Implementation and scalability of a digital intervention to reduce depressive symptoms in people with diabetes, hypertension or both in Brazil and Peru: a qualitative study of health system's stakeholders' perspectives.

Two randomized controlled trials (RCTs) in Brazil and Peru demonstrated the effectiveness of CONEMO, a digital intervention supported by trained nurses or nurse assistants (NAs), to reduce depressive symptoms in people with diabetes and/or hypertension. This paper extends the RCTs findings by reflecting on the conditions needed for its wider implementation in routine care services. A qualitative study using semi-structured interviews and content analysis was conducted with nurses/NAs, clinicians, healthcare administrators, and policymakers. Informants reported that CONEMO would be feasible to implement in their health services, but some conditions could be improved before its scale-up: reducing workloads of healthcare workers; raising mental health awareness among clinicians and administrators; being able to inform, deliver and accompany the intervention; assuring appropriate training and supervision of nurses/NAs; and supporting the use of technology in public health services and by patients, especially older ones. We discuss some suggestions on how to overcome these challenges.

Management of peri-prosthetic joint infection and severe bone loss after total hip arthroplasty using a long-stemmed cemented custom-made articulating spacer (CUMARS).

BACKGROUND: There is little evidence on techniques for management of peri-prosthetic infection (PJI) in the context of severe proximal femoral bone loss. Custom-made articulating spacers (CUMARS) utilising cemented femoral stems as spacers was described providing better bone support and longer survival compared to conventional articulating spacers. We retrospectively report our experience managing PJI by adaptation of this technique using long cemented femoral stems where bone loss precludes use of standard stems. METHODS: Patients undergoing 1st stage revision for infected primary and revision THA using a cemented long stem (> 205 mm) and standard all-polyethylene acetabulum between 2011 and 2018 were identified. After excluding other causes of revision (fractures or aseptic loosening), Twenty-one patients remained out of total 721 revisions. Medical records were assessed for demographics, initial microbiological and operative treatment, complications, eradication of infection and subsequent operations. 2nd stage revision was undertaken in the presence of pain or subsidence. RESULTS: Twenty-one patients underwent 1st stage revision with a cemented long femoral stem. Mean follow up was 3.9 years (range 1.7-7.2). Infection was eradicated in 15 (71.4%) patients. Two patients (9.5%) required repeat 1st stage and subsequently cleared their infection. Three patients (14.3%) had chronic infection and are on long term suppressive antibiotics. One patient (4.8%) was lost to follow up before 2 years. Complications occurred in seven patients (33%) during or after 1st stage revision. Where infection was cleared, 2nd stage revision was undertaken in 12 patients (76.5%) at average of 9 months post 1st stage. Five (23.8%) CUMARS constructs remained in-situ at an average of 3.8 years post-op (range 2.6-5.1). CONCLUSIONS: Our technique can be used in the most taxing of reconstructive scenarios allowing mobility, local antibiotic delivery, maintenance of leg length and preserves bone and soft tissue, factors not afforded by alternative spacer options.

LATIN-MH: a model for building research capacity within Latin America.

BACKGROUND: Latin America Treatment and Innovation Network in Mental Health (LATIN-MH) is a research hub located in Brazil and Peru that conducts a research project to help reduce the treatment gap in mental health in Latin America (LA). Besides its research core, LATIN-MH has a Capacity Building (CB) component that aims to help young researchers receive the specific training to contribute to the growing scientific production in mental health in LA. METHODS: LATIN-MH proposal in CB includes a series of actions to prepare professionals in the research area. The main proposals are described here, which include online study groups, promotion of scientific meetings, hands-on training in different levels and sharing of information. RESULTS: LATIN-MH CB activities are at its initial stages but the proposed activities were well evaluated by the participants. The first participating fellows who finished their fellowships are contributing elsewhere in the mental treatment and human resources formation area. CONCLUSION: The repercussion of LATIN-MH actions in CB and its evaluation, particularly on the formation of human resources and dissemination of information, show that the hub is contributing to the critic formation of young researchers and the circulation of important information.

Intravenous fluid and electrolyte administration in elective gastrointestinal surgery: mechanisms of excessive therapy.

