Using a modified Delphi methodology to gain consensus on the use of dressings in chronic wounds management

Objective: Managing chronic wounds is associated with a burden to patients, caregivers, health services and society and there is a lack of clarity regarding the role of dressings in improving outcomes. This study aimed to provide understanding on a range of topics, including: the definition of chronicity in wounds, the burden of illness, clinical outcomes of reducing healing time and the impact of early interventions on clinical and economic outcomes and the role of matrix metalloproteinases (MMPs) in wound healing. Method: A systematic review of the literature was carried out on the role of dressings in diabetic foot ulcer (DFU), and venous leg ulcer (VLU) management strategies, their effectiveness, associated resource use/cost, and quality of life (QoL) impact on patients. From this evidence-base statements were written regarding chronicity in wounds, burden of illness, healing time, and the role of MMPs, early interventions and dressings. A modified Delphi methodology involving two iterations of email questionnaires followed by a face-to-face meeting was used to validate the statements, in order to arrive at a consensus for each. Clinical experts were selected, representing nurses, surgeons, podiatrists, academics, and policy experts. Results: In the first round, 38/47 statements reached or exceeded the consensus threshold of 80% and none were rejected. According to the protocol, any statement not confirmed or rejected had to be modified using the comments from participants and resubmitted. In the second round, 5/9 remaining statements were confirmed and none rejected, leaving 4 to discuss at the meeting. All final statements were confirmed with at least 80% consensus. Conclusion: This modified Delphi panel sought to gain clarity from clinical experts surrounding the use of dressings in the management of chronic wounds. A full consensus statement was developed to help clinicians and policy makers improve the management of patients with these conditions

Three Residency Programs’ Lessons Learned about Disparities from a Deep Dive into Our Population Data

Introduction/Background To deliver person-centric, best-in class health care we must transition to value-based care. As part of managing this transition, we must identify at risk populations – those with disparities in clinical measures - by leveraging our existing data sets to provide actionable data to inform how we manage these populations. Currently our health care system provides clinical quality metrics to support providers’ ability to engage in continuous improvement. This data is complimented by provider’s knowledge of the literature, which consistently identifies certain populations, often using the REAL-G categories, as at risk. For example, hypertension has well established risk factors including age, gender, and race: HTN increases through early middle age; women are more likely to develop HTN \u3e 65; HTN is more common among blacks. However, our current clinical quality data does not normally provide detailed clinical/service level population specific metrics (e.g., REAL-G specific data) limiting providers’ ability to understand the clinical quality disparities in their patient populations. Hypothesis/Aim Statement To identify actionable disparity gaps for quality improvement through detailed analysis of selected clinic level quality metrics by REAL-G Categories (Race, Ethnicity, Age, Language, Gender). Methods Three residency programs participating in the Alliance of Independent Academic Medical Center’s National Initiative V (AIAMC-NIV) identified a current system-wide quality metric that was not at/above system goal: Family Medicine - colorectal cancer (CRC) screening; Internal Medicine – diabetes; and Ob/Gyn - postpartum readmission for hypertension. Through a partnership between Graduate Medical Education (GME) and Service Quality leaders, a retrospective analysis of selected quality metrics was undertaken to determine if there were disparities using REAL-G categories over a 12-month period (12.2014-11.2015). Each residency team then reviewed the data to identify the largest disparities by REAL-G category for quality improvement. Results The largest disparities in our clinics/service areas were sometimes consistent with the literature (e.g., 65% of African American DM Patients \u3e HbA1cs compared to 70% of White-Hispanic and 71% White-Non Hispanic) but not always! For example the largest CRC screening disparity was not race, ethnicity or gender ( Conclusions Diving into our clinical quality metrics using REAL-G categories, provided the actionable data needed in each of our three residency programs to plan disparity targeted improvement cycles