Delphi methodology in healthcare research: How to decide its appropriateness

British Oncology Pharmacy Association Delphi consensus guidelines: Co-infusion of trometamol-containing calcium folinate (Leucovorin) with systemic anti-cancer treatments

Drug stability and compatibility are critical factors influencing the cost and logistics of treatment delivery, therapeutic effectiveness, and patient safety. This is particularly significant in the realm of cancer chemotherapeutics, where stability and compatibility studies play a vital role in ensuring rational and safe medicine administration. Oxaliplatin, fluorouracil, and irinotecan, commonly used in various combinations for gastrointestinal cancers, are complemented by co-administration of folinic acid in certain protocols. Notably, some folinic acid preparations include trometamol as an excipient, potentially impacting the stability of the chemotherapeutic agents if infused concomitantly. This study seeks to establish guidelines for oncology multidisciplinary teams, addressing potential risks associated with the combination of trometamol-containing folinic acid and chemotherapeutics. To achieve this, a quantitative questionnaire was distributed to members of the British Oncology Pharmacy Association (BOPA) and non-BOPA members through an online survey. Nineteen healthcare professionals with oncology experience, comprising 18 pharmacists and one nurse, completed the questionnaires. Each participant rated the validity and clarity of statements on a 5-point scale. The Delphi process concluded after the fourth round, consolidating the findings and recommendations from the multidisciplinary team. Twelve recommendations for safe practice have been made.

Consensus Recommendations for the Management of Neurosarcoidosis: A Delphi Survey of Experts Across the United States

Background and Objectives

Neurosarcoidosis poses a diagnostic and management challenge due to its rarity, phenotypic variability, and lack of randomized controlled studies to guide treatment selection. Recommendations for management based on expert opinion are useful in clinical practice and provide a framework for designing prospective studies.

Methods

In this Delphi survey study, specialists with experience in managing patients with neurosarcoidosis were invited to anonymously complete 2 surveys about key elements of evaluation, diagnosis, treatment, monitoring, and long-term management of neurosarcoidosis. Expert consensus recommendations were adopted if >80% threshold of agreement was reached.

Results

Of the 41 invited expert clinicians across the United States, 32 (78%) participated in the study. All round 1 respondents self-identified as neuroimmunologists (except for 1 pulmonologist). Consensus was reached regarding the need to consider neurosarcoidosis phenotype and severity to guide the choice of initial immunosuppression in both the acute (relapse) and maintenance phases. Experts endorsed the use of TNF-α inhibitors as first-line agents in selected phenotypes with poor prognosis. Neuroimaging was recommended to complement clinical surveillance for treatment response.

Discussion

There was agreement on several key issues, most importantly on the need to consider neurosarcoidosis phenotype and severity when deciding initial treatment. No consensus was achieved on the dosing and duration of specific immunosuppressants, nor regarding the management of the peripheral nervous system manifestation of neurosarcoidosis. These topics warrant further investigation.

Quality indicators for the community care of MSK conditions: An online modified-Delphi study

BACKGROUND

Quality indicators can be used within healthcare to measure and benchmark performance. Variations in the access and quality of healthcare for musculoskeletal conditions highlights the need for a nationally agreed set of indicators.

OBJECTIVES

The study's primary aim was to develop a set of care quality themes and indicators for musculoskeletal community care.

METHODS

An online Delphi process was used, that included clinicians, managers, researchers, and patients. In round one, participants rated 79 indicators, across six care quality themes, for their importance to quality community musculoskeletal care. Following this, participants discussed the results of the first round in an online panel and then re-rated indicators in a second-round survey. The panel discussion focused on a) the importance rating of indicators, and b) the wording of care quality themes. Consensus for high importance was set at ≥60% in both rounds of the study.

RESULTS/FINDINGS

Forty-six individuals participated in the first round of the study, with 21 participating in the second round. After the second round, six care quality themes emerged: 1) Optimising patient access and assessment, 2) Optimising patient education, self-management, and rehabilitation, 3) Optimising personalised care, 4) Optimising diagnosis, imaging, investigation, and referrals, 5) Optimising patient experience and outcomes, and 6) Population health relevant to musculoskeletal conditions. Within the six themes, 59 indicators were ranked as highly important.

CONCLUSIONS

This study has developed a set of care quality themes and indicators for community musculoskeletal care. In the next stage of indicator development, real-world data will be used to validate the indicators across several constructs.

Physiotherapy of the Trunk Related to Sitting Function After Stroke: A Delphi Study

ObjectiveTo develop consensus statements from a Delphi panel about physiotherapy of the trunk related to sitting function for people with subacute stroke, with the express aim of facilitating treatment choices by novice physiotherapists.DesignA four-round e-Delphi study using free-text responses and 5-point Likert scales for agreement.ParticipantsTwenty-six panel members with expertise in clinical and/or research in neurological rehabilitation.Main measuresRound 1 consisted of 5 free-text questions. Subsequent rounds ascertained agreement and consensus on statements formulated from Round 1 responses. Consensus was defined a priori as ≥70% agreement. Round 3 presented an additional two clinical observation queries related to the statements for comment.ResultsTwenty participants completed all four rounds. Nineteen of 26 participants (73%) thought physiotherapy of the trunk was important through all stages of recovery after stroke. Different interpretations about what constitutes physiotherapy of the trunk following stroke were identified. Fourteen statements of agreement regarding physiotherapy of the trunk were formulated. The majority of statements involved different activities in sitting such as control of movement over the base of support and reaching with the unaffected arm. In addition to the statements of agreement clinical observations for implementation of the statements were developed.ConclusionsIn the absence of detail in clinical guidelines and a wide range of interventions in systematic reviews, this study provides clear and specific options for novice physiotherapists of treatment of the trunk related to functional task practice in sitting and as preparation for sit to stand.

Translating digital health services for nutrition care management of chronic conditions in outpatient settings: A multi-stakeholder e-Delphi study

AIM

To identify and achieve expert consensus on the most important and feasible strategies to implement digital health services for nutrition care management of chronic conditions in outpatient settings.