INTRODUCTION While clinical guidelines stress the importance of the judicious perioperative intravenous fluid administration, data show that adherence to these protocols is poor. The reasons have not been identified. We therefore audited the magnitude and indications of fluid and electrolyte administration in a teaching hospital. We hypothesised that epidural analgesia is associated with excessive fluid therapy. MATERIALS AND METHODS Intravenous fluid and electrolyte administration during the day of surgery and the subsequent 2 days in consecutive patients undergoing elective gastrointestinal surgery between November 2013 and May 2014 were retrospectively audited. Timing, volumes and indications were recorded. RESULTS One hundred patients undergoing elective gastrointestinal resection were studied. Patients received 9030 ml ± 2860 ml (mean ± standard deviation) intravenous fluids containing a total of 1180 ml ± 420 mmol sodium and resulting in a cumulative fluid balance of +5120 ml ± 2510 ml; 44% ± 14% of total volumes were given in theatre. Nearly all fluid was given for maintenance, 100% (96-100%, interquartile range), with 17 patients only receiving replacement or resuscitation. Independent predictors of increased volumes included open surgery, upper gastrointestinal surgery, increased duration and epidural analgesia but not body weight. Postoperative fluid volume was the only independent predictor of postoperative complication grade (P = 0.0044). CONCLUSIONS Despite published guidelines, perioperative fluid and electrolyte administration were excessive and were associated with postoperative morbidity. Substantial volumes were administered in theatre. Nearly all administration was for maintenance, yet patients received approximately five times the amount of sodium required. Epidural analgesia was an independent predictor of fluid volumes but body weight was not.

Caveolar disruption causes contraction of rat femoral arteries via reduced basal NO release and subsequent closure of BKCa channels.

Background and Purpose. Caveolae act as signalling hubs in endothelial and smooth muscle cells. Caveolar disruption by the membrane cholesterol depleting agent methyl-ß-cyclodextrin (M-ß-CD) has various functional effects on arteries including (i) impairment of endothelium-dependent relaxation, and (ii) alteration of smooth muscle cell (SMC) contraction independently of the endothelium. The aim of this study was to explore the effects of M-ß-CD on rat femoral arteries. Methods. Isometric force was measured in rat femoral arteries stimulated to contract with a solution containing 20 mM K(+) and 200 nM Bay K 8644 (20 K/Bay K) or with one containing 80 mM K(+)(80 K). Results. Incubation of arteries with M-ß-CD (5 mM, 60 min) increased force in response to 20 K/Bay K but not that induced by 80 K. Application of cholesterol saturated M-ß-CD (Ch-MCD, 5 mM, 50 min) reversed the effects of M-ß-CD. After mechanical removal of endothelial cells M-ß-CD caused only a small enhancement of contractions to 20 K/Bay K. This result suggests M-ß-CD acts via altering release of an endothelial-derived vasodilator or vasoconstrictor. When nitric oxide synthase was blocked by pre-incubation of arteries with L-NAME (250 µM) the contraction of arteries to 20 K/Bay K was enhanced, and this effect was abolished by pre-treatment with M-ß-CD. This suggests M-ß-CD is inhibiting endothelial NO release. Inhibition of large conductance voltage- and Ca(2+)-activated (BKCa) channels with 2 mM TEA(+) or 100 nM Iberiotoxin (IbTX) enhanced 20 K/Bay K contractions. L-NAME attenuated the contractile effect of IbTX, as did endothelial removal. Conclusions. Our results suggest caveolar disruption results in decreased release of endothelial-derived nitric oxide in rat femoral artery, resulting in a reduced contribution of BKCa channels to the smooth muscle cell membrane potential, causing depolarisation and contraction.

Outcomes of surgery for chronic exertional compartment syndrome in a military population.

AIM: To determine the outcome following fasciectomy for chronic exertional compartment syndrome (CECS) in the UK military, and the association between presurgical intramuscular pressure (IMP) and outcome. METHODS: All patients who underwent fasciectomy for anterior CECS were identified between 2007 and 2010. Presurgery and postsurgery military medical grading for leg function was extracted from the medical records system. The Wilcoxon signed-rank test compared grades before and after surgery. Spearman's rank correlation examined the relationship between IMP and outcome. RESULTS: Presurgery and postsurgery grading was available for 63% of patients. These patients had significantly better leg function after surgery (Z=-3.63, p<0.001). Of these, 49% improved by at least one grade, 36% showed no improvement in grading and 15% had a poorer outcome. There were no significant correlations between IMP and outcome. CONCLUSIONS: A large proportion of patients do not return to full fitness following fasciectomy in the military population. This is in line with a recent study in the US military, but conflicts with most civilian reports. The reasons for these differences are not clear. Furthermore, the lack of a relationship between IMP and outcome questions the role of pressure in this condition. These results suggest that the role of postoperative rehabilitation protocols and other conservative options should be explored.

