Patient-specific approach

The Mirrors of Medicine models are developed using the RAND/UCLA Appropriateness Method (RUAM).1 This modified Delphi method has been used 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 model, 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 treatment options for a series of patient profiles that has been prepared by the Scientific Committee and reviewed by all participants.

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.

A conference is organised to discuss the results in light of the available evidence from clinical studies. Thereafter a second individual rating round is conducted. Based on the second round ratings and the results of the panel discussion, a summary of the available evidence is prepared for each of the clinical scenarios included in the model. After review and approval by the Scientific Committee and panel members, the final model is established.

  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.