METHODS

Determinants and strategies for implementing digital health services for nutrition care management were identified in line with the literature and the Consolidated Framework for Implementation Research. These were presented to team leaders and senior clinicians, as well as dietetic and allied health directors in a two-round e-Delphi process. Consensus was reached when strategies were rated very important/feasible by at least 75% of respondents, calculated by the median, interquartile range and frequency. Following the two survey rounds, a final prioritisation survey was distributed to participants, where participants were asked to prioritise their top strategy for each determinant, which was analysed by frequency calculations.

RESULTS

Twenty participants participated in round one of the survey and 18 completed the final prioritisation round. Following the two rounds, 3 strategies did not meet consensus for importance and 7 strategies did not meet consensus for feasibility out of 25 strategies presented. Nine strategies were prioritised following the survey rounds. Key concepts of the strategies that met consensus and were prioritised related to (i) adhering to quality of care with effective evaluation processes; (ii) providing options for digital health upskilling and support; and (iii) individualising patient care.

CONCLUSION

Team leaders and senior clinicians as well as dietetic and allied health directors have indicated that there are many important digital health strategies yet not all are feasible to implement within current resourcing and systems.

Management of human epidermal growth factor receptor inhibitors-related acneiform rash: A position paper based on the first Europe/USA Delphi consensus process

BACKGROUND

There is a need for unified guidance in the management of acneiform rash induced by epidermal growth factor receptor inhibitors (EGFRi) among dermatologists.

OBJECTIVE

To establish unified international guidelines for the management of acneiform rash caused by EGFR inhibitors, based on an experts' Delphi consensus.

METHODS

The initiative was led by five members of the European Academy of Dermatology and Venereology Task Force 'Dermatology for Cancer Patients' who developed a questionnaire that was circulated to a group of 32 supportive oncodermatology experts in Europe, Canada, Argentina, the US States and Asia. The questionnaire consisted of 84 statements in total, regarding diagnosis and treatment of EGFRi-induced acneiform rash. Experts responded to an anonymous 5-point Likert scale survey. The coordinators collected the first-round responses that were checked for consensus (≥75% agreement in positive [agree or strongly agree] or in negative [disagree or strongly disagree] vote). The statements that did not reach strong consensus in the first round were revised, according to experts' feedback, for a second-round survey.

RESULTS

Strong consensus was reached in 75/84 (89.3%) of the statements, whilst moderate consensus was achieved in 6/84 elements. Key points include consideration of low-dose isotretinoin for refractory grade II/III acneiform rash, use of topical steroid-sparing agents like topical pimecrolimus in the maintenance phase and use of doxycycline in either 100 or 200 mg per day as prophylactic treatment. Interestingly, experts did not recommend topical antibiotics, neither for prevention, nor for treatment. Consensus failure in 3/84 objects is mostly related to the lack of robust data on these topics.

CONCLUSION

This consensus offers crucial insights often overlooked by radiotherapists, general practitioners, dermatologists and oncologists, and it is expected to improve the management of oncologic patients treated with EGFRi in different settings and continents.

A T2 Translational Science Modified Delphi Study: The Ethical Triage and Treatment of Entrapped and Mangled Extremities in Resource-Scarce Environments

BACKGROUND

There is a lack of ethical triage and treatment guidelines for the entrapped and mangled extremity (E&ME) in resource-scarce environments (RSE): mass casualty incidents, low- to middle-income countries, complex humanitarian emergencies including conflict, and prolonged transport times (RSE). The aim of this study is to use a modified Delphi (mD) approach to produce statements to develop treatment guidelines of the E&ME in RSE.

METHOD

Experts rated their agreement with each statement on a 7-point linear numeric scale. Consensus amongst experts was defined as a standard deviation ≤ 1. Statements attaining consensus after the first round moved to the final report. Those not attaining consensus moved to the second round in which experts were shown the mean response of the expert panel and their own response for the opportunity to reconsider their rating for that round. Statements attaining consensus after the second round moved to the final report. This process was repeated in the third round. Statements attaining consensus were moved to the final report. The remaining statements did not attain consensus.

RESULTS

Seventy-seven experts participated in the first, 75 in the second, and 74 in the third round. Twenty-three statements attained consensus. Twenty-one statements did not attain consensus.

CONCLUSION

A modified Delphi technique was used to establish consensus regarding the numerous complex factors influencing treatment of the E&ME in RSEs. Twenty-three statements attained consensus and can be incorporated into guidelines to advance the ethical treatment of the E&ME in RSEs.

Prerequisites for Clinical Implementation of Whole-Heart 4D-Flow MRI: A Delphi Analysis

Whole-heart 4D-flow MRI is a valuable tool for advanced visualization and quantification of blood flow in cardiovascular imaging. Despite advantages over 2D-phase-contrast flow, clinical implementation remains only partially exploited due to many hurdles in all steps, from image acquisition, reconstruction, postprocessing and analysis, clinical embedment, reporting, legislation, and regulation to data storage. The intent of this manuscript was 1) to evaluate the extent of clinical implementation of whole-heart 4D-flow MRI, 2) to identify hurdles hampering clinical implementation, and 3) to reach consensus on requirements for clinical implementation of whole-heart 4D-flow MRI. This study is based on Delphi analysis. This study involves a panel of 18 experts in the field on whole-heart 4D-flow MRI. The experience with and opinions of experts (mean 13 years of experience, interquartile range 6) in the field were aggregated. This study showed that among experts in the cardiovascular field, whole-heart 4D-flow MRI is currently used for both clinical and research purposes. Overall, the panelists agreed that major hurdles currently hamper implementation and utilization. The sequence-specific hurdles identified were long scan time and lack of standardization. Further hurdles included cumbersome and time-consuming segmentation and postprocessing. The study concludes that implementation of whole-heart 4D-flow MRI in clinical routine is feasible, but the implementation process is complex and requires a dedicated, multidisciplinary team. A predefined plan, including risk assessment and technique validation, is essential. The reported consensus statements may guide further tool development and facilitate broader implementation and clinical use. LEVEL OF EVIDENCE: NA TECHNICAL EFFICACY: Stage 5.

