensure that patients and those close to them experience care as personalised, coherent and consistent.
doi:10.1186/1472-6963-12-163
PMCID: PMC3413598  PMID: 22709349
Case management; End of life care; Palliative care
14.  The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews 
Background
In the era of evidence based medicine, with systematic reviews as its cornerstone, adequate quality assessment tools should be available. There is currently a lack of a systematically developed and evaluated tool for the assessment of diagnostic accuracy studies. The aim of this project was to combine empirical evidence and expert opinion in a formal consensus method to develop a tool to be used in systematic reviews to assess the quality of primary studies of diagnostic accuracy.
Methods
We conducted a Delphi procedure to develop the quality assessment tool by refining an initial list of items. Members of the Delphi panel were experts in the area of diagnostic research. The results of three previously conducted reviews of the diagnostic literature were used to generate a list of potential items for inclusion in the tool and to provide an evidence base upon which to develop the tool.
Results
A total of nine experts in the field of diagnostics took part in the Delphi procedure. The Delphi procedure consisted of four rounds, after which agreement was reached on the items to be included in the tool which we have called QUADAS. The initial list of 28 items was reduced to fourteen items in the final tool. Items included covered patient spectrum, reference standard, disease progression bias, verification bias, review bias, clinical review bias, incorporation bias, test execution, study withdrawals, and indeterminate results. The QUADAS tool is presented together with guidelines for scoring each of the items included in the tool.
Conclusions
This project has produced an evidence based quality assessment tool to be used in systematic reviews of diagnostic accuracy studies. Further work to determine the usability and validity of the tool continues.
doi:10.1186/1471-2288-3-25
PMCID: PMC305345  PMID: 14606960
15.  Palliative Care Symptom Assessment for Patients with Cancer in the Emergency Department: Validation of the Screen for Palliative and End-of-Life Care Needs in the Emergency Department Instrument 
Journal of Palliative Medicine  2011;14(6):757-764.
Abstract
Objective
We sought to develop and validate a novel palliative medicine needs assessment tool for patients with cancer in the emergency department.
Methods
An expert panel trained in palliative medicine and emergency medicine reviewed and adapted a general palliative medicine symptom assessment tool, the Needs at the End-of-Life Screening Tool. From this adaptation a new 13-question instrument was derived, collectively referred to as the Screen for Palliative and End-of-life care needs in the Emergency Department (SPEED). A database of 86 validated symptom assessment tools available from the palliative medicine literature, totaling 3011 questions, were then reviewed to identify validated test items most similar to the 13 items of SPEED; a total of107 related questions from the database were identified. Minor adaptations of questions were made for standardization to a uniform 10-point Likert scale. The 107 items, along with the 13 SPEED items were randomly ordered to create a single survey of 120 items. The 120-item survey was administered by trained staff to all patients with cancer who met inclusion criteria (age over 21 years, English-speaking, capacity to provide informed consent) who presented to a large urban academic emergency department between 8:00 am and 11:00 pm over a 10-week period. Data were analyzed to determine the degree of correlation between SPEED items and the related 107 selected items from previously validated tools.
Results
A total of 53 subjects were enrolled, of which 49 (92%) completed the survey in its entirety. Fifty-three percent of subjects were male, age range was 24–88 years, and the most common cancer diagnoses were breast, colon, and lung. Cronbach coefficient α for the SPEED items ranged from 0.716 to 0.991, indicating their high scale reliability. Correlations between the SPEED scales and related assessment tools previously validated in other settings were high and statistically significant.
Conclusion
The SPEED instrument demonstrates reliability and validity for screening for palliative care needs of patients with cancer presenting to the emergency department.
doi:10.1089/jpm.2010.0456
PMCID: PMC3107583  PMID: 21548790
16.  A systematic review of psychosocial interventions for family carers of palliative care patients 
BMC Palliative Care  2010;9:17.
