We Agree, Don't We? The Delphi Method for Health Environments Research

Multidisciplinary DEprescribing review for Frail oldER adults in long-term care (DEFERAL): Implementation strategy design using behaviour science tools and stakeholder engagement

INTRODUCTION

Deprescribing is a strategy for reducing the use of potentially inappropriate medications for older adults. Limited evidence exists on the development of strategies to support healthcare professionals (HCPs) deprescribing for frail older adults in long-term care (LTC).

OBJECTIVE

To design an implementation strategy, informed by theory, behavioural science and consensus from HCPs, which facilitates deprescribing in LTC.

METHODS

This study was consisted of 3 phases. First, factors influencing deprescribing in LTC were mapped to behaviour change techniques (BCTs) using the Behaviour Change Wheel and two published BCT taxonomies. Second, a Delphi survey of purposively sampled HCPs (general practitioners, pharmacists, nurses, geriatricians and psychiatrists) was conducted to select feasible BCTs to support deprescribing. The Delphi consisted of two rounds. Using Delphi results and literature on BCTs used in effective deprescribing interventions, BCTs which could form an implementation strategy were shortlisted by the research team based on acceptability, practicability and effectiveness. Finally, a roundtable discussion was held with a purposeful, convenience sample of LTC general practitioners, pharmacists and nurses to prioritise factors influencing deprescribing and tailor the proposed strategies for LTC.

RESULTS

Factors influencing deprescribing in LTC were mapped to 34 BCTs. The Delphi survey was completed by 16 participants. Participants reached consensus that 26 BCTs were feasible. Following the research team assessment, 21 BCTs were included in the roundtable. The roundtable discussion identified lack of resources as the primary barrier to address. The agreed implementation strategy incorporated 11 BCTs and consisted of an education-enhanced 3-monthly multidisciplinary team deprescribing review, led by a nurse, conducted at the LTC site.

CONCLUSION

The deprescribing strategy incorporates HCPs' experiential understanding of the nuances of LTC and thus addresses systemic barriers to deprescribing in this context. The strategy designed addresses five determinants of behaviour to best support HCPs engaging with deprescribing.

Expert consensus guidance on respiratory physiotherapy and rehabilitation of patients with rib fractures: An international, multidisciplinary e-Delphi study

BACKGROUND

There is limited research supporting optimal respiratory physiotherapy or physical rehabilitation strategies for patients with rib fractures. The aim of this study was to develop key recommendations for the physiotherapy management of patients with rib fractures.

METHODS

A three-round modified e-Delphi survey design, using an international Delphi panel including physiotherapy clinicians, researchers and lecturers, physician associates, trauma surgeons, and intensivists, was used in this study. The draft recommendations were developed by the Steering Group, based on available research. Over three rounds, panelists rated their agreement (using a Likert scale) with regard to recommendation for physiotherapists delivering respiratory physiotherapy and physical rehabilitation to patients following rib fractures. Recommendations were retained if they achieved consensus (defined as ≥70% of panelists ≥5/7) at the end of each round.

RESULTS

A total of 121 participants from 18 countries registered to participate in the study, with 87 (72%), 77 (64%), and 79 (65%) registrants completing the three rounds, respectively. The final guidance document included 18 respiratory physiotherapy and rehabilitation recommendations, mapped over seven clinical scenarios for patients (1) not requiring mechanical ventilation, (2) requiring mechanical ventilation, (3) with no concurrent fracture of the shoulder girdle complex, (4) with a concurrent fracture of the shoulder girdle complex, (5) with/without concurrent upper limb orthopedic injuries, (6) undergoing surgical stabilization of rib fractures, and (7) at hospital discharge.

CONCLUSION

This guidance provides key recommendations for respiratory physiotherapy and physical rehabilitation of patients with rib fractures. It could also be used to inform future research priorities in the field.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Acid sphingomyelinase deficiency (ASMD): addressing knowledge gaps in unmet needs and patient journey in Italy-a Delphi consensus

Acid sphingomyelinase deficiency (ASMD) is an ultra-rare disease, and several gaps of knowledge on various issues remain, particularly at a regional/national level. Expert opinions collected through well-defined consensus methodologies are increasingly used to make available reliable information in the context of rare/ultra-rare diseases. With the aim to provide indications on infantile neurovisceral ASMD (also formerly known as Niemann-Pick disease type A), chronic neurovisceral ASMD (formerly known as Niemann-Pick disease type A/B) and chronic visceral ASMD (formerly known as Niemann-Pick disease type B) in Italy, we conducted a Delphi consensus of experts focused on five main areas: (i) patients and disease characteristics; (ii) unmet needs and quality of life; (iii) diagnostic issues; (iv) treatment-related aspects; and (v) patient journey. Pre-specified, objective criteria were used to outline the multidisciplinary panel, based on 19 Italian experts in ASMD in paediatric and adult patients from different Italian Regions, including both clinicians (n = 16) and ASMD patients' advocacy or payors with expertise in rare diseases (n = 3). During two Delphi rounds, a high ratio of agreement was found on several topics related to ASMD characteristics, diagnosis, management and disease burden. Our findings may provide valuable indications for management of ASMD at a public health level in Italy.

Lexicon for adrenal terms at CT and MRI: a consensus of the Society of Abdominal Radiology adrenal neoplasm disease-focused panel

PURPOSE

Substantial variation in imaging terms used to describe the adrenal gland and adrenal findings leads to ambiguity and uncertainty in radiology reports and subsequently their understanding by referring clinicians. The purpose of this study was to develop a standardized lexicon to describe adrenal imaging findings at CT and MRI.

METHODS

Fourteen members of the Society of Abdominal Radiology adrenal neoplasm disease-focused panel (SAR-DFP) including one endocrine surgeon participated to develop an adrenal lexicon using a modified Delphi process to reach consensus. Five radiologists prepared a preliminary list of 35 imaging terms that was sent to the full group as an online survey (19 general imaging terms, 9 specific to CT, and 7 specific to MRI). In the first round, members voted on terms to be included and proposed definitions; subsequent two rounds were used to achieve consensus on definitions (defined as ≥ 80% agreement).