Requirements and Study Design for the Next Proton FLASH Clinical Trials: an International Multidisciplinary Delphi Consensus

PURPOSE

The FLASH effect, defined as normal tissue sparing while maintaining tumor control with ultra-high dose-rate irradiation, has been demonstrated preclinically in different tumors and tissues. Although the biological mechanisms are unclear, there is a need for clinical trials investigating the value of proton FLASH irradiation (pFLASH). The purpose of this study was to establish an expert consensus regarding prerequisites, study design, and endpoints for the next clinical trials exploring the clinical potentials of pFLASH.

METHODS AND MATERIALS

Delphi methodology was used to develop a systematic expert consensus. An international expert panel was composed of 21 clinicians, physicists, and biologists, well-balanced in expertise and geography, using predefined inclusion criteria. Statements were scored on a 5-point Likert scale in 2 rounds of online questionnaire voting. The definition of consensus was set a priori.

RESULTS

The response rate was 100% in both rounds. Preclinical in vivo demonstration of the FLASH effect in normal tissue while maintaining tumor response was deemed essential before starting a clinical trial in a specific tumor site. The next clinical pFLASH trials are advised to include adult patients only, with a minimal expected overall survival of 1 year for palliative settings or, preferably, oligometastatic disease in the ablative setting. The pFLASH effect should be studied in a single treatment modality setting with toxicity reduction as the primary endpoint. Recommendations were formulated on the use of clinical targets and organs at risk constraints, requirements for evaluation and reporting, and accuracy levels and pretreatment verification of dose rates. No consensus was reached on the use of multiple beams, multiple fractions, and fraction dose.

CONCLUSIONS

There is a need for additional data regarding the influence of fractionation and multiple beam planning. The results of this study can be used to develop roadmaps to guide future clinical trial design.

Quality indicators for substance use disorder care: a scoping review protocol

INTRODUCTION

Substance use disorders (SUDs) are a major public health challenge, affecting millions of individuals globally and contributing to substantial morbidity and mortality. Individuals with SUDs face numerous barriers to accessing high-quality healthcare, leaving vulnerable populations susceptible to the undertreatment of SUDs. Despite the availability of clinical practice guidelines and effective interventions for SUD, there is a notable gap in the implementation and adherence to evidence-based care.Measuring the quality of care (QoC) is a critical initial step toward enhancing the treatment and services provided to individuals with SUDs. While quality indicators (QIs) for SUD care have been established in various regions, including the USA, Canada and the UK, the application of QIs for the routine measurement of QoC for SUDs is not common. Identifying and characterising the areas of low QoC in SUD management can highlight critical targets for quality improvement initiatives. However, QoC measurement in SUD care is complex, with potentially redundant indicators derived from different sources, each with its own definitions, criteria and data requirements. This scoping review aims to explore the range of QIs that are currently available to assess the QoC for individuals with SUDs.

METHODS

The review will follow the Arksey and O'Malley framework and incorporate methods proposed by the Joanna Briggs Institute (JBI) and Levac et al. Reporting will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review guidelines (PRISMA). Stage 1: the research question will be identified, clarifying the purpose of the scoping review. Stage 2: six academic databases (Cochrane Library, Embase, CINAHL, Medline, APA PsycINFO and Scopus) and grey literature sources will be searched for studies reporting QIs and published from 1990 until 2023. Stage 3: study screening and selection will be completed by two reviewers independently to review titles, abstracts and full texts based on study inclusion criteria. Stage 4: a pilot data charting form has been developed to capture information from each study, including study design, population details, setting, methodology for QI development and reported QIs. Stage 5: data synthesis and consultation will employ thematic analysis and frequency counts to categorise identified QIs within established domains for quality of healthcare. Any discrepancies in data extraction or thematic synthesis will be identified and resolved using a third reviewer when necessary. A consultation exercise using a modified Delphi process will engage experts to prioritise identified QIs, aligning with JBI recommendations for stakeholder involvement in scoping reviews.

PATIENTS AND PUBLIC INVOLVEMENT

Patients and the public will not be directly involved in the design or conduct of this scoping review. However, stakeholder consultation, including individuals with lived experience of SUDs, will be incorporated during the Delphi process to prioritise identified QIs for SUD care.

ETHICS AND DISSEMINATION

Ethics approval is not necessary for stages 1-4 of this scoping review as it will not involve primary data collection. Ethics approval will be obtained from the University of Calgary Health Research Ethics Board prior to the commencement of stakeholder consultation (Stage 5) in January 2025. This scoping review was preregistered on the Open Science Framework. The results of this scoping review will be disseminated through peer-reviewed publications and conference presentations. Findings will be shared with local clinicians through presentations and with the research and clinical community at relevant conferences. This study represents a necessary first step towards establishing routine QoC measurement for SUDs. Results will be used in a stakeholder consensus exercise aimed at identifying key QIs for SUD care in Alberta, Canada, that will guide the future development of continuous QoC measurement using population-based data.

Guidelines for Designing and Conducting Delphi Consensus Studies: An Expert Consensus Delphi Study

PURPOSE

To conduct a Delphi project to develop guidelines for the design and execution of Delphi studies within medical and surgical specialties.

METHODS

Open-ended questions in round 1 and open-ended and semi-open questions in round 2 were answered. The results of the first 2 rounds were used to develop a Likert-style questionnaire for round 3. The level of agreement and consensus was defined as 80%. Consensus was further categorized into specific percentage ranges for clarity: 100% unanimous consensus, 90% to 99% very strong consensus, and 80% to 89% consensus.

RESULTS

Consensus was achieved for 35 of 63 items (56%). Unanimous agreement was reached for 4 items (6.3%), while very strong consensus was established for 12 items (19%). Consensus was reached for an additional 19 items (30.1%), and the panel remained undecided on 7 items (11.1%).

