Reliability of clinical guideline development using mail-only versus in-person expert panels.
BACKGROUND
Clinical practice guidelines quickly become outdated. One reason they might not be updated as often as needed is the expense of collecting expert judgment regarding the evidence. The RAND-UCLA Appropriateness Method is one commonly used method for collecting expert opinion. We tested whether a less expensive, mail-only process could substitute for the standard in-person process normally used.


METHODS
We performed a 4-way replication of the appropriateness panel process for coronary revascularization and hysterectomy, conducting 3 panels using the conventional in-person method and 1 panel entirely by mail. All indications were classified as inappropriate or not (to evaluate overuse), and coronary revascularization indications were classified as necessary or not (to evaluate underuse). Kappa statistics were calculated for the comparison in ratings from the 2 methods.


RESULTS
Agreement beyond chance between the 2 panel methods ranged from moderate to substantial. The kappa statistic to detect overuse was 0.57 for coronary revascularization and 0.70 for hysterectomy. The kappa statistic to detect coronary revascularization underuse was 0.76. There were no cases in which coronary revascularization was considered inappropriate by 1 method, but necessary or appropriate by the other. Three of 636 (0.5%) hysterectomy cases were categorized as inappropriate by 1 method but appropriate by the other.


CONCLUSIONS
The reproducibility of the overuse and underuse assessments from the mail-only compared with the conventional in-person conduct of expert panels in this application was similar to the underlying reproducibility of the process. This suggests a potential role for updating guidelines using an expert judgment process conducted entirely through the mail.
Washington
Donna L
DL
VA Greater Los Angeles Healthcare System, Los Angeles, California 90073, USA. donna.washington@med.va.gov
Bernstein
Steven J
SJ
Kahan
James P
JP
Leape
Lucian L
LL
Kamberg
Caren J
CJ
Shekelle
Paul G
PG
D002983:Clinical Competence; D032921:Consensus; D015709:Correspondence as Topic; D003362:Cost-Benefit Analysis; D003697:Delphi Technique; D019317:Evidence-Based Medicine / Q000379:methods* / Q000592:standards; D030141:Feedback, Psychological; D005260:Female; D006300:Health Services Misuse; D006801:Humans; D007044:Hysterectomy / Q000592:standards / Q000706:statistics & numerical data; D008297:Male; D009204:Myocardial Revascularization / Q000592:standards / Q000706:statistics & numerical data; D018579:Patient Selection; D017410:Practice Guidelines as Topic / Q000592:standards; D011367:Professional Staff Committees / Q000191:economics / Q000592:standards*; D012680:Sensitivity and Specificity; D013997:Time Factors