RESULTS

Consensus for inclusion was reached on 33/35 terms with two terms excluded (anterior limb and normal adrenal size measurements). Greater than 80% consensus was reached on the definitions for 15 terms following the first round, with subsequent consensus achieved for the definitions of the remaining 18 terms following two additional rounds. No included term had remaining disagreement.

CONCLUSION

Expert consensus produced a standardized lexicon for reporting adrenal findings at CT and MRI. The use of this consensus lexicon should improve radiology report clarity, standardize clinical and research terminology, and reduce uncertainty for referring providers when adrenal findings are present.

Screening criteria for interstitial lung disease associated to rheumatoid arthritis: Expert proposal based on Delphi methodology

OBJECTIVE

To develop a joint proposal for screening criteria of interstitial lung disease (ILD) in patients with rheumatoid arthritis (RA) and vice versa, which serves as a guidelines in patient referral between the Rheumatology and Pneumology departments to early detection of these patients.

METHODS

A systematic literature review was carried out on the risk factors for the development of ILD in RA patients, and for the referral criteria to Rheumatology for suspected early RA. Based on the available evidence, screening criteria were agreed using the Delphi method by a panel of pneumologists and rheumatologists with expertise in these pathologies.

RESULTS

Screening criteria for ILD in patients with RA and for the early detection of RA in cases with ILD of unknown etiology have been developed. In both cases, a detection strategy was based on clinical risk factors. Recommendations also included the complementary tests to be carried out in the different clinical scenarios and on the periodicity that screening should be repeated.

CONCLUSION

A selective screening strategy is recommended for the first time in the early diagnosis of patients with ILD-RA. This multidisciplinary proposal aims to solve some common clinical questions and help decision-making, although its usefulness to identify these patients with good sensitivity must be confirmed in a validation study.

Psychometric Properties of an Instrument to Determine the Factors Affecting Treatment Adherence Among Patients Receiving Hemodialysis in Sri Lanka

Nonadherence is a widespread problem among patients receiving hemodialysis, while contributing factors are underexplored due to lack of a validated instrument. The study aimed to develop and validate a new disease-specific instrument determining the factors affecting treatment adherence behaviors among patients receiving hemodialysis in a Sri Lankan hospital. The content validation process using a modified Delphi technique suggested 42-item instrument with an average Item-level Content Validity Index (I-CVI) of 0.94. Subsequent principal component analysis (PCA) revealed 5 components with 17 items (patient-centered psychological and physical factors, factors associated with health care, hemodialysis therapy-related factors, socioeconomic factors, and factors associated with the continuity of the treatment), explaining 67.24% total variance. The reliability estimate based on Mislevy and Bock for each component greater than 0.8 and overall standardized Cronbach's alpha of 0.605, indicated acceptable internal consistency reliability. Root mean square residual (RMSR) and weighted root mean square residual (WRMR) indices of 0.084 and 0.059, respectively, indicated acceptable model fit. The final 17-item instrument provides a valid measure for the factors affecting treatment adherence behaviors of the patients receiving hemodialysis in a Sri Lankan hospital.

The Societal Value of Vaccines: Expert-Based Conceptual Framework and Methods Using COVID-19 Vaccines as a Case Study

Health technology assessments (HTAs) of vaccines typically focus on the direct health benefits to individuals and healthcare systems. COVID-19 highlighted the widespread societal impact of infectious diseases and the value of vaccines in averting adverse clinical consequences and in maintaining or resuming social and economic activities. Using COVID-19 as a case study, this research work aimed to set forth a conceptual framework capturing the broader value elements of vaccines and to identify appropriate methods to quantify value elements not routinely considered in HTAs. A two-step approach was adopted, combining a targeted literature review and three rounds of expert elicitation based on a modified Delphi method, leading to a conceptual framework of 30 value elements related to broader health effects, societal and economic impact, public finances, and uncertainty value. When applying the framework to COVID-19 vaccines in post-pandemic settings, 13 value elements were consensually rated highly important by the experts for consideration in HTAs. The experts reviewed over 10 methods that could be leveraged to quantify broader value elements and provided technical forward-looking recommendations. Limitations of the framework and the identified methods were discussed. This study supplements ongoing efforts aimed towards a broader recognition of the full societal value of vaccines.

Comparison of the Users' Attitudes Toward Cannabidiol on Social Media Platforms: Topic Modeling Study

BACKGROUND

As one of the major constituents of the cannabis sativa plant, cannabidiol (CBD) is approved for use in medical treatment and cosmetics because of its potential health benefits. With the rapid growth of the CBD market, customers purchase these products, and relevant discussions are becoming more active on social media.

OBJECTIVE

In this study, we aimed to understand the users' attitudes toward CBD products in various countries by conducting text mining on social media in countries with different substance management policies.

METHODS

We collected posts from Reddit and Xiaohongshu, conducted topic mining using the latent Dirichlet allocation model, and analyzed the characteristics of topics on different social media. Subsequently, a co-occurrence network of high-frequency keywords was constructed to explore potential relationships among topics. Moreover, we conducted sentiment analysis on the posts' comments and compared users' attitudes toward CBD products on Reddit and Xiaohongshu using chi-square test.

RESULTS

CBD-related posts on social media have been rapidly increasing, especially on Xiaohongshu since 2019. A total of 1790 posts from Reddit and 1951 posts from Xiaohongshu were included in the final analysis. The posts on the 2 social media platforms, Reddit and Xiaohongshu, were categorized into 7 and 8 topics, respectively, by the latent Dirichlet allocation model, and these topics on the 2 social media were grouped into 5 themes. Our study showed that the themes on Reddit were mainly related to the therapeutic effects of CBD, whereas the themes on Xiaohongshu concentrated on cosmetics, such as facial masks. Theme 2 (CBD market information) and theme 3 (attitudes toward CBD) on Reddit had more connections with other themes in the co-occurrence network, and theme 3 and theme 1 (CBD therapeutic effects) had a high co-occurrence frequency (22,803/73,865, 30.87%). Meanwhile, theme 1 (CBD cosmetics) on Xiaohongshu had various connections with others (169,961/384,575, 44.19%), and the co-occurrence frequency of theme 4 (CBD ingredients) and theme 1 was relatively prominent (27,128/49,312, 55.01%). Overall, users' comments tended to be positive for CBD-related information on both Reddit and Xiaohongshu, but the percentage was higher on Xiaohongshu (82.25% vs 86.18%; P<.001), especially in cosmetics and medical health care products.