CONCLUSIONS

Unanimous agreement was reached for iteration, the ability to establish treatment guidelines, a proven track record of panel members, and the requirement for at least 1 steering committee member to be a Delphi expert. Very strong consensus was reached on several key requirements: a clear definition of consensus, controlled feedback between rounds, precise definitions of expert and expertise, and the need for panel members to show experience through publications and clinical practice. Criteria for panel selection should ensure diversity and specialization, with steering committee members being content experts and a minimum of 20 to 30 panel members for broader topics. Regional experts should provide consensus on specific topics only. The steering committee should develop questions, with open-ended questions in round 1 and both types in round 2. Limiting the process to 3 rounds is advisable, aiming for at least 80% consensus in the final round.

LEVEL OF EVIDENCE

Level V, expert opinion.

Best Practice Guide for Reducing Barriers to Video Call-Based Telehealth: Modified Delphi Study Among Health Care Professionals

BACKGROUND

Telehealth has grown, especially during the COVID-19 pandemic, improving access for those in remote or underserved areas. However, its implementation faces technological, practical, and interpersonal barriers.

OBJECTIVE

The aim of this study was to identify and consolidate best practices for telehealth delivery, specifically for video call sessions, by synthesizing the insights of health care professionals across various disciplines.

METHODS

We first identified 15 common telehealth barriers from a preceding scoping review. Subsequently, a modified Delphi method was used, involving 9 health care professionals (physiotherapists, speech and language therapists, dietitians, and midwife) with telehealth experience in qualitative interviews and 2 iterative rounds of web-based surveys to form consensus.

RESULTS

This study addressed 15 telehealth barriers and identified 105 best practices. Among these, 20 are technology-related and 85 concern health care practices. Emphasis was placed on setting up telehealth environments, ensuring safety, building relationships and trust, using nonmanual methods, and enhancing observation and assessment skills. Best practice recommendations for dealing with patients or caregiver skepticism or lack of telehealth-specific knowledge were developed. Further, approaches for unstable networks and privacy and IT security issues were identified. Areas with fewer best practices were the lack of technology skills or technology access, unreliability of hardware and software, increased workload, and a lack of caregiver support.

CONCLUSIONS

This guide of best practices serves as an actionable resource for health care providers to navigate the complexities of telehealth. Despite a small participant sample and the potential for profession-specific biases, the findings provide a foundation for improving telehealth services and inform future research for its application and education.

Essential criteria for reporting of aromatherapy-focused research in humans: An international Delphi consensus study protocol

BACKGROUND

Reporting quality of aromatherapy-focused research in humans is inconsistent and often incomplete yet there are no (North American or American) nationally or internationally agreed upon core criteria for aromatherapy-focused research. The Aromatic Research Quality Appraisal Task Force developed the Transparent Reporting for Essential oil and Aroma Therapeutic Studies (TREATS) checklist as initial steps toward developing a reporting guideline. The purpose of this Delphi study is to engage with an international community of aromatherapy researchers to reach consensus on which items should be included in reports of aromatherapy-focused studies in humans. The result of the consensus process will be to publish an aromatherapy research reporting guideline that can be used as an extension to existing research reporting guidelines for various studies such as randomized controlled trials, observational studies, and case reports.

METHODS

A modified Delphi consensus study will be used. The consensus study, approved by the West Virginia University Institutional Review Board, will consist of up to four rounds of an online survey. To improve understanding and buy-in, experts attending a large international aromatherapy-focused conference will take part in a four-hour in-person/virtual hybrid introductory meeting where they can learn the study process and ask questions. The 48-item survey is divided into categories covering study products, processes, aromatherapy intervention, safety, sustainability, and olfactory ability and aroma preference. Participants will be asked to rate each checklist item for relevance on a 5-point Likert scale ranging from "of little importance" to "extremely important". During the Delphi study, participants can provide comments and, in the first and second rounds, may suggest additional items or modifications to existing items. An item will be automatically included in the final guidelines if it is rated as "very important" or "extremely important" by at least ≥80% of the participants in Rounds 1-3, and automatically excluded if > 50% of participants rate the item as "not important" or "of little importance". Aggregated ratings will be statistically analyzed for response rates, level of agreement, medians, and interquartile ranges.

DISCUSSION

This protocol supports conducting a Delphi consensus that will add to the current knowledge of items considered necessary for complete and consistent reporting of aromatherapy-focused research in humans. This is of international significance as world-wide use and research of aromatherapy and essential oils in humans has continued to increase, currently without consistent and clear reporting. The Delphi method is appropriate for developing consensus between diverse experts, researchers, and practitioners as it offers anonymity and minimizes bias. Findings will contribute to creating an extension to primary reporting guidelines.

ORCHESTRA Delphi consensus: clinical management of SARS-CoV-2 infection in people with HIV

OBJECTIVES

The interaction between HIV and COVID-19 resulted in a syndemic that showed an excess burden of disease for people with HIV (PWH). Four years of the COVID-19 pandemic have raised many unsolved questions about the optimal care of COVID-19 in PWH.

METHODS

We performed a study using a three-round Delphi methodology involving a panel of physicians with expertise in HIV and COVID-19 infections. The main aim of the study was to provide recommendations on critical clinical issues of COVID-19 among PWH and to inform physicians and policy-makers for improving care and prevention of COVID-19 in PWH. A total of 27 questions were conceived, focusing on four main areas of interest in the management of COVID-19 in PWH; a panel of 34 experts in HIV and COVID-19 care expressed their level of agreement on each item. Questions that received agreement/disagreement ≥79.4% of panellists were identified and statements were generated accordingly.

RESULTS

Consensus was reached on 19/27 items, resulting in 18 final statements. These statements addressed: (a) risk of COVID-19 progression to severe disease among PWH; (b) COVID-19 diagnostics and laboratory procedures; (c) early treatments with antivirals and/or monoclonal antibodies; (d) use of corticosteroids; (e) COVID-19 preventive strategies.

