The RAND Corporation and the University of California developed a method to combine best evidence from clinical studies with the collective judgement of clinical experts to produce recommendations at the patient-specific level. Using a modified Delphi-method, a panel of experts is asked to rate the appropriateness of a medical or surgical procedure for a large number of hypothetical patient profiles (cases).

These cases are unique combinations of the values of several clinical variables, considered relevant by the panel for the decision making process. Based on scientific knowledge and personal insights, panellists firstly individually rate the appropriateness of a particular procedure for all patient profiles. Appropriateness is expressed using a 9-point scale in which a 9 is “extremely appropriate” and a 1 is “extremely inappropriate”. The panel then convenes to discuss the results, adapt (if needed) the rating structure, after which a second individual round is conducted. Based on the median panel score and the extent of agreement between panellists, final appropriateness statements (appropriate, inappropriate, uncertain) are then calculated for each of the patient profiles included.

Example of a final appropiateness statement

Since its development in the mid-eighties, approximately 150 of such panel studies have been conducted in various fields of medicine. The reliability and validity of the method has been studied extensively, generally with very favourable results.*

A professional mirror

Although the specificity of the recommendations forms the strength of the patient-tailored approach, the large number of different patient profiles used (often more than 3000), impedes the translation of the panel results to clear written guidelines. We therefore developed electronic decision tools that can be used by practising physicians as a ‘professional mirror’ to compare their personal decision with that of an expert panel. The program provides an interface by which the patient variables can be selected.

After documenting the initial decision, the panel recommendation is displayed, after which the user is ask to make his final decision. The electronic programs can be used as a web-based application or as an off line system.