Psoriasis is a condition in which skin cells build up and form scales and itchy, dry patches. It is a challenging condition to treat considering the lack of literature, the simultaneous presence of 2 chronic diseases in patients, and in its difficulty to diagnose. A consensus panel of 14 experts in the psoriasis field was formed to use a Delphi method exercise for the purpose of identifying challenging clinical scenarios and to rank treatment approaches, in an effort to provide guidance to the practicing clinician. The Delphi method is well suited to address healthcare-related issues since the outcome is the representation of the collective judgment of the panel of experts. The 3 basic characteristics of the Delphi method include:
1. Repeated individual questioning of the experts
2. The avoidance of direct confrontation among the experts
3. Interspersed controlled opinion and feedback\
The Delphi method works to achieve a consensus on complex scenarios where rigorous data is lacking. The panelists extensively review all available data before presenting and discussing it. One of the most important aspects is the use of anonymous voting by the panelists as it eliminates the effects of reputation in order to settle controversy. The anonymity also allows panelists to vote honestly, thus avoiding “groupthink” and as well as any following of charismatic panelists and dogmatism. Delphi is applied in 3 steps over about 5 months to difficult-to-treat clinical scenarios in patients with moderate-to-severe psoriasis. The steps are:
1. Selection of difficult-to-treat psoriasis clinical scenarios;
2. Selection of potential psoriasis treatment
3. The matching, through systematic, iterative rounds of voting of clinical scenarios with the most appropriate treatments based on data assessment of peer-reviewed literature.
Once 14 psoriasis experts from the U.S. were identified, each individual panelist was asked to list challenging clinical scenarios and therapeutic options for psoriasis. The scenarios were then selected and ranked, and the treatment options were listed. The panelists discussed 24 of the top-ranked scenarios during a live meeting and they voted and ranked the treatment choices for each. The article presents 5 of the 24 discussed case scenarios. The Delphi exercise resulted in guidelines for practicing physicians to use when confronted with patients with challenging cases of psoriasis.
Critique:While the Delphi method is well suited to address healthcare-related issues as the panel of experts select rational treatment choices for each of their discussed scenarios, their solutions are not yet supported by rigorous studies to back up their conclusions as well as the effectiveness of Delphi. Delphi has potential limitations with conflicting interests among the panelists and their experiences and backgrounds. Additionally, the experts were only chosen from the U.S. along with treatment options based on what is locally available in the U.S. so conclusions may not be relevant world-wide. Nonetheless, Delphi’s use of anonymity provides an unbiased view of available clinical data which leads to a more objective consensus in accomplishing the goal.
"A Delphi Consensus Approach to Challenging Case Scenarios in Moderate-to-Severe Psoriasis: Part 2"
By: Bruce E. Strober, Jennifer Clay Cather, David Cohen, Jeffrey J. Crowley, Kenneth B. Gordon, Alice B. Gottlieb, Arthur F. Kavanaugh, Neil J. Korman, Gerald G. Krueger, Craig L. Leonardi, Sergio Schwartzman, Jeffrey M. Sobell, Gary E. Solomon, and Melodie Young