CONCLUSIONS

The CBD market has grown rapidly, and the topics related to CBD on social media have become active. There are apparent differences in users' attitudes toward CBD in countries with different substance management policies. Targeted CBD management measures should be formulated to suit the prevalence of CBD use of each country.

Identification and management of connective tissue disease-associated interstitial lung disease: evidence-based Japanese consensus statements

BACKGROUND

Interstitial lung disease (ILD) is a common complication of connective tissue diseases (CTD), but there are few clinical trials to guide disease management. We aimed to develop expert consensus statements and an algorithm for CTD-ILD management.

RESEARCH DESIGN AND METHODS

Based on a targeted literature review, we developed 109 statements on managing CTD-ILD across six domains. We used a modified Delphi process to survey 22 physicians in Japan involved in managing CTD-ILD (specialists in pulmonology, rheumatology, pathology, and radiology). These panelists participated in two rounds of web-based survey to establish consensus statements, which were used to define an algorithm. Consensus was defined as a mean value ≥70 on a scale of 0 (strong disagreement) to 100 (strong agreement).

RESULTS

Between May-August 2022, consensus was reached on 93 statements on CTD-ILD management. The most important consensus statements included screening CTD patients for ILD (typically with high-resolution computed tomography), using imaging, pulmonary function testing and serum biomarkers for diagnosis and severity assessment, regularly following up patients, and multidisciplinary management of CTD-ILD. Consensus statements were interpreted into an algorithm for clinical guidance.

CONCLUSIONS

Using the Delphi process, we have developed consensus statements and an algorithm to guide clinical decision-making for CTD-ILD.

Utilizing the Delphi method to develop parent and child surveys to understand exposure to farming hazards and attitudes toward farm safety

Children on farms are at increased risk of injury. In Australia, children under 15 years consistently represent ~15% of all farm-related fatalities. This study aimed to develop parent and child surveys to gain a greater understanding of children's (5-14 years) exposure to occupational risk on farms by exploring their exposure to farm hazards, risk-taking behavior, their use and attitudes toward safety measures, and experience of farm-related injury. As farming communities are heterogeneous, a modified Delphi method was undertaken to ensure input from a diverse group. Seventeen experts participated in a three round process-the first two rounds required rating of proposed survey questions in an online questionnaire and the final round was an online discussion. Consensus was defined as 75% agreement or higher. This process resulted in 155 parent questions and 124 child questions reaching consensus to include. The modified Delphi method developed surveys that provide insight into the behaviors and attitudes of children (individuals) and their parents on farms (family) and will assist in informing how community, organizations and policy frameworks can improve child safety on farms. It will assist in identifying and understanding common farming exposures/behaviors of children and their parents to inform the development of targeted and culturally appropriate injury prevention strategies. As farming groups are heterogeneous, these survey scan be used on varying farming cohorts to identify their unique farming hazards and challenges. Child farm-related injuries are a problem globally and must be addressed; children are dependent on adults and communities to create safe environments for them.

Stakeholder-driven principles for advancing equity through shared measurement

OBJECTIVE

To advance equity by developing stakeholder-driven principles of shared measurement, which is using a common set of measurable goals that reflect shared priorities across communities and systems, such as health care, public health, and human and social services.

DATA SOURCES

From October 2019 to July 2021, we collected primary data from leaders in cross-systems alignment, measurement, and community engagement-including community members and community-based organization leaders-across the United States.

STUDY DESIGN

In partnership with equity and community engagement experts, we conducted a mixed-methods study that included multiple formative research activities and culminated in a six-week, stakeholder-engaged modified-Delphi process.

DATA COLLECTION

Formative data collection occurred through an environmental scan, interviews, focus groups, and an online survey. Principles were developed using a virtual modified Delphi with iterative rapid-analysis. Feedback on the final principles was collected through virtual focus groups, an online feedback form, and during virtual presentations.

PRINCIPAL FINDINGS

We developed a set of five guiding principles. Measurement that aligns systems with communities toward equitable outcomes: (1) Requires upfront investment in communities; (2) Is co-created by communities; (3) Creates accountability to communities for addressing root causes of inequities and repairing harm; (4) Focuses on a holistic and comprehensive view of communities that highlights assets and historical context; and (5) Reflects long-term efforts to build trust. Using an equity-focused process resulted in principles with broad applicability.

CONCLUSIONS

Leaders across systems and communities can use these shared measurement principles to reimagine and transform how systems create equitable health by centering the needs and priorities of the communities they serve, particularly communities that historically have been harmed the most by inequities. Intentionally centering equity across all project activities was essential to producing principles that could guide others in advancing equity.

Comprehensive evaluation of military training-induced fatigue among soldiers in China: A Delphi consensus study

Objective

Military training-induced fatigue (MIF) often results into non-combat attrition. However, standard evaluation of MIF is unavailable. This study aimed to provide credible suggestions about MIF-evaluation.

Methods

A 3-round Delphi study was performed. The authority of the experts was assessed by the authority coefficient (Aa). In round 1, categories of indicators were collected via anonymous survey of experts, then potential indicators were selected via literature search. In round 2, experts should evaluate the clinical implication, practical value, and importance of each potential indicators, or recommend new indicators based on feedback of round 1. Indicators with recommendation proportions ≥ 70% and new recommended indicators would be included in round 3 to be rated on a 5-point Likert scale. "Consensus in" was achieved when coefficient of concordance (Kendall's W) of a round was between 0.2 and 0.5 and the coefficient of variation (CV) of each aspect for an indicator was < 0.5. If round 3 could not achieve "consensus in," more rounds would be conducted iteratively based on round 3. Indicators included in the recommendation set were ultimately classified into grade I (highly recommended) or grade II (recommended) according to the mean score and CV of the aspects.

Results

Twenty-three experts participated with credible authority coefficient (mean Aa = 0.733). "Consensus in" was achieved in round 3 (Kendall's W = 0.435, p < 0.001; all CV < 0.5). Round 1 recommended 10 categories with 73 indicators identified from 2,971 articles. After 3-round consultation, consensus was reached on 28 indicators focusing on the cardiovascular system (n = 4), oxygen transport system (n = 5), energy metabolism/metabolite level (n = 6), muscle/tissue damage level (n = 3), neurological function (n = 2), neuropsychological/psychological function (n = 3), endocrine function (n = 3), and exercise capacity (n = 2). Among these, 11 indicators were recommended as grade I: basic heart rate, heart-rate recovery time, heart rate variability, hemoglobin, blood lactic acid, urine protein, creatine kinase, reaction time, Borg Rating of Perceived Exertion Scale, testosterone/cortisol, and vertical jump height.