DISCUSSION

This consensus's study guides infectious diseases physicians in making decisions regarding the care of PWH for COVID-19, where results from the scientific literature are limited or conflicting.

Are military fitness tests safe for members with a total hip arthroplasty?

INTRODUCTION

Canadian Armed Forces (CAF) members must complete an annual fitness evaluation. Members with a total hip arthroplasty (THA) may be at risk of injury during these strenuous tests. To inform CAF policy, we sought expert consensus on the safety of fitness testing for members with a THA.

METHODS

We conducted a three-round Delphi study with a panel of hip arthroplasty experts to determine the safety of CAF operational fitness evaluations for members with a THA. The experts evaluated videos of the 10 individual tasks included in the evaluations.

RESULTS

All individual tasks were judged to be safe by consensus. One task, which involves digging with a shovel, was considered safe provided that participants avoid deep hip flexion. The nine other tasks were judged to be safe without modifications or interventions. The experts also supported a policy recommendation that would allow members to perform military fitness evaluations if they (1) have a primary THA, (2) had no episodes of instability, (3) are at least 12 months postoperatively and (4) have been cleared by an orthopaedic surgeon and a physiatrist/physiotherapist.

CONCLUSION

A panel of arthroplasty experts concluded, based on video analysis, that CAF fitness evaluations are generally safe for members with a THA.

ESM-Q: A consensus-based quality assessment tool for experience sampling method items

The experience sampling method (ESM) is increasingly used by researchers from various disciplines to answer novel questions about individuals' daily lives. Measurement best practices have long been overlooked in ESM research, and recent reviews show that item quality is often not reported in ESM studies. The absence of information about item quality may be partly explained by the lack of consensus on how ESM item quality should be evaluated. As part of the ESM Item Repository project (esmitemrepository.com)-an international open science initiative that collects ESM items in an open item bank and evaluates their quality-we brought together 42 international ESM experts to develop an ESM item quality assessment tool. In four Delphi phases, experts suggested 57 item quality criteria, rated the criteria, provided arguments for and against the criteria, and rated the criteria again, considering reflections from other experts. The result of the Delphi process is ESM-Q: a quality assessment tool consisting of 10 core criteria, as well as an additional 15 supplementary criteria, to be used depending on the type of items being rated and the availability of supplementary information. The criteria cover topics ranging from construct validity to the optimal wording of items. ESM-Q can aid ESM researchers in selecting existing ESM items, developing new high-quality ESM items, and evaluating the quality of ESM items in systematic reviews. Expert reflections also highlight open research questions surrounding ESM item design that form a research agenda for ESM measurement.

Definitions of determinants of physical activity behaviour: process and outcome of consensus from the DE-PASS expert group

BACKGROUND

Despite extensive research on physical activity behaviour (PAB), consensus is lacking on related terms and definitions, thereby hindering the ability to compare findings between studies and to develop reliable assessment tools. This study therefore aimed to establish consensus on the definitions of key PAB determinants.

METHODS

First, an international expert steering committee was established, comprising members of the European Cooperation in Science and Technology (COST) action "DEterminants of Physical ActivitieS in Settings" (DE-PASS). Recently published review-level studies were used to identify key determinants of PAB. Two independent reviewers systematically reviewed the literature to catalogue the range of definitions used for key determinants of PAB (steps 1-2). A two-round modified Delphi survey was conducted online from February to September 2023, to determine the optimal definition for each determinant. In round 1, experts selected the most suitable definition for each of the 41 initially identified determinants. In round 2, experts ranked the appropriateness of the definition selected from round 1 on a 5-point Likert scale. Consensus was defined a priori as ≥ 75% agreement on the definition (i.e., ratings of ≥ 4 points). A professional English language expert ensured concise, coherent wording and high-quality editing of the definitions (steps 3-6).

RESULTS

Eighty-five experts in PAB research participated in round 1, and sixty-nine experts in round 2. Consensus of definitions was achieved for 39 of the 41 determinants (88.4%-98.6% agreement). The consensus threshold was not achieved for two determinants: genetic profile and regulation (69.6%) and backyard access/size (73.9%).

CONCLUSIONS

The findings of this study offer a consensus-based set of definitions for 39 key determinants of PAB. These definitions can be used homogenously in academic research on physical activity.

Fetal intracerebral hemorrhage: review of the literature and practice considerations

Fetal intracerebral hemorrhage is increasingly recognized on prenatal imaging. In this review, we discuss clinically relevant aspects of fetal intracerebral hemorrhage, including germinal matrix-intraventricular hemorrhage, as well as intraparenchymal hemorrhage. We discuss current clinical practice for prenatal counseling and postnatal management of fetal intracerebral hemorrhage, and offer practical recommendations for clinicians. We propose standardized terminology for classification of fetal intracerebral hemorrhage to be used in future research. We also highlight gaps in the literature and priorities for future research, namely the need for prospective large-scale studies to better understand underlying etiologies and neurodevelopmental outcomes in fetal intracerebral hemorrhage. IMPACT STATEMENT: We discuss the diverse etiologies and outcomes of fetal intracerebral hemorrhage, and propose standardized terminology for classification. We outline current practice and offer practical recommendations for management and counseling of fetal intracerebral hemorrhage, recognizing the need for capacity-building in the newly emerging subspecialty of fetal neurology. We highlight gaps in the literature and research priorities in fetal intracerebral hemorrhage to promote collaborative research, and the development of interventions to improve pregnancy and child outcomes.

Developing practice-level quality indicators to assist in evaluating the application of the Australasian Triage Scale: A modified e-Delphi process

BACKGROUND

Triage quality is central to patient safety and the efficient distribution of emergency department resources. Currently, there are no identified quality indicators for application of the Australasian Triage Scale.

AIM

To address a gap in quality indicators specific to triage.

DESIGN

A literature review and modified Delphi technique.