A low energy paediatric clavicle fracture associated with acute brachial plexus injury and subclavian artery compression.

Paediatric clavicle fractures are common injuries presenting to orthopaedic surgeons. The majority of these represent midshaft low energy fractures, which in the vast majority of cases are treated non-operatively and recover rapidly. The main indications to consider operative intervention include high energy of injury, >2 cm shortening, open fractures and associated vascular or neurological injuries. Brachial plexus (BP) injuries are uncommon with variable outcomes. They often result from high energy motorcycle related accidents with potentially fatal associated injuries such as vascular disruption. Their management is complex, requiring expertise, and they are therefore usually managed in supraregional centres. We present a unique case of a low energy midshaft clavicle fracture in a paediatric patient in whom there was an acute BP injury and subclavian artery compression that has not been described previously.

HCN4 subunit expression in fast-spiking interneurons of the rat spinal cord and hippocampus.

Hyperpolarisation-activated (Ih) currents are considered important for dendritic integration, synaptic transmission, setting membrane potential and rhythmic action potential (AP) discharge in neurons of the central nervous system. Hyperpolarisation-activated cyclic nucleotide-gated (HCN) channels underlie these currents and are composed of homo- and hetero-tetramers of HCN channel subunits (HCN1-4), which confer distinct biophysical properties on the channel. Despite understanding the structure-function relationships of HCN channels with different subunit stoichiometry, our knowledge of their expression in defined neuronal populations remains limited. Recently, we have shown that HCN subunit expression is a feature of a specific population of dorsal horn interneurons that exhibit high-frequency AP discharge. Here we expand on this observation and use neuroanatomical markers to first identify well-characterised neuronal populations in the lumbar spinal cord and hippocampus and subsequently determine whether HCN4 expression correlates with high-frequency AP discharge in these populations. In the spinal cord, HCN4 is expressed in several putative inhibitory interneuron populations including parvalbumin (PV)-expressing islet cells (84.1%; SD: ±2.87), in addition to all putative Renshaw cells and Ia inhibitory interneurons. Similarly, virtually all PV-expressing cells in the hippocampal CA1 subfield (93.5%; ±3.40) and the dentate gyrus (90.9%; ±6.38) also express HCN4. This HCN4 expression profile in inhibitory interneurons mirrors both the prevalence of Ih sub-threshold currents and high-frequency AP discharge. Our findings indicate that HCN4 subunits are expressed in several populations of spinal and hippocampal interneurons, which are known to express both Ih sub-threshold currents and exhibit high-frequency AP discharge. As HCN channel function plays a critical role in pain perception, learning and memory, and sleep as well as the pathogenesis of several neurological diseases, these findings provide important insights into the identity and neurochemical status of cells that could underlie such conditions.

A pre-hospital technique for controlling haemorrhage from traumatic perineal and high amputation injuries.

Perineal trauma resulting from the adaptive use of improvised explosive devices (IEDs) has become an increasingly common problem during current operational conflicts in Afghanistan. Control of haemorrhage from the perineum and high amputations is a particular challenge due to the bony anatomy, rich pelvic vascular supply and the difficulty in achieving haemostasis by direct pressure. In this article, the authors describe a potential pre-hospital solution for controlling haemorrhage from perineal and high amputation injuries.

Caveolin-1 and caveolin-3 regulate Ca2+ homeostasis of single smooth muscle cells from rat cerebral resistance arteries.

The role of caveolins, signature proteins of caveolae, in arterial Ca(2+) regulation is unknown. We investigated modulation of Ca(2+) homeostasis by caveolin-1 and caveolin-3 using smooth muscle cells from rat cerebral resistance arteries. Membrane current and Ca(2+) transients were simultaneously measured with voltage-clamped single cells. Membrane depolarization triggered Ca(2+) current and increased intracellular Ca(2+) concentration ([Ca(2+)](i)). After repolarization, elevated [Ca(2+)](i) returned to the resting level. Ca(2+) removal rate was determined from the declining phase of the Ca(2+) transient. Application of caveolin-1 antibody or caveolin-1 scaffolding domain peptide, corresponding to amino acid residues 82-101 of caveolin-1, significantly slowed Ca(2+) removal rate at a measured [Ca(2+)](i) of 250 nM, with little effect at a measured [Ca(2+)](i) of 600 nM. Application of caveolin-3 antibody or caveolin-3 scaffolding domain peptide, corresponding to amino acid residues 55-74 of caveolin-3, also significantly slowed Ca(2+) removal rate at a measured [Ca(2+)](i) of 250 nM, with little effect at a measured [Ca(2+)](i) of 600 nM. Likewise, application of calmodulin inhibitory peptide, autocamtide-2-related inhibitory peptide, and cyclosporine A, inhibitors for calmodulin, Ca(2+)/calmodulin-dependent protein kinase II, and calcineurin, also significantly inhibited Ca(2+) removal rate at a measured [Ca(2+)](i) of 250 nM but not at 600 nM. Application of cyclopiazonic acid, a sarcoplasmic reticulum Ca(2+) ATPase inhibitor, also significantly inhibited Ca(2+) removal rate at a measured [Ca(2+)](i) of 250 nM but not at 600 nM. Our results suggest that caveolin-1 and caveolin-3 are important in Ca(2+) removal of resistance artery smooth muscle cells.