Conclusion

This study developed a reliable foundation for the comprehensive evaluation of MIF among soldiers.

Identifying the important social outcomes for childhood cancer survivors: an e-Delphi study protocol

INTRODUCTION

Optimising the health of childhood cancer survivors is important given the high long-term survival rate coupled with a significant late effects burden. Included within the WHO's definition of 'Health' are social outcomes. These are of interest given their impact on adult functioning within society, complex interactions with physical and mental health outcomes and potential for cross generational effects. Categories included within the definition of social outcomes are ill defined leading to potential gaps in research and service provision which could affect the ability of survivors to achieve their maximal potential. An e-Delphi study will be used to achieve expert consensus on the most important social outcomes for childhood cancer survivors to inform future research and ultimately, service provision.

METHODS AND ANALYSIS

A heterogeneous sample of at least 48 panel members will be recruited across four groups chosen to provide different perspectives on the childhood cancer journey: childhood cancer survivors, health professionals, social workers and teachers. Purposive sampling from a UK, regional long-term follow-up clinic will be used to recruit a representative sample of survivors. Other panel members will be recruited through local channels and national professional working groups. Opinions regarding breakdown and relevance of categories of social outcome will be collected through 3-5 rounds of questionnaires using an e-Delphi technique. Open ended, 7-point Likert scale and ranking questions will be used. Each round will be analysed collectively and per group to assess inter-rater agreement. Agreement and strength of agreement will be indicated by a median score of 6 or 7 and mean absolute deviation from the median, respectively.

ETHICS AND DISSEMINATION

Ethical approval for this study has been granted by Regional Ethics Committee 4, West of Scotland (ID 297344). Study findings will be disseminated to involved stakeholders, published in a peer-reviewed journal and presented at conferences.

Validation of a Script to Facilitate Social Determinant of Health Conversations with Adolescent Patients

Current social determinants of health (SDOH) tools exist to assess patient exposure; however, healthcare providers for the adolescent population are unsure of how to integrate SDOH knowledge into clinical practice. The purpose of this study was to validate a focused history script designed to facilitate SDOH conversations between clinicians and adolescents through the use of the Delphi method. Six individuals (1 clinician, 5 educators/researchers) participated as expert panelists. Panelists provided critical feedback on the script for rounds 1 and 2. For rounds 3-7, panelists received an electronic questionnaire asking them to indicate agreement on a 6-point Likert scale (1 = strongly disagree, 6 = strongly agree). We defined consensus as mean item agreement ≥ 5.0 and percent agreement ≥ 80%. In round 7, panelists rated overall script level of agreement. After seven rounds of feedback, the focused history script achieved content validity with 100% of panelists agreeing on the final 40-item script. A focused history script for the SDOH was content validated to aid conversations between healthcare providers and adolescent patients on factors that affect their life, school, and play. Addressing social determinants of health with adolescent patients will improve cultural proficiency and family-centered care delivered by school healthcare professionals.

Maternity research priorities in country Western Australia: a Delphi study

Objective Health research priorities are commonly identified and resourced by strategic leaders. The importance of recognising the expertise of clinician-researchers is being prioritised by a national funding shift towards applied research. There is a dearth of evidence regarding research priorities for maternity care in rural and remote health in Australia. This study aimed to develop an evidence-based consensus of maternity research priorities in regional, rural, and remote areas of Australia's largest rural health service (by land area) in Western Australia. Methods A three-phased Delphi method was selected to achieve an interdisciplinary, evidence-based consensus on maternity research priorities within Western Australian Country Health Service. Results Across three study phases, 432 participants responded. Representation was from seven regions and all stakeholder roles within the regions. Phase 1 included 173 responses yielding 53 concepts categorised under five domains. Phase 2 involved 161 participants who prioritised concepts under domains of (i) workforce and education; (ii) health equity; (iii) Aboriginal health; (iv) logistics and health systems; and (v) clinical. Phase 3 included 96 participants revealing 15 maternity research priorities with the top four ranked concepts: 'recruitment and retention of staff'; 'care for women and families with vulnerabilities', 'models of care offering continuity' and 'systems efficiencies'. Conclusions The novel evidence provided in this study, in conjunction with a strong consensus on research priorities and an interdisciplinary approach, strengthens the findings of this study and amplifies the mandate of action without delay.

Development and Validation of New Exercises to Promote Physical Activity in Nursing Home Settings

Background: GAMotion is a giant physical activity board game intended to improve levels of physical activity and a broader array of physical and psychological outcomes among nursing home residents. Objective: The aim of the present study is to develop and validate new balance, flexibility, muscle strength, and walking exercises to be included in GAMotion. Methods: A two-step design combining the Focus group and Delphi method was conducted among healthcare professionals divided into two independent samples of experts. The first sample was asked to develop exercises during a focus group. The second sample participated in a two-round Ranking-type Delphi method. During the first round, the participants were asked to rate the exercises developed during the focus group on a four-point Likert scale (from 1: not adapted at all to 4: very adapted). The exercises that did not reach consensus were removed (consensus established: median ≥ 3 on the Likert scale and at least 75% of experts rating the exercises as « adapted » or « very adapted »). During the second round, it was asked to rank the exercises selected at the end of the first round from most suitable to least suitable. Results: The Focus group developed nine balance, twelve flexibility, twelve strength, and nine walking exercises. Following the first round of the Delphi method, two exercises in each category did not reach a consensus and were then removed. In the second round, the remaining seven balance, ten flexibility, ten strength, and seven walking exercises were ranked by the experts, and this classification allowed us to determine the four most suitable exercises from each category to be included in the GAMotion. Conclusion: A consensus-based approach among healthcare professionals allowed us to contribute to the development of new exercises to promote physical activity in nursing homes. These validated exercises can be included in the GAMotion board game.

