Method

Selection of cases and topics

The Mirrors of Medicine PinPoint cases are clustered around essential topics (clinical questions) in daily practice. Topics and cases are selected and developed together with the experts and associated clinicians within a particular disease area:

MiMe schema

Best available evidence

In establishing the best available evidence for a clinical decision at the level of individual patients, the RAND/UCLA Appropriateness Method (RUAM)1 is used. This modified Delphi method has been applied in various fields of medicine, and is particularly helpful when the evidence from clinical studies is insufficient or insufficiently detailed to apply to the wide range of patients seen in everyday clinical practice.2 The RUAM encompasses a systematic approach to combine evidence from clinical studies with the collective judgment of experts.1 Several studies have shown that the RUAM produces reliable, internally consistent and clinically valid results.3

For each topic, a literature study is done to critically appraise and summarise the evidence from clinical studies. A multidisciplinary team of 9-15 experts is then asked to individually assess the appropriateness of diagnostic or therapeutic options included in the case series.

A diagnostic or therapeutic option is called ‘appropriate’ when the expected benefits (e.g. symptom reduction) exceed the expected risks (e.g. adverse events) by a sufficient margin.1 The extent of appropriateness is expressed using a 9-point scale in which 9 = extremely appropriate, 1 = extremely inappropriate, and 5 = equivocal or uncertain. Based on the median panel score and the extent of agreement, appropriateness statements (inappropriate, uncertain, appropriate) are calculated for all clinical options included in the model.

Updates

Periodic meetings (face-to-face or WebEx) are organised by the editors to discuss the results in light of the available evidence from clinical studies. Where needed, re-ratings are performed. All materials are reviewed and approved by the panel members.

  1. Brook RH, Chassin MR, Fink A, et al. A method for the detailed assessment of the appropriateness of medical technologies. Int J Technol Assess Health Care 1986;2:53-63.
  2. Fitch K, Bernstein SJ, Aguilar MD, et al. The RAND/UCLA Appropriateness Method. Santa Monica: RAND, 2001.
  3. Lawson EH, Gibbons MM, Ko CY, Shekelle PG. The appropriateness method has acceptable reliability and validity for assessing overuse and underuse of surgical procedures. J Clin Epidemiol 2012;65:1133-43.