METHOD

A review of the literature published between 2001 and 2024 was conducted to identify potential indicators and metrics of triage quality, and were categorised across six quality of care domains (patient-centeredness, timeliness, effectiveness, equity, efficiency and safety). Three consecutive online surveys where panellists rated these indicators for perceived appropriateness, validity and feasibility were completed between August and December 2023.

RESULTS

From the review, 17 initial quality indicators across six quality of care domains were developed. Following round 1, 3 indicators were modified and 8 indicators were added. After two further survey rounds, 18 (72 %) indicators met consensus.

CONCLUSION

An expert panel validated a set of triage quality indicators for measuring Australian triage practice. A continuous quality improvement approach is required to optimise triage practice, develop processes for detecting and reducing patient harm and minimising variation. Further research is needed to test applicability of the indicators.

Implementation science research priorities for Universal Health Coverage: methodological lessons from the design and implementation of a multicountry modified Delphi study

Delphi studies are rapidly gaining prominence in global health research. However, researchers' modifications to the Delphi method are often not well-described or justified, limiting opportunities to systematically learn from these studies when the methods are applied to other topics and settings. This paper aims to describe an approach to implementing a modified Delphi study and reflect on the research process in the context of a multicountry study of implementation science research priorities to advance Universal Health Coverage (UHC). We review trends in the use of the modified Delphi method in global health research, outline our three-phased modified Delphi approach, and share reflections on five decision points for implementing the study: (I) identifying and recruiting participants for the expert panel, (II) addressing participant attrition between rounds, (III) justifying the most appropriate cutoff points, (IV) incorporating new items raised by participants in open-ended survey sections, and (V) ensuring maximum variation in perspective in the panel of experts. Insights from this work foster greater understanding of the underlying assumptions for, and interpretation of, 'modified' in modified Delphi studies. This study will encourage critical dialogue about points of methodological contention in Delphi methodology and thus are relevant for scaling the use of modified Delphi studies in public health, including global health research.

Metastatic triple-negative breast cancer - current treatment strategies in the Nordics: a modified Delphi study

BACKGROUND AND PURPOSE

This study aimed to assess current treatment strategies for metastatic triple-negative breast cancer (mTNBC) and the perceptions of clinical experts in Sweden, Denmark, Norway, Finland, and Iceland, comparing them to international guidelines to provide insights into how these therapies are implemented and adapted to national Nordic guidelines.

METHODS

A three-round modified Delphi method was followed with consensus defined as 70% agreement. A steering committee selected 20 experienced oncologists as panellists and developed the questionnaires. Questions included items related to treatment preferences in different treatment lines with different clinical scenarios in mTNBC patients.

RESULTS

In the first round, eight out of 33 questions on clinical treatment reached consensus with 14 out of 27 in the second round reaching consensus. In round three, eight out of eight questions reached consensus. The preferred treatment for mTNBC patients with PD-L1 positive was checkpoint inhibitors (CPI) in combination with chemotherapy. For patients with germline BRCA mutation and PD-L1 negative disease, PARP-inhibitors were preferred as 1L and sacituzumab govitecan (SG) in both 2L and later lines. Disagreement was observed for chemotherapy in later lines where evidence is sparse or lacking.

INTERPRETATION

The high level of consensus for new treatment strategies, such as CPI and PARP-inhibitors in 1L and SG in 2L or later lines, in comparison with the limited consensus for older treatments, such as chemotherapy, may reflect the growing academic evidence for different treatment strategies. Understanding the treatment patterns across different countries contributes to gaining consensus on the upcoming therapeutic advances.

Atrial fibrillation burden in clinical practice, research, and technology development: a clinical consensus statement of the European Society of Cardiology Council on Stroke and the European Heart Rhythm Association

Atrial fibrillation (AF) is one of the most common cardiac diseases and a complicating comorbidity for multiple associated diseases. Many clinical decisions regarding AF are currently based on the binary recognition of AF being present or absent with the categorical appraisal of AF as continued or intermittent. Assessment of AF in clinical trials is largely limited to the time to (first) detection of an AF episode. Substantial evidence shows, however, that the quantitative characteristic of intermittent AF has a relevant impact on symptoms, onset, and progression of AF and AF-related outcomes, including mortality. Atrial fibrillation burden is increasingly recognized as a suitable quantitative measure of intermittent AF that provides an estimate of risk attributable to AF, the efficacy of antiarrhythmic treatment, and the need for oral anticoagulation. However, the diversity of assessment methods and the lack of a consistent definition of AF burden prevent a wider clinical applicability and validation of actionable thresholds of AF burden. To facilitate progress in this field, the AF burden Consensus Group, an international and multidisciplinary collaboration, proposes a unified definition of AF burden. Based on current evidence and using a modified Delphi technique, consensus statements were attained on the four main areas describing AF burden: Defining the characteristics of AF burden, the recording principles, the clinical relevance in major clinical conditions, and implementation as an outcome in the clinic and in clinical trials. According to this consensus, AF burden is defined as the proportion of time spent in AF expressed as a percentage of the recording time, undertaken during a specified monitoring duration. A pivotal requirement for validity and comparability of AF burden assessment is a continuous or near-continuous duration of monitoring that needs to be reported together with the AF burden assessment. This proposed unified definition of AF burden applies independent of comorbidities and outcomes. However, the disease-specific actionable thresholds of AF burden need to be defined according to the targeted clinical outcomes in specific populations. The duration of the longest episode of uninterrupted AF expressed as a time duration should also be reported when appropriate. A unified definition of AF burden will allow for comparability of clinical study data to expand evidence and to establish actionable thresholds of AF burden in various clinical conditions. This proposed definition of AF burden will support risk evaluation and clinical treatment decisions in AF-related disease. It will further promote the development of clinical trials studying the clinical relevance of intermittent AF. A unified approach on AF burden will finally inform the technology development of heart rhythm monitoring towards validated technology to meet clinical needs.