Design a protocol to investigate the effects of climate change in vivo

Climate change has a variety of effects on communities and the environment, most of which have been directly addressed, such as floods, droughts, and fires. To date, the impacts of climate change on health in in vivo conditions have not been assessed, and no protocol has been developed in this regard. Therefore, the purpose of the current study is to develop a protocol as well as design and build a pilot to deal with climate change in vivo to show the direct effects of climate change on health. For this purpose, twenty specialists, comprising ten experts active in field climate and 10 experts in field medicine and anatomy, have been consulted to design the proposed exposure protocol using the Delphi method. According to the prepared protocol, an exposure pilot was then designed and built, which provides the climatic conditions for animal exposure with a fully automatic HMI-PLC system. The results showed the average 12:12-h day/night temperature, humidity, and circadian cycle for three consecutive ten-year periods selected for exposure of 1-month-old male rats. The duration of the exposure period is four months, which is equivalent to a ten-year climatic period. This study is a framework and a starting point for examining the effects of climate change on in vivo conditions that have not yet been considered.

Developing consensus in Histopathology: the role of the Delphi method

The Delphi method is a well-established research tool, used for consensus building across a number of fields. Despite its widespread use, and popularity in many medical specialities, there is a paucity of literature on the use of the Delphi method in Histopathology. This literature review seeks to critique the Delphi methodology and explore its potential applications to histopathology-based clinical and research questions. We review those published studies that have utilized the Delphi methodology in Histopathology settings and specifically outline the advantages and limitations of this technique, highlighting situations where its application can be most effective.

Preference Testing in Medical Devices: Current Framework and Regulatory Gaps

Preference testing is a valuable source of information that can be provided by both healthcare professionals (HCPs) and patients (users). It can be used to improve the design and development of medical devices by feeding into device usability and, ultimately, risk management. Furthermore, it can aid with selecting the most appropriate clinical endpoints to be used in the clinical evaluation of a device and increase patient engagement by incorporating patient-relevant outcomes. Preference testing is widely conducted in the food industry but is not widespread in the medical field due to limited guidelines and a lack of regulatory framework. As such, manufacturers may be unaware of the benefits of preference testing and fail to take full advantage of it, or conversely, may use inappropriate methodology and/or analyses and consequently fail to collect meaningful data. In this position paper, we aim to highlight the benefits and uses of preference testing, along with potential methods that could be used for preference testing of medical devices. A key step towards the wider implementation of preference testing in medical devices is for the publication of international standards and guidelines for the collection, assessment, and implementation of preference data into the life cycle of a medical device.

Consensus on Nasal Irrigation in Infants: A Delphi Study

INTRODUCTION

Nasal irrigation is regularly used in infants to relieve upper airway symptoms. However, because there is no consensus on good practice, nasal irrigation in infants is described and applied heterogeneously among clinicians and between clinical trials.

OBJECTIVE

The aim of this study was to establish consensus regarding the use of nasal irrigation in infants.

METHODS

A panel of Belgian physiotherapists and physicians experienced in performing nasal irrigation in infants were surveyed using the Delphi technique. Three survey rounds were used. Participants rated their level of (dis)agreement to each statement in each round using a 6-point Likert scale. Consensus was defined for statements which collected at least 75% of responses in agreement or disagreement. The questionnaire of Round 1 was built on nasal irrigation practice habits previously collected from parents, childcare workers, and healthcare professionals. Questionnaires from rounds 2 and 3 were amended based on experts written feedback.

RESULTS

Thirty experts (12 physicians and 18 physiotherapists) completed all 3 questionnaires. Consensus was achieved for 47 of 75 statements (63%) distributed over the following domains: "contraindications," "indications and frequency of use," "irrigation means," "solution preparation," "solution volume," "realization of the technique," and "assessment of the efficacy of nasal irrigation."

CONCLUSION

This study provides the first well-constructed consensus on good practice on nasal irrigation in infants. Consensus on several statements across different domains were established but require validation in future trials. This study also proposes direction for future research focusing on statements that did not reach consensus.

Learning on the periphery: a modified Delphi study of a nursing student communities of practice model

OBJECTIVES

To develop a contemporary student placement model to address current placement challenges, impact student learning, and alleviate supervisor burden.

METHODS

A modified Delphi technique was used to seek opinions, insights, and creative solutions.

RESULTS

A draft Communities of Practice placement model, based on a systematic literature review, was introduced to a heterogenous expert panel (n=12). A contemporary placement model was developed and refined via video conference and email over three rounds.

CONCLUSIONS

Despite initial reluctance concerning a new model, participants became conversant with the concept of peer-to-peer learning, where incidental, albeit essential, learning and support occurs between students, which also supports supervising staff. Greater flexibly and student screening were also incorporated to enable greater learning, confidence building, and reflection. The model's success is contingent upon students working within their scope of practice and provides a contemporary approach to best responds to student, education provider, and health service needs.

Design and validity of an instrument to assess healthcare professionals' perceptions, behaviour, self-efficacy and attitudes towards evidence-based health practice: I-SABE

OBJECTIVES

To develop and validate an instrument to measure Brazilian healthcare professionals' perceptions, behaviour, self-efficacy and attitudes towards evidence-based health practice.

DESIGN

Validation of an instrument using the Delphi method to ensure content validity and data from a cross-sectional survey to evaluate psychometric characteristics (psychometric sensitivity, factorial validity and reliability).

SETTING

National Register of Health Establishments database.

PARTICIPANTS

We included clinical health professionals who were working in the Brazilian public health system.

RESULTS

The Instrument to assess Evidence-Based Health (I-SABE) was constructed with five domains: self-efficacy; behaviour; attitude; results/benefits and knowledge/skills. Content validity was done by 10-12 experts (three rounds). We applied I-SABE to 217 health professionals. Bartlett's sphericity test and the Kaiser-Meyer-Olkin (KMO) index were adequate (χ²=1455.810, p<0.001; KMO=0.847). Considering the factorial loads of the items and the convergence between the Scree Plot and the Kaiser criterion the four domains tested in this analysis, explaining 59.2% of the total variance. The internal consistency varied between the domains: self-efficacy (α=0.76), behaviour (α=0.30), attitudes (α=0.644), results/benefits to the patient (α=0.835).