Effects of hypoxia, anoxia, and metabolic inhibitors on KATP channels in rat femoral artery myocytes.

Vascular ATP-sensitive potassium (KATP) channels have an important role in hypoxic vasodilation. Because KATP channel activity depends on intracellular nucleotide concentration, one hypothesis is that hypoxia activates channels by reducing cellular ATP production. However, this has not been rigorously tested. In this study we measured KATP current in response to hypoxia and modulators of cellular metabolism in single smooth muscle cells from the rat femoral artery by using the whole cell patch-clamp technique. KATP current was not activated by exposure of cells to hypoxic solutions (Po2 approximately 35 mmHg). In contrast, voltage-dependent calcium current and the depolarization-induced rise in intracellular calcium concentration ([Ca2+]i) was inhibited by hypoxia. Blocking mitochondrial ATP production by using the ATP synthase inhibitor oligomycin B (3 microM) did not activate current. Blocking glycolytic ATP production by using 2-deoxy-D-glucose (5 mM) also did not activate current. The protonophore carbonyl cyanide m-chlorophenylhydrazone (1 microM) depolarized the mitochondrial membrane potential and activated KATP current. This activation was reversed by oligomycin B, suggesting it occurred as a consequence of mitochondrial ATP consumption by ATP synthase working in reverse mode. Finally, anoxia induced by dithionite (0.5 mM) also depolarized the mitochondrial membrane potential and activated KATP current. Our data show that: 1) anoxia but not hypoxia activates KATP current in femoral artery myocytes; and 2) inhibition of cellular energy production is insufficient to activate KATP current and that energy consumption is required for current activation. These results suggest that vascular KATP channels are not activated during hypoxia via changes in cell metabolism. Furthermore, part of the relaxant effect of hypoxia on rat femoral artery may be mediated by changes in [Ca2+]i through modulation of calcium channel activity.

Molecular analysis of the subtype-selective inhibition of cloned KATP channels by PNU-37883A.

1. In this study, we have used Kir6.1/Kir6.2 chimeric proteins and current recordings to investigate the molecular basis of PNU-37883A inhibition of cloned K(ATP) channels. 2. Rat Kir6.1, Kir6.2 and Kir6.1/Kir6.2 chimeras were co-expressed with either SUR2B or SUR1, following RNA injection into Xenopus oocytes, and fractional inhibition of K(ATP) currents by 10 microm PNU-37883A reported. 3. Channels containing Kir6.1/SUR2B were more sensitive to inhibition by PNU-37883A than those containing Kir6.2/SUR2B (mean fractional inhibition: 0.70, cf. 0.07). 4. On expression with SUR2B, a chimeric channel with the Kir6.1 pore and the Kir6.2 amino- and carboxy-terminal domains was PNU-37883A insensitive (0.06). A chimera with the Kir6.1 carboxy-terminus and Kir6.2 amino-terminus and pore was inhibited (0.48). These results, and those obtained with other chimeras, suggest that the C-terminus is an important determinant of PNU-37883A inhibition of Kir6.1. Similar results were seen when constructs were co-expressed with SUR1. Further chimeric constructs localised PNU-37883A sensitivity to an 81 amino-acid residue section in the Kir6.1 carboxy-terminus. 5. Our data show that structural differences between Kir6.1 and Kir6.2 are important in determining sensitivity to PNU-37883A. This compound may prove useful in probing the structural and functional differences between the two channel subtypes.

Ca2+-induced Ca2+ release in cardiac and smooth muscle cells.