Building consensus: development of a best practice guideline (BPG) for avoiding errors in robotic-assisted spine surgery (RASS)

INTRODUCTION

With the rapid increase in the use of robotic-assisted spine surgery (RASS), reports describing complications have inevitably emerged. This study builds on previous work done to identify, characterize, and classify potential sources of error in spine surgery performed with enabling technology in the operating room. The goal of this study is to leverage expert opinion to develop a set of best practice guidelines that can be employed to minimize complications and optimize patient safety, specifically as it relates to RASS.

METHODS

After assembling a group of attending spine surgeons experienced in the use of RASS across the country, formal consensus regarding the best practices was developed using the Delphi method and nominal group technique. After a review of the relevant literature and evidence, an initial survey of study group members (n=12) helped frame potential areas for investigation. Statements were subsequently edited, removed, or elaborated upon during four iterative rounds of live discussion with the opportunity for panelists to propose new guidelines at any point in the process. Respondents were able to suggest modifications and refine the statements until consensus, defined as ≥ 80% agreement, was achieved.

RESULTS

After a three-round iterative survey and video conference Delphi process, followed by an in-person meeting at the Summit for Safety in Spine Surgery, consensus was achieved on 27 best practice guideline statements. This BPG had the key focus areas of 1) general protocols, 2) screw planning/execution, 3) optimization of surgical technique, and 4) areas for robotic improvement. (available at https://safetyinspinesurgery.com/ ).

CONCLUSION

This work provides expert insight into the best practices for minimizing errors in RASS with the presentation of 27 recommendations that can serve to reduce practice variability, optimize safety, and guide future research.

Readiness for Return to Dance After Lower Extremity Injury in the Female Dancer: A Modified Delphi Study

The aim of this paper is to establish consensus among subject area experts on readiness criteria for return to dance (RTD) in female dancers after forced time loss due to lower extremity injury. Recommendations for RTD protocols have previously been published, which generally guide the dancer to progress from barre work to center. However, the question of when to initiate an RTD protocol can be a complex decision itself. We performed a modified, 2-round Delphi study among a diverse group of experts who work closely with preprofessional and professional dancers. Criteria for RTD that achieved ≥75% agreement were included in the final consensus recommendations. Fleiss Kappa was utilized to determine the overall rater agreement. Experts agree on the importance of certain functional tests, such as the single-leg sauté test, the 30-second single-leg balance test, and the airplane test for establishing RTD readiness after various lower extremity injuries.

A Delphi consensus on diagnosis, management, and treatment with allergen immunotherapy of polysensitized children in Spain: CAPP study, Part 2

BACKGROUND

The study aimed to evaluate the level of agreement between specialists in pediatric allergology regarding the diagnosis and indications for allergen immunotherapy (AIT) for dust mites, molds, animal dander, and Hymenoptera venom allergen, as well as mixtures of several allergen sources in polysensitized children in Spain.

MATERIALS AND METHODS

A Delphi study was performed using an online survey designed by a committee of pediatric AIT experts: 46 and 44 panelists participated in Rounds 1 and 2, respectively. In Round 1, 204 statements on 8 dimensions were evaluated (Diagnosis, Therapeutic management, and Pollens - Part I; Mites, molds, animals, hymenoptera venom, and mixtures - Part II). A total of 148 statements were finally accepted after Round 2. Panel members rated their level of agreement with assessments on a 9-point Likert scale based on acceptance by ≥ 66.7 of them.

RESULTS

Panel experts recommended molecular diagnosis for dust mite allergy diagnosis in polysensitized pediatrics and mixtures of nonhomologous mites (Dermatophagoides and Lepidoglyphus) for optimal AIT management. Subcutaneous AIT with mold extracts is recommended, but no agreement was reached on mixing different mold types. Panel experts agreed that Fel d 1 and Can f 1 sIgE are better predictors for animal dander allergy , but no agreement exists on the acceptance of AIT with dander mixtures. Panelists accepted that Api m 2 (hyaluronidase) sIgE indicates Vespid and Apis mellifera cross-reactivity in children; and Api m 4 (melittin) sIgE is a marker of risk for systemic reaction with AIT in Apis mellifera allergy. According to the consensus, SCIT is more suitable for allergen mixtures than SLIT. and agreement was reached for pollen allergens and Alternaria alternata mixtures if stability, safety, and efficacy have been demonstrated.

CONCLUSIONS

This Delphi study provides, where evidence is lacking, current expert-based opinions on clinical decision-making for managing polysensitized children.

A Delphi consensus on diagnosis, management, and treatment with allergen immunotherapy of polysensitized children in Spain: CAPP study, Part 1

BACKGROUND

The study aimed to evaluate the level of agreement between specialists in pediatric allergology regarding the diagnosis and indications for pollen allergen immunotherapy (AIT) of polysensitized children in Spain.

MATERIALS AND METHODS

A Delphi study was performed using an online survey designed by a committee of pediatric AIT experts: 46 and 44 panelists participated in rounds 1 and 2, respectively. In round 1, 204 statements on 8 dimensions were evaluated (Diagnosis; Therapeutic management; Pollens - Part I; Mites; Moulds; Animals; Hymenoptera venom; and Mixtures - Part II). A total of 148 statements were finally accepted after round 2. Panel members rated their level of agreement with assessments on a 9-point Likert scale based on acceptance by ≥ 66.7% of them.

RESULTS

According to the results, the polysensitization determination in allergic patients is confirmed by clinical history, skin prick test, total and specific IgE, and molecular diagnostics. Clinical assessments are recommended for the AIT effectiveness evaluation. Follow-ups should be performed 6 months after AIT initiation. According to experts, pollens are the most representative allergens in allergic rhinitis but AIT is more effective in bronchial asthma treatment. The IgE levels are positively related to the intensity of the symptomatology and the efficacy of Grass AIT. In pollen mixtures, a maximum mixture of three AIT allergens is established between Grass, Olive, and Cupressaceae. Mixing pollen from Platanus acerifolia and Parietaria is not recommended.