CONCLUSIONS

The results of the psychometric analysis of the I-SABE confirm the good quality of this tool. The I-SABE can be used both in educational activities as well as an assessment tool among healthcare professionals in the Brazilian public health settings.

Development of a Patient Reported Experience Measure (PREM) for Chronic Inflammatory Skin Diseases

Background

Patient involvement and high‐quality patient‐provider interactions are critical factors for quality of care in chronic inflammatory skin diseases. Also, assessing the patient's perspective contributes to optimizing care delivery and patient's experience. Until today, no user‐friendly tools to measure patient experiences exist within immunodermatology.

Objectives

The aim of this study was to identify the relevant items for patient's experience in immunodermatology and develop a concise questionnaire to assess patient's experience in routine clinical care.

Methods

Potential relevant items for measuring patient's perspective of immunodermatology care were identified by a literature search. From this longlist, a shortlist from patient's perspective was distilled by semi‐structured interviews with a diverse patient group. This list was reduced to final items using a modified Delphi method in a multi‐stakeholder focus group. For each item, one question was formulated to generate the Patient‐Reported Experience Measure (PREM) questionnaire. A first internal validation was achieved by an email round.

Results

Forty longlist items were categorized into five domains (access to care, patient centeredness, access to information, care process and satisfaction). During interview rounds, 19 shortlist items were selected if mentioned by ≥40% of interviewees. Via the focus group, the most important items were chosen by participant consensus. For each item, a question was formulated. The final PREM covers 11 items (plus 2 in case of a first consult). The first internal validation showed that the tool is clear, understandable and has an ideal length.

Conclusion

This short user‐friendly PREM can be used in scientific and routine settings to improve care for patients who suffer from chronic inflammatory skin diseases.

Linked Commentary: A.‐H. Fink‐Wagner. J Eur Acad Dermatol Venereol 2022; 36: 767–768. https://doi.org/10.1111/jdv.18153.

Do professional perspectives on evidence-based smoking cessation methods align? A Delphi study among researchers and healthcare professionals

The use of evidence-based smoking cessation interventions (SCIs) can significantly increase the number of successful smoking cessation attempts. To obtain an overview of the knowledge and viewpoints on the effectiveness and use of SCIs, a three-round online Delphi study was conducted among researchers and primary care professionals (PCPs). The four objectives of this study are to gain an overview of (i) the criteria important for recommending SCIs, (ii) the perceptions of both groups on the effectiveness of SCIs, (iii) the factors to consider when counseling different (high-risk) groups of smokers and (iv) the perceptions of both groups on the use of e-cigarettes as an SCI. We found a high level of agreement within groups on which smoker characteristics should be considered when recommending an SCI to smokers. We also found that PCPs display a lower degree of consensus on the effectiveness of SCIs. Both groups see a value in the use of special protocols for different (high-risk) groups of patients, but the two groups did not reach consensus on the use of e-cigarettes as a means to quit. Making an inventory of PCPs' needs regarding SCIs and their usage may provide insight into how to facilitate a better uptake in the primary care setting.

Modelling the abstract knots in supply chains using interpretive structural modelling (ISM) approaches: a review-based comprehensive toolkit

Purpose

This study endeavours to (a) develop a comprehensive interpretive structural modelling (ISM) toolkit containing sufficient details about the suitability and procedural aspects of each ISM approach and offer points of reference for budding researchers, (b) highlight the compatibility of ISM approaches with other qualitative and quantitative approaches, and (c) chalk-out an agenda for future research.

Design/methodology/approach

This study is based on an extensive review of 74 studies where researchers have used one or more ISM approaches. These studies span across the different industry sectors.

Findings

There exists a huge void in terms of the methodological synthesis of ISM approaches. ISM approaches are frequently used in sync with other qualitative and quantitative approaches. Furthermore, it highlights the need of improving the robustness of the proposed ISM models by sharing the critical details of research process.

Research limitations/implications

Being a review-based work, it could not illustrate the discussed ISM approaches with real data. However, it offers a research agenda for the prospective researchers.

Practical implications

The prerequisites, pitfalls, suitability and the procedural aspects of various ISM approaches contained in this toolkit are equally useful for the academicians as well as practitioners.

Originality/value

In the absence of a synthesized framework, this study contributes a comprehensive ISM toolkit which will help the researchers to choose a suitable ISM approach in a given case.

Development of a national pain management competency profile to guide entry-level physiotherapy education in Canada

BACKGROUND

National strategies from North America call for substantive improvements in entry-level pain management education to help reduce the burden of chronic pain. Past work has generated a valuable set of interprofessional pain management competencies to guide the education of future health professionals. However, there has been very limited work that has explored the development of such competencies for individual professions in different regions. Developing profession-specific competencies tailored to the local context is a necessary first step to integrate them within local regulatory systems. Our group is working toward this goal within the context of entry-level physiotherapy (PT) programs across Canada.

AIMS

This study aimed to create a consensus-based competency profile for pain management, specific to the Canadian PT context.

METHODS

A modified Delphi design was used to achieve consensus across Canadian university-based and clinical pain educators.

RESULTS

Representatives from 14 entry-level PT programs (93% of Canadian programs) and six clinical educators were recruited. After two rounds, a total of 15 competencies reached the predetermined endorsement threshold (75%). Most participants (85%) reported being "very satisfied" with the process.

CONCLUSIONS

This process achieved consensus on a novel pain management competency profile specific to the Canadian PT context. The resulting profile delineates the necessary abilities required by physiotherapists to manage pain upon entry to practice. Participants were very satisfied with the process. This study also contributes to the emerging literature on integrated research in pain management by profiling research methodology that can be used to inform related work in other health professions and regions.

Validation of the Brazilian Portuguese version of the Venous International Assessment Scale and proposal of revision

ABSTRACT Objective: To validate the Brazilian Portuguese translation and analyze the cultural adaptation of the Venous International Assessment Scale. Methods: Observational study by employing the Delphi technique and an equivalence evaluation by experts. The results were analyzed using item scores and by content validity index calculations of item, scale, and universal agreement. Results: Three rounds of evaluation were necessary for consensus. Explanatory contents were incorporated into the original scale throughout the process, resulting in a new version: VIA Scale - Revised. This scale obtained a content validity index of 0.96 and a universal agreement of 0.78. In the cross-cultural adequacy analysis phase, a score of 0.77 was obtained. The majority (90.5%) of the participants judged the scale’s decision support property as positive. Conclusion: The VIA Scale was validated and culturally adapted to the Brazilian Portuguese language, resulting in the VIA Scale - Revised (VIA-R).