Ca(2+) influx across plasma membranes may trigger Ca(2+) release by activating ryanodine-sensitive receptors in the sarcoplasmic reticulum. This process is called Ca(2+)-induced Ca(2+) release, and may be important in regulating cytosolic Ca(2+) concentration ([Ca(2+)](i)). In cardiac cells, the initial [Ca(2+)](i) increase, caused by L-type Ca(2+) current, is profoundly amplified with Ca(2+) release. The synchronized opening of several ryanodine-sensitive Ca(2+)-releasing channels was detected as discreet and highly localized Ca(2+) elevation, and termed as a 'Ca(2+) spark'. A Ca(2+) spark is under local control of an L-type Ca(2+) channel, and therefore a Ca(2+) spark does not normally trigger subsequent Ca(2+) sparks in the neighbouring area. In smooth muscle cells, the importance of Ca(2+)-induced Ca(2+) release in elevating [Ca(2+)](i) appears to differ among preparations and species. Significant elevation in [Ca(2+)](i) during depolarization was attributed to Ca(2+) release in some smooth muscle cells, but not in others. Ca(2+) sparks are also identified in smooth muscle cells, and may play a role as functional elementary events for Ca(2+)-induced Ca(2+) release. At rest, Ca(2+) sparks may be also important in regulating smooth muscle membrane potential. Ca(2+) sparks occurring at rest do not raise global [Ca(2+)](i), but trigger spontaneous transient outward currents (STOCs) or spontaneous transient inward currents (STICs), the former producing hyperpolarization; the latter, depolarization. Thus there may be multiple facets for Ca(2+)-induced Ca(2+) release in regulating the contractile status of smooth muscle cells.

Working memory, metacognitive uncertainty, and belief bias in syllogistic reasoning.

Studies of syllogistic reasoning have shown that the size of the belief bias effect varies with manipulations of logical validity and problem form. This paper presents a mental models-based account, which explains these findings in terms of variations in the working-memory demands of different problem types. We propose that belief bias may reflect the use of a heuristic that is applied when a threshold of uncertainty in one's processing--attributable to working-memory overload--is exceeded during reasoning. Three experiments are reported, which tested predictions deriving from this account. In Experiment 1, conclusions of neutral believability were presented for evaluation, and a predicted dissociation was observed in confidence ratings for responses to valid and invalid arguments, with participants being more confident in the former. In Experiment 2, an attempt to manipulate working-memory loads indirectly by varying syllogistic figure failed to produce predicted effects upon the size of the belief bias effect. It is argued that the employment of a conclusion evaluation methodology minimized the effect of the figural manipulation in this experiment. In Experiment 3, participants' articulatory and spatial recall capacities were calibrated as a direct test of working-memory involvement in belief bias. Predicted differences in the pattern of belief bias observed between high and low spatial recall groups supported the view that limited working memory plays a key role in belief bias.

Assessing the appropriateness of paediatric hospital admissions in the United Kingdom.

BACKGROUND: In order to assess whether the documented rise in paediatric admissions was due to inappropriate admissions, an objective measure of the appropriateness of paediatric admissions, modified for use in the United Kingdom, was used to measure the level of inappropriate admissions. The relationship of appropriateness of admissions to age, gender, time of admission and source of referral was investigated. METHODS: A retrospective review was carried out of a sample of paediatric records in 13 NHS district general hospitals in South Eastern England between April 1990 and March 1991 using the Paediatric Appropriateness Evaluation Protocol (PAEP) modified for use in the United Kingdom. RESULTS: A total of 3,324 paediatric admissions in 13 hospitals were assessed. Eight per cent of the sampled admissions were inappropriate. Age [odds ratio (OR)=0.87], gender (OR = 1.39) and weekend admissions (OR = 1.42) were associated with inappropriate admissions. After controlling for these factors, there was no significant variation between hospitals. CONCLUSION: The low level of inappropriate admissions may be a reflection of well-developed primary care services in the United Kingdom. Alternatives to hospital admission for the assessment of minor self-limiting illness in young children may have a role in reducing inappropriate admissions.

Favorable short-term and long-term outcome after elective radical rectal cancer resection in patients 75 years of age or older.

