The field of geriatric medicine has long struggled with a relative lack of evidence-based studies and data. Randomized, controlled pharmaceutical trials are rare in the vulnerable older adult population, and this is particularly apparent in the post-acute and long-term care setting. A prime example was one of the major antihypertensive studies, the Hypertension in the Very Elderly Trial (HYVET), which specifically excluded nursing home residents (N Engl J Med 2008; 358:1887–1898).
Those of us practicing geriatrics and long-term care medicine have to find our way through education, experience, and trusted colleagues. We must also acknowledge the paucity of evidence-based literature. A scientific, structured, and methodical response to this is the modified Delphi process, in which experts are brought together to share their collective experiences and collaborate to find common ground. Everyone’s voice is heard, and ideas are filtered through a rigorous process to develop consensus-driven recommendations.
My first experience with the Delphi process was nearly two decades ago when I participated in the development of a set of clinical glidepaths for older adults (J Am Geriatr Soc 2002;50:1886–1901). Not long before the COVID-19 pandemic began, I finished writing the preface to the forthcoming 5th edition of Springer’s Geriatric Medicine: A Person-Centered Evidence-Based Approach, in which I wrote about the importance of the Delphi process in geriatric medicine. Shortly thereafter, the first report of COVID-19 in a Washington state nursing home came to our attention (New York Times, Feb. 29, 2020; https://nyti.ms/3e4Hrb7).
In an immediate response to the coming pandemic, the California Association of Long Term Care Medicine (CALTCM), the California state chapter of AMDA – The Society for Post-Acute and Long-Term Care Medicine, began to hold weekly webinars. Over the next couple of months, experts in geriatrics and long-term care medicine from around the country began corresponding via telephone, text, and email. One of those email threads began to focus on the issue of testing for COVID-19 in nursing homes. Using this as a starting point, CALTCM decided to put together a panel of experts from across the country to develop testing recommendations.
That first Delphi panel shared our findings with the Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention as well as the California Department of Public Health (CDPH) just before we published our recommendations (J Nutr Health Aging 2020;24:538–443). We are confident that our findings had an impact on governmental policy and guidance related to testing. We subsequently put together another Delphi panel to provide recommendations regarding visitation (J Am Med Dir Assoc 2020;21:1759–1766). Another expert-driven consensus process was formed around effectively using advance directives in nursing homes in the wake of the COVID-19 pandemic. The latter group was facilitated by the Coalition for Compassionate Care of California and led to a CDPH All-Facilities Letter on the topic (CDPH, AFL 20-72, Sept. 22, 2020; https://bit.ly/3eIbFQr).
In the summer of 2020, CDPH developed a proposal to impact the effectiveness of the survey process in California. We put together another Delphi panel to weigh in on their proposal. Although our panel’s recommendations were not incorporated CDPH’s final proposal, they may well provide a starting point for further discussion on this topic, which has gotten a lot more attention as of late (J Am Med Dir Assoc 2020;21:1818–1820; J Am Med Dir Assoc, April 3, 2021, https://doi.org/10.1016/j.jamda.2021.03.015).
In October 2020 we formed our Vaccine Implementation Delphi Group composed of experts who began to meet for discussions on developing the guidance and recommendations necessary for effective vaccine implementation in nursing homes. We were able to engage staff from the CDC and CMS in addition to the CDPH to informally participate in our group. We hope that this type of collaborative process continues with future projects because we have found it to be quite constructive. In December we put out our first consensus statement on implementing the vaccine in long-term care (CALTCM, “Vaccine Implementation Delphi Consensus Statement [Final],” https://bit.ly/2QH7ZXa). On January 8, 2021, we shared additional recommendations in an attempt to influence policy related to the vaccine rollout in long-term care (CALTCM, “Vaccine Delphi Recommendations 01082021,” https://bit.ly/3u57ch3). We recently sent a letter to CMS with further recommendations to maximize vaccination efforts in nursing homes (AMDA et al., Delphi LTC Vaccination Letter to CMS, March 26, 2021; https://bit.ly/3eNEpHI). This letter led to a productive meeting with CMS.
Many of us have long complained that the voices of the experts in geriatrics and PALTC medicine are often not heard by health systems, industry, and government. We hope that our Delphi Steering Committee and Delphi panels provide both a framework and methodology for effective engagement in the months and years ahead. Our experience developing recommendations on improving survey effectiveness was a reminder that the Delphi process doesn’t just have to be focused on clinical recommendations. Bringing experts together to develop consensus statements can help drive and develop a variety of policies.
The nursing home survey process seems ripe for this type of approach. The recent attention to long-term services and supports is also an area that lends itself to similar input from subject matter experts, rather than the more traditional “stakeholder” model. Geriatrics and PALTC medicine has found an effective and influential voice through the use of the Delphi process. We must build upon what we’ve started. The lives of vulnerable older adults depend on it.
Dr. Wasserman is a geriatrician and chair of CALTCM’s Public Policy Committee. He is medical director at Eisenberg Village, Los Angeles Jewish Home. He was formerly the CEO overseeing the largest nursing home chain in California and was Executive, Care Continuum for HSAG, the QIN-QIO in California. He can be reached at [email protected], or can be found on Twitter (@wassdoc). https://nyti.ms/3e4Hrb7