Undergraduate Students' Online Health Information-Seeking Behavior during the COVID-19 Pandemic

As the COVID-19 pandemic has swept across the world, the amount of health-related information available has skyrocketed. Individuals can easily access health information through the internet, which may influence their thoughts or behavior, causing potential technological risks that may affect their lives. This study examined the online health information-seeking behavior of undergraduate students. Taking health issues as a guiding framework, content analysis was adopted to assess participants' online health information-seeking behavior using a computer screen recording software, and coding analysis was conducted. The study was conducted during the COVID-19 pandemic with a formal sample of 101 participants. In terms of online health information-seeking behavior, 59% of the study participants used nouns as keywords, only 27% used Boolean logic retrieval techniques, 81% paid attention to the date of the data, and 85% did not consider the author's professionalism. The results indicate that health information-seeking behavior and outcome judgments may be a missing piece of the puzzle in higher education. Consequently, the development of online health information-seeking skills through programs for undergraduate students is suggested to ensure that online readers have access to appropriate health information.

International consensus on clinical severity scale use in evaluating Niemann-Pick disease Type C in paediatric and adult patients: results from a Delphi Study

Background

Several scales have been developed in the past two decades to evaluate Niemann–Pick disease Type C (NPC) severity in clinical practice and trials. However, a lack of clarity concerning which scale to use in each setting is preventing the use of standardised assessments across the world, resulting in incomparable data sets and clinical trial outcome measures. This study aimed to establish agreed approaches for the use of NPC severity scales in clinical practice and research.

Methods

A Delphi method of consensus development was used, comprising three survey rounds. In Round 1, participants were asked nine multiple-choice and open-ended questions to gather opinions on the six severity scales and domains. In Rounds 2 and 3, questions aimed to gain consensus on the opinions revealed in Round 1 using a typical Likert scale.

Results

Nineteen experts, active in NPC paediatric and adult research and treatment, participated in this study. Of these, 16/19 completed Rounds 1 and 2 and 19/19 completed Round 3. Consensus (defined as ≥ 70% agreement or neutrality, given the study aim to identify the severity scales that the clinical community would accept for international consistency) was achieved for 66.7% of the multiple-choice questions in Round 2 and 83% of the multiple-choice questions in Round 3. Consensus was almost reached (68%) on the use of the 5-domain NPCCSS scale as the first choice in clinical practice. Consensus was reached (74%) for the 17-domain NPCCSS scale as the first choice in clinical trial settings, but the domains measured in the 5-domain scale should be prioritised as the primary endpoints. Experts called for educational and training materials on how to apply the NPCCSS (17- and 5-domains) for clinicians working in NPC.

Conclusions

In achieving a consensus on the use of the 17-domain NPCCSS scale as the first choice for assessing clinical severity of NPC in clinical trial settings but prioritising the domains in the 5-domain NPCCSS scale for routine clinical practice, this study can help to inform future discussion around the use of the existing NPC clinical severity scales. For routine clinical practice, the study helps provide clarity on which scale is favoured by a significant proportion of a representative body of experts, in this case, the 5-domain NPCCSS scale.

Learning from terrorist mass casualty incidents: a global survey

BACKGROUND

Reports published directly after terrorist mass casualty incidents frequently fail to capture difficulties that may have been encountered. An anonymised consensus-based platform may enable discussion and collaboration on the challenges faced. Our aim was to identify where to focus improvement for future responses.

METHODS

We conducted a mixed methods study by email of clinicians' experiences of leading during terrorist mass casualty incidents. An initial survey identified features that worked well, or failed to, during terrorist mass casualty incidents plus ongoing challenges and changes that were implemented as a result. A follow-up, quantitative survey measured agreement between responses within each of the themes using a Likert scale.

RESULTS

Thirty-three participants responded from 22 hospitals that had received casualties from a terrorist incident, representing 17 cities in low-middle, middle and high income countries. The first survey identified themes of sufficient (sometimes abundant) human resource, although coordination of staff was a challenge. Difficulties highlighted were communication, security, and management of blast injuries. The most frequently implemented changes were education on specific injuries, revising future plans and preparatory exercises. Persisting challenges were lack of time allocated to training and psychological well-being. The follow-up survey recorded highest agreement amongst correspondents on the need for re-triage at hospital (90% agreement), coordination roles (85% agreement), flexibility (100% agreement), and large-scale exercises (95% agreement).

CONCLUSION

This survey collates international experience gained from clinicians managing terrorist mass casualty incidents. The organisation of human response, rather than consumption of physical supplies, emerged as the main finding. NHSH Clinical Effectiveness Unit project registration number: 2020/21-036.

King's Parkinson's Disease Pain Scale (KPPS): Cross-cultural adaptation to Brazilian Portuguese and content validity

Pain is one of the most common and troublesome non-motor symptoms of Parkinson's disease (PD). The King's Parkinson's Disease Pain Scale (KPPS) is the first scale of its kind to evaluate the burden and characterization of various phenotypes of pain in individuals with PD. The purpose of this study was to adapt the KPPS to Brazilian culture and to assess its content validity using the Delphi method. The process of adapting the original instrument to the Brazilian context occurred in six stages according to international standards. Following the pilot tests with individuals with PD, the pre-final version of the KPPS-Brazil was developed and submitted to judges to assess content validity. Three evaluation rounds were conducted, in which several corrections and changes suggested by the judges were accepted. The Content Validity Index (CVI) was calculated to determine the judges' degree of agreement. The results demonstrated that the KPPS-Brazil showed a quite satisfactory level of semantic, idiomatic, cultural, and conceptual equivalence. The judges' opinion showed adequate content validity for all of the KPPS-Brazil items and the scale. The use of the KPPS-Brazil will enable an adequate assessment of pain in individuals with PD, contributing to clinical practice and research.

Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method

BACKGROUND

Coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented pressure on healthcare system globally. Lack of high-quality evidence on the respiratory management of COVID-19-related acute respiratory failure (C-ARF) has resulted in wide variation in clinical practice.