Background
Being a family carer to a patient nearing the end of their life is a challenging and confronting experience. Studies show that caregiving can have negative consequences on the health of family carers including fatigue, sleep problems, depression, anxiety and burnout. One of the goals of palliative care is to provide psychosocial support to patients and families facing terminal illness. A systematic review of interventions for family carers of cancer and palliative care patients conducted at the start of this millennium demonstrated that there was a dearth of rigorous inquiry on this topic and consequently limited knowledge regarding the types of interventions likely to be effective in meeting the complex needs of family carers. We wanted to discern whether or not the evidence base to support family carers has improved. Furthermore, undertaking this review was acknowledged as one of the priorities for the International Palliative Care Family Carer Research Collaboration http://www.centreforpallcare.org.
Methods
A systematic review was undertaken in order to identify developments in family carer support that have occurred over the last decade. The focus of the review was on interventions that targeted improvements in the psychosocial support of family carers of palliative care patients. Studies were graded to assess their quality.
Results
A total of fourteen studies met the inclusion criteria. The focus of interventions included psycho-education, psychosocial support, carer coping, symptom management, sleep promotion and family meetings. Five studies were randomised controlled trials, three of which met the criteria for the highest quality evidence. There were two prospective studies, five pre-test/post-test projects and two qualitative studies.
Conclusions
The systematic review identified a slight increase in the quality and quantity of psychosocial interventions conducted for family carers in the last decade. More rigorous intervention research is required in order to meet the supportive care needs of family carers of palliative care patients.
doi:10.1186/1472-684X-9-17
PMCID: PMC2924287  PMID: 20687960
17.  "Good idea but not feasible" – the views of decision makers and stakeholders towards strategies for better palliative care in Germany: a representative survey 
BMC Palliative Care  2009;8:10.
Background
Statements on potential measures to improve palliative care in Germany predominantly reflect the points of view of experts from specialized palliative care organizations. By contrast, relatively little is known about the views of representatives of organizations and institutions that do not explicitly specialize in palliative care, but are involved to a relevant extent in the decision-making and policy-making processes. Therefore, for the first time in Germany, we carried out a representative study of the attitudes of a broad range of different stakeholders acting at the national or state level of the health care system.
Methods
442 organizations and institutions were included and grouped as follows: patient organizations, nursing organizations, medical associations, specialized palliative care organizations, political institutions, health insurance funds and others. Using a standardized questionnaire, the participants were asked to rate their agreement with the World Health Organization's definition of palliative care (five-point scale: 1 = completely agree, 5 = completely disagree) and to evaluate 18 pre-selected improvement measures with regard to their general meaningfulness and the feasibility of their introduction into the German health care system (two-point scale: 1 = good, 2 = poor).
Results
The response rate was 67%. Overall, the acceptance of the aims of palliative care in the WHO definition was strong. However, the level of agreement among health insurance funds' representatives was significantly less than that among representatives of the palliative care organizations. All the improvement measures selected for evaluation were rated significantly higher in respect of their meaningfulness than of their feasibility in Germany. In detail, the meaningfulness of 16 measures was evaluated positively (70–100% participants chose the answer "good"); for six of these measures feasibility was evaluated negatively (0–30% "good"), while for the remaining ten measures feasibility was evaluated inconsistently (31–69% "good").
Conclusion
The reason why potentially meaningful improvement measures are considered to be not very feasible in Germany may be the existence of barriers resulting from the high degree of fragmentation of health care provision and responsibilities. In overcoming these barriers and further improving palliative care it may be helpful that the basic understanding of the palliative care approach seems to be quite homogenous among the different groups.
doi:10.1186/1472-684X-8-10
PMCID: PMC2722585  PMID: 19622177
18.  What Are the Components of CBT for Psychosis? A Delphi Study 
Schizophrenia Bulletin  2009;36(1):136-142.
There is strong evidence supporting the implementation of cognitive behavior therapy (CBT) for people with psychosis. However, there are a variety of approaches to the delivery and conceptual underpinnings within different research groups, and the degree of consensus or disagreement regarding what are the intrinsic components has not been explored. This study uses the Delphi method to try to establish what a group of experts in CBT for psychosis view as important. Experts were invited to participate in 3 rounds of producing and rating statements that addressed areas such as principles, assessment, models, formulation, change strategies, homework, and therapists’ assumptions in order to consolidate consensus of opinion. Seventy-seven items were endorsed as important or essential for CBT for psychosis by >80% of the panel. These recommendations should ensure greater fidelity in clinical practice, allow greater evaluation of adherence within clinical trials, facilitate the development of competency frameworks, and be of value in relation to training and dissemination of CBT for psychosis.
doi:10.1093/schbul/sbp118
PMCID: PMC2800146  PMID: 19880824
cognitive behavior therapy; schizophrenia; psychosis; Delphi method
19.  Forecasting the Use of Electronic Health Records: An Expert Opinion Approach 
Medicare & Medicaid Research Review  2013;3(2):mmrr.003.02.a02.
Background
To promote the widespread adoption and use of electronic health records (EHRs), in 2011, CMS started making Medicare and Medicaid incentive payments to providers who demonstrate that they are “meaningful users” of certified EHR systems.
Data and Methods
This paper combines an expert opinion method, a modified Delphi technique, with a technological diffusion framework to create a forecast of the percent of office-based physicians who will become adopters and “meaningful users” of health information technology from 2012 to 2019. The panel consisted of 18 experts from industry, academia, and government who are knowledgeable about the adoption and use of EHRs in office-based settings and are recognized as opinion leaders in their respective professions.
Results
Overall, the expert panel projected that primary care physicians in large group practices are more likely to achieve the meaningful use of EHRs relative to primary care physicians in small group practices and all other specialists: the group projected that 65 percent of primary care physicians in large group practices, 45 percent of primary care physicians in small group practices, and 44 percent of all other specialists could achieve meaningful use by 2015. In 2019, these projections increase to 80 percent, 65 percent, and 66 percent for these three groups, respectively.
Conclusions and Policy Implications
The information from this study is especially valuable when there is a lack of data and a high degree of uncertainty in a new policy environment and could help inform and evaluate government programs, such as the Regional Extension Centers (REC), by providing data from leading experts.
doi:10.5600/mmrr.003.02.a02
PMCID: PMC3983723  PMID: 24753964
Health Policy/Politics/Law/Regulation; Incentives in Health Care; Information Technology; Primary Care; Program Evaluation; Qualitative Research; Technology Adoption/Diffusion/Use; Medicare Medicaid
20.  Importance of different types of prior knowledge in selecting genome-wide findings for follow-up 
Genetic epidemiology  2013;37(2):10.1002/gepi.21705.
Biological plausibility and other prior information could help select genome-wide association (GWA) findings for further follow-up, but there is no consensus on which types of knowledge should be considered or how to weight them. We used experts’ opinions and empirical evidence to estimate the relative importance of 15 types of information at the single nucleotide polymorphism (SNP) and gene levels. Opinions were elicited from ten experts using a two-round Delphi survey. Empirical evidence was obtained by comparing the frequency of each type of characteristic in SNPs established as being associated with seven disease traits through GWA meta-analysis and independent replication, with the corresponding frequency in a randomly selected set of SNPs. SNP and gene characteristics were retrieved using a specially developed bioinformatics tool. Both the expert and the empirical evidence rated previous association in a meta-analysis or more than one study as conferring the highest relative probability of true association, while previous association in a single study ranked much lower. High relative probabilities were also observed for location in a functional protein domain, while location in a region evolutionarily conserved in vertebrates was ranked high by the data but not by the experts. Our empirical evidence did not support the importance attributed by the experts to whether the gene encodes a protein in a pathway or shows interactions relevant to the trait. Our findings provide insight into the selection and weighting of different types of knowledge in SNP or gene prioritization, and point to areas requiring further research.
doi:10.1002/gepi.21705
PMCID: PMC3725558  PMID: 23307621
Gene prioritization; Genome-wide association studies; Bioinformatics databases
21.  Pharmacist provision of primary health care: a modified Delphi validation of pharmacists' competencies 
BMC Family Practice  2012;13:27.