CONCLUSIONS

This study provides, where evidence is lacking, current expert-based opinions on clinical decision-making for managing pollen AIT in polysensitized children.

A Brazilian Association of Women´s Health Physical Therapy (ABRAFISM) guideline on the terminology of pelvic floor muscle function and assessment

BACKGROUND

There has been many efforts and updates over the years to develop a consensus for English terminology related to the pelvic floor (PF). There is a similar need to standardize physical therapy related PF terminology in Brazil.

OBJECTIVE

To propose a guideline in Brazilian Portuguese language on the terminology related to the female PF function and assessment.

METHODS

The Brazilian Association of Physical Therapy in Women's Health (ABRAFISM) established a working group (Steering committee) responsible for conducting a systematic review on PF terminology, propose definitions in Portuguese, and manage the developmental stages. A systematic review of international consensus was conducted and the terms related to the PF were identified, listed, and defined in Portuguese. A Delphi method was used to reach a consensus on the definitions by querying a panel of expert professionals with clinical and research experience in the PF field. This panel included 19 physical therapists from all Brazilian regions and two physicians. The Delphi process included the following steps: evaluation of proposed terms by the panel of experts; review of suggestions made by the panel of experts, modification of terms based on those suggestions, and a new round of evaluation of the modified terms until reaching an 80% agreement.

RESULTS

Two rounds were necessary for terms related to anatomy and signs/symptoms of the PF, while a 90% consensus for terms related to assessment of the PF muscles was achieved in the first round.

CONCLUSION

A final Brazilian-Portuguese guideline with consensus terminology on anatomy, symptoms, signs, and terms related to assessment of PF muscles was developed.

Australasian hidradenitis suppurativa management guidelines

Hidradenitis Suppurativa is a burdensome inflammatory skin disease with significant quality of life impact. These management guidelines were developed to direct appropriate clinical management in the Australasian context. A systematic review was used for the basis of the consensus guidelines. Thirteen clinical experts were involved in a modified Delphi consensus process to develop the guidelines and treatment algorithms. Overall management strategies include appropriate severity assessment of disease and comorbidities, multimodal therapy with systemic and local treatments, and evidence-based progression along the therapeutic ladder in the event of inadequate response. Sequential monotherapy with antibiotics and/or single agent therapy is discouraged and aggressive treatment of moderate to severe disease to capture the window of opportunity is highly emphasised. Specific considerations in the setting of disease comorbidities, pregnancy and breastfeeding are also addressed. Overall, the complex nature of HS requires a complex and multimodal therapeutic response with medical, physical and surgical therapies to achieve best patient outcomes.

Guidance for Creating Morally Healthy Organizations That Remediate the Experience of Moral Injury in Health Care: Findings From an International e-Delphi Study

OBJECTIVE

To date, research and policy directives have focused on identifying individual risk factors for moral injury, with less attention to solutions for establishing nonmorally injurious cultures and practices.

METHODS

Experts with academic or clinical knowledge of moral injury were recruited to a three-round e-Delphi survey exploring descriptors and characteristics of nonmorally injurious organizations.

RESULTS

Forty-nine, 41, and 39 experts responded at each round. Morally "healthy," "congruent," and "centered" were endorsed as descriptors for nonmorally injurious organizations. Consensus was also obtained on 111 characteristics and behaviors relating to organizational identity (eg, just culture), behaviors and practices (eg, transparency in decision-making), and self-awareness (eg, monitoring of moral injury in workforce).

CONCLUSIONS

The findings implicate the need for a strengths-oriented, solution-focused approach to addressing moral injury. The recommendations proposed warrant evaluation and operationalization within formal guidance.

Development of a Novel Evidence-Based Practice-Specific Competency for Doctor of Physical Therapy Students in Clinical Education: A Modified Delphi Approach

INTRODUCTION

Evidence-based practice (EBP) results in high-quality care and decreases unwarranted variation in practice.

REVIEW OF THE LITERATURE

Few performance criteria related to EBP are included in physical therapy clinical education (CE) performance measures, despite EBP requirements in Doctor of Physical Therapy education. The purpose of this study was to develop EBP-specific competencies that may be used for Doctor of Physical Therapy students for use throughout CE.

SUBJECTS

Thirteen subject matter experts (SME) participated in this study.

METHODS

Subject matter experts were asked to rank each core EBP competency, from a previously described framework, using a 3-point Likert scale, which included "Not Essential," "Essential," and "Not Sure." A consensus of 70% or greater for the "Essential" rating advanced the competency to the final Delphi round, whereas a consensus of 70% or greater for the "Not Essential" rating was required for competency elimination. Subject matter experts voted to either "Accept" or "Modify" the competencies that had reached the inclusion consensus threshold. All competencies that reached consensus for inclusion after all 3 rounds were included in the final EBP Domain of Competence.

RESULTS

Consensus was achieved in round one for 38% ( n = 26) of items. In round 2, a consensus was achieved for 20% ( n = 8) of items. Of the items remaining after rounds 1 and 2, 6 overarching competencies were identified, and all remaining items served as descriptions and specifications in the final EBP Domain of Competence.

DISCUSSION AND CONCLUSIONS

The 6 competencies developed from this study constitute the EBP Domain of Competence and may be used throughout CE to assess students' EBP competency in clinical practice.

Using real-time Delphi methods to develop a consensus-based framework to improve nursing assessment in residential aged care

OBJECTIVES

Evidence-based tools are needed to support aged care nurses in recognising and responding to changes in residents' conditions and clinical deterioration. Systematised emergency nursing frameworks such as HIRAID® (History including Infection risk, Red flags, Assessment, Interventions, Diagnostics, reassessment and communication) assist nurses in accurately assessing and documenting a patient's condition and identifying and prioritising care needs. This study aimed to adapt the HIRAID® emergency nursing framework for use in the residential aged care setting.

METHODS

A real-time Delphi method was employed to contextually adapt the HIRAID® framework. Twelve