METHODS

Using a Delphi process, an international panel of 39 experts developed clinical practice statements on the respiratory management of C-ARF in areas where evidence is absent or limited. Agreement was defined as achieved when > 70% experts voted for a given option on the Likert scale statement or > 80% voted for a particular option in multiple-choice questions. Stability was assessed between the two concluding rounds for each statement, using the non-parametric Chi-square (χ2) test (p < 0·05 was considered as unstable).

RESULTS

Agreement was achieved for 27 (73%) management strategies which were then used to develop expert clinical practice statements. Experts agreed that COVID-19-related acute respiratory distress syndrome (ARDS) is clinically similar to other forms of ARDS. The Delphi process yielded strong suggestions for use of systemic corticosteroids for critical COVID-19; awake self-proning to improve oxygenation and high flow nasal oxygen to potentially reduce tracheal intubation; non-invasive ventilation for patients with mixed hypoxemic-hypercapnic respiratory failure; tracheal intubation for poor mentation, hemodynamic instability or severe hypoxemia; closed suction systems; lung protective ventilation; prone ventilation (for 16-24 h per day) to improve oxygenation; neuromuscular blocking agents for patient-ventilator dyssynchrony; avoiding delay in extubation for the risk of reintubation; and similar timing of tracheostomy as in non-COVID-19 patients. There was no agreement on positive end expiratory pressure titration or the choice of personal protective equipment.

CONCLUSION

Using a Delphi method, an agreement among experts was reached for 27 statements from which 20 expert clinical practice statements were derived on the respiratory management of C-ARF, addressing important decisions for patient management in areas where evidence is either absent or limited.

TRIAL REGISTRATION

The study was registered with Clinical trials.gov Identifier: NCT04534569.

Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method

BACKGROUND

Coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented pressure on healthcare system globally. Lack of high-quality evidence on the respiratory management of COVID-19-related acute respiratory failure (C-ARF) has resulted in wide variation in clinical practice.

METHODS

Using a Delphi process, an international panel of 39 experts developed clinical practice statements on the respiratory management of C-ARF in areas where evidence is absent or limited. Agreement was defined as achieved when > 70% experts voted for a given option on the Likert scale statement or > 80% voted for a particular option in multiple-choice questions. Stability was assessed between the two concluding rounds for each statement, using the non-parametric Chi-square (χ²) test (p < 0·05 was considered as unstable).

RESULTS

Agreement was achieved for 27 (73%) management strategies which were then used to develop expert clinical practice statements. Experts agreed that COVID-19-related acute respiratory distress syndrome (ARDS) is clinically similar to other forms of ARDS. The Delphi process yielded strong suggestions for use of systemic corticosteroids for critical COVID-19; awake self-proning to improve oxygenation and high flow nasal oxygen to potentially reduce tracheal intubation; non-invasive ventilation for patients with mixed hypoxemic-hypercapnic respiratory failure; tracheal intubation for poor mentation, hemodynamic instability or severe hypoxemia; closed suction systems; lung protective ventilation; prone ventilation (for 16-24 h per day) to improve oxygenation; neuromuscular blocking agents for patient-ventilator dyssynchrony; avoiding delay in extubation for the risk of reintubation; and similar timing of tracheostomy as in non-COVID-19 patients. There was no agreement on positive end expiratory pressure titration or the choice of personal protective equipment.

CONCLUSION

Using a Delphi method, an agreement among experts was reached for 27 statements from which 20 expert clinical practice statements were derived on the respiratory management of C-ARF, addressing important decisions for patient management in areas where evidence is either absent or limited.

TRIAL REGISTRATION

The study was registered with Clinical trials.gov Identifier: NCT04534569.

Developing a Model of Care for a 4- to 6-Bedded Postanesthetic Recovery Unit: A Delphi Study

PURPOSE

Recovery units are typically open-plan rooms where all patients can be seen at all times; however, a new hospital has been built with 4- to 6-bed perioperative bays. The purpose of the study was to establish expert consensus regarding problems, benefits, and suggested solutions for the new design across four domains: patient safety, staff satisfaction, organizational efficiency, and maintenance of professional standards.

DESIGN

We conducted a Delphi study to inform the development of a model of care for this new design.

METHODS

A two-round Delphi study involved 71 recovery unit nurses from 13 countries. Problems, solutions, and any potential benefits of the new design were collected in round 1 and ranked in round 2.

FINDINGS

The highest ranked problems were mixing conscious and unconscious patients and need for safe skilled staffing levels. The highest ranked solutions were division of patients, increased safe skilled staffing, and staff education.

CONCLUSIONS

Participants identified clear risks and mitigation strategies. Implementing these strategies should allow for a safer environment for both patients and staff. A model of care to ensure safety and quality in 4- to 6-bedded bay postanesthetic recovery units should address mixing of patients, staffing levels and staff education.

Common Clinical Practice for Low Back Pain Treatment: A Modified Delphi Study

INTRODUCTION

Low back pain (LBP) is a common reason for adults to seek medical care and is associated with important functional limitation and patient burden. Yet, heterogeneity in the causes and presentation of LBP and a lack of standardization in its management impede effective prevention and treatment.

METHODS

We conducted a modified Delphi study to generate consensus statements for the diagnosis, management, and prognosis of LBP. A panel of five experts proposed 19 statements that were subsequently evaluated by physicians who treat LBP in their everyday clinical practice. Physicians were asked to validate statements in the form of a web survey assessing level of agreement on a five-point Likert-like scale.

RESULTS

Consensus (≥ 70% agreement) was obtained for all 19 statements. Strength of agreement and physician comments highlighted the importance of pain management, but also strategies to ameliorate functional limitation and prevent future LBP episodes. Respondents favored multidisciplinary approaches and multimodal management for LBP, although there was some ambiguity as to how multidisciplinary strategies could be feasibly incorporated into daily practice. Finally, the results indicated some conflict regarding the use of imaging for the diagnosis of LBP and how to classify LBP for targeted treatment.

CONCLUSION

The results of this study provide a summary of favored clinical practice for the management of chronic LBP. While the consensus statements were generally agreeable to survey respondents, some areas of ambiguity, including how to increase the feasibility of multidisciplinary strategies, when and how to use diagnostic imaging in LBP, and LBP classification, necessitate clarification in future studies and guidelines.