Background
Pharmacists have expanded their roles and responsibilities as a result of primary health care reform. There is currently no consensus on the core competencies for pharmacists working in these evolving practices. The aim of this study was to develop and validate competencies for pharmacists' effective performance in these roles, and in so doing, document the perceived contribution of pharmacists providing collaborative primary health care services.
Methods
Using a modified Delphi process including assessing perception of the frequency and criticality of performing tasks, we validated competencies important to primary health care pharmacists practising across Canada.
Results
Ten key informants contributed to competency drafting; thirty-three expert pharmacists replied to a second round survey. The final primary health care pharmacist competencies consisted of 34 elements and 153 sub-elements organized in seven CanMeds-based domains. Highest importance rankings were allocated to the domains of care provider and professional, followed by communicator and collaborator, with the lower importance rankings relatively equally distributed across the manager, advocate and scholar domains.
Conclusions
Expert pharmacists working in primary health care estimated their most important responsibilities to be related to direct patient care. Competencies that underlie and are required for successful fulfillment of these patient care responsibilities, such as those related to communication, collaboration and professionalism were also highly ranked. These ranked competencies can be used to help pharmacists understand their potential roles in these evolving practices, to help other health care professionals learn about pharmacists' contributions to primary health care, to establish standards and performance indicators, and to prioritize supports and education to maximize effectiveness in this role.
doi:10.1186/1471-2296-13-27
PMCID: PMC3372430  PMID: 22455482
Primary health care; Pharmacy; Pharmacists; Competencies; Scope of practice
22.  Paediatric palliative home care by general paediatricians: a multimethod study on perceived barriers and incentives 
BMC Palliative Care  2010;9:11.
Background
Non-specialist palliative care, as it is delivered by general practitioners, is a basic component of a comprehensive palliative care infrastructure for adult patients with progressive and far advanced disease. Currently palliative care for children and adolescents is recognized as a distinct entity of care, requiring networks of service providers across different settings, including paediatricians working in general practice. In Germany, the medical home care for children and adolescents is to a large extent delivered by general paediatricians working in their own practice. However, these are rarely confronted with children suffering from life-limiting diseases. The aim of this study was therefore to examine potential barriers, incentives, and the professional self-image of general paediatricians with regard to paediatric palliative care.
Methods
Based on qualitative expert interviews, a questionnaire was designed and a survey among general paediatricians in their own practice (n = 293) was undertaken. The survey has been developed and performed in close cooperation with the regional professional association of paediatricians.
Results
The results showed a high disposition on part of the paediatricians to engage in palliative care, and the majority of respondents regarded palliative care as part of their profile. Main barriers for the implementation were time restrictions (40.7%) and financial burden (31.6%), sole responsibility without team support (31.1%), as well as formal requirements such as forms and prescriptions (26.6%). Major facilitations were support by local specialist services such as home care nursing service (83.0%), access to a specialist paediatric palliative care consultation team (82.4%), as well as an option of exchange with colleagues (60.1%).
Conclusions
Altogether, the high commitment to this survey reflects the relevance of the issue for paediatricians working in general practice. Education in basic palliative care competence and communication skills was seen as an important prerequisite for the engagement in paediatric palliative home care. A local network of specialist support on site and a 24/7 on-call service are necessary in order to facilitate the implementation of basic palliative care by paediatricians in their own practice.
doi:10.1186/1472-684X-9-11
PMCID: PMC2902453  PMID: 20525318
23.  Expert Consensus for Discharge Referral Decisions Using Online Delphi 
This paper describes the results of using a modified Delphi approach designed to achieve consensus from eight discharge planning experts regarding the decision to refer hospitalized older adults for post-discharge follow-up. Experts reviewed 150 cases using an online website designed to facilitate their interaction and efforts to reach agreement on the need for a referral for post-discharge care and the appropriate site for such care. In contrast to an average of eight weeks to complete just 50 cases using the traditional mail method, the first online Delphi round for 150 cases were completed in six weeks. Data provided by experts suggest that online Delphi is a time efficient and acceptable methodology for reaching group consensus. Other benefits include instant access to Delphi decision results, live knowledge of the time requirements and progress of each expert, and cost savings in postage, paper, copying, and storage of paper documents. This online Delphi methodology is highly recommended.
PMCID: PMC1479920  PMID: 14728143
24.  Intervention for depression among palliative care patients and their families: A study protocol for evaluation of a training program for professional care staff 
BMC Palliative Care  2011;10:11.
Background
Clinical depression is highly prevalent yet under-detected and under-treated in palliative care settings and is associated with a number of adverse medical and psychological outcomes for patients and their family members. This article presents a study protocol to evaluate a training intervention for non-physician palliative care staff to improve the recognition of depression and provide support for depressed patients and their family members. Details of the hypotheses and expected outcomes, study design, training program development and evaluation measures are described.
Methods and Design
A randomised controlled trial will be implemented across two palliative care services to evaluate the "Training program for professional carers to recognise and manage depression in palliative care settings". Pre-, post- and three-month follow-up data will be collected to assess: the impact of the training on the knowledge, attitudes, self-efficacy and perceived barriers of palliative care staff when working with depression; referral rates for depression; and changes to staff practices. Quantitative and qualitative methods, in the form of self-report questionnaires and interviews with staff and family members, will be used to evaluate the effectiveness of the intervention.
Discussion
This study will determine the effectiveness of an intervention that aims to respond to the urgent need for innovative programs to target depression in the palliative care setting. The expected outcome of this study is the validation of an evidence-based training program to improve staff recognition and appropriate referrals for depression, as well as improve psychosocial support for depressed patients and their family members.
Trial Registration
Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12610000183088
doi:10.1186/1472-684X-10-11
PMCID: PMC3132731  PMID: 21668988
25.  Transmural palliative care by means of teleconsultation: a window of opportunities and new restrictions 
BMC Medical Ethics  2013;14:12.
Background
Audio-visual teleconsultation is expected to help home-based palliative patients, hospital-based palliative care professionals, and family physicians to jointly design better, pro-active care. Consensual knowledge of the possibilities and limitations of teleconsultation in transmural palliative care is, however, largely lacking.
This paper aims at describing elements of both the physical workplace and the cultural-social context of the palliative care practice, which are imperative for the use of teleconsultation technologies.
Methods
A semi-structured expert meeting and qualitative, open interviews were deployed to explore professionals’ assumptions and wishes, which are considered to contain latent presumptions about the practice’s physical workplace and latent elements of the cultural-social context, regarding (1) the mediating potential of audio-visual teleconsultation, (2) how the audio-visual teleconsultations will affect medical practice, and (3) the design and usage of the teleconsultation technology. We used a qualitative analysis to investigate how palliative care professionals interpret the teleconsultation package in preparation. The analysis entailed open and axial coding techniques developed in a grounded theory approach.
Results
Respondents assume: 1. teleconsultation will hinder physical proximity, thereby compromising anamnesis and diagnosis of new or acutely ill patients as well as “real contact” with the person behind the patient; 2. teleconsultation will help patients becoming more of a pivotal figure in their own care trajectory; 3. they can use teleconsultation to keep a finger on the pulse; 4. teleconsultations have a healing effect of their own due to offered time and digital attention; 5. teleconsultation to open up an additional “gray” network outside the hierarchical structures of the established chain of transmural palliative care. This network could cause bypassing of caregivers and uncertainty about responsibilities; 6. teleconsultations lead to an extended flow of information which helps palliative care professionals to check the stories of patients and medical specialists.
Conclusions
Professionals assume teleconsultation co-defines a new patient–professional relationship by extending hospital-based caregivers’ perceptions of as well as attention for their patients. At the cost, however, of clinical and personal connectedness. Secondly, a hermeneutics is needed to carefully interpret teleconsultation images. Thirdly, teleconsultations transform caregiving cultures as formerly separated care domains collide, demanding a redefinition of roles and responsibilities.
doi:10.1186/1472-6939-14-12
PMCID: PMC3608168  PMID: 23497307
Telecare; Audio-visual teleconsultations; Palliative care; Transmural care; Integrated health care; Mediation of professional-patient relations; Ethics; Philosophy of technology

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