PURPOSE: Because the elderly population in Western countries is rapidly increasing, as is their life expectancy, studies aimed at determining the impact of major surgery for primary rectal cancer in this group are warranted. The purpose of this study was to compare perioperative morbidity and mortality and long-term disease-specific and overall survival in primary rectal cancer patients, older and younger than 75 years of age, subject to major pelvic surgery. METHODS: From September 1986 to December 1996, the Prospective Colorectal Service Database identified 1,120 consecutive patients who underwent major pelvic surgery for primary rectal cancer. Of these, 157 (15 percent) were 75 years of age or older and comprise the elderly group. From the remaining 963 patients younger than 75 years of age, a representative random sample of 174 was selected and constitutes the younger group. Data were obtained from computerized databases and confirmed via chart review and telephone interviews. RESULTS: Perioperative complications were observed in 53 (34 percent) elderly and 63 (36 percent; P = not significant) younger patients. Perioperative deaths occurred in two (1.3 percent) elderly and one (0.6 percent; P = not significant) younger patient. The median follow-up time was 48 months. Although the overall survival was lower in the elderly group (P = 0.02; the 5-year overall survival rates were 51 and 66 percent), the disease-specific survival rate was similar in the two groups (P = 0.75; the 5-year disease-specific survival rates were 69 and 71 percent). CONCLUSION: In select individuals 75 years of age or older, major pelvic surgery for primary rectal cancer can be done with perioperative morbidity and mortality rates comparable to those obtained in younger individuals, while achieving excellent disease-specific and overall long-term survival.

Inhibition of vascular K(ATP) channels by U-37883A: a comparison with cardiac and skeletal muscle.

1 The aim of this study was to investigate the selectivity of the ATP-sensitive potassium (K(ATP)) channel inhibitor U-37883A (4-morpholinecarboximidine-N-1-adamantyl-N'-1-cyclohexyl). Membrane currents through K(ATP) channels were recorded in single muscle cells enzymatically isolated from rat mesenteric artery, cardiac ventricle and skeletal muscle (flexor digitorum brevis). K(ATP) currents were induced either by cell dialysis with 0.1 mM ATP and 0.1 mM ADP, or by application of synthetic potassium channel openers (levcromakalim or pinacidil). 2 U-37883A inhibited K(ATP) currents in smooth muscle cells from rat mesenteric artery. Half inhibition of 10 microM levcromakalim-induced currents occurred at a concentration of 3.5 microM. 3 Relaxations of rat mesenteric vessels caused by levcromakalim were reversed by U-37883A. 1 microM levcromakalim-induced relaxations were inhibited at a similar concentration of U-37883A (half inhibition, 1.1 microM) to levcromakalim-induced KATP currents. 4 K(ATP) currents activated by 100 microM pinacidil were also studied in single myocytes from rat mesenteric artery, skeletal muscle and cardiac ventricle. 10 microM U-37883A substantially inhibited K(ATP) currents in vascular cells, but had little effect in skeletal or cardiac myocytes. Higher concentrations of U-37883A (100 microM) caused a modest decrease in K(ATP) currents in skeletal and cardiac muscle. The sulphonylurea K(ATP) channel antagonist glibenclamide (10 microM) abolished currents in all muscle types. 5 The effect of U-37883A on vascular inward rectifier (KIR) and voltage-dependent potassium (KV) currents was also examined. While 10 microM U-37883A had little effect on these currents, some inhibition was apparent at higher concentrations (100 microM) of the compound. 6 We conclude that U-37883A inhibits K(ATP) channels in arterial smooth muscle more effectively than in cardiac and skeletal muscle. Furthermore, this compound is selective for K(ATP) channels over KV and KIR channels in smooth muscle cells.

The effect of panel membership and feedback on ratings in a two-round Delphi survey: results of a randomized controlled trial.

BACKGROUND: Past observational studies of the RAND/UCLA Appropriateness Method have shown that the composition of panels affects the ratings that are obtained. Panels of mixed physicians make different judgments from panels of single specialty physicians, and physicians who use a procedure are more likely to rate it more highly than those who do not. OBJECTIVES: To determine the effect of using physicians and health care managers within a panel designed to assess quality indicators for primary care and to test the effect of different types of feedback within the panel process. METHOD: A two-round postal Delphi survey of health care managers and family physicians rated 240 potential indicators of quality of primary care in the United Kingdom to determine their face validity. Following round one, equal numbers of managers and physicians were randomly allocated to receive either collective (whole sample) or group-only (own professional group only) feedback, thus, creating four subgroups of two single-specialty panels and two mixed panels. RESULTS: Overall, managers rated the indicators significantly higher than physicians. Second-round scores were moderated by the type of feedback received with those receiving collective feedback influenced by the other professional group. CONCLUSIONS: This paper provides further experimental evidence that consensus panel judgments are influenced both by panel composition and by the type of feedback which is given to participants during the panel process. Careful attention must be given to the methods used to conduct consensus panel studies, and methods need to be described in detail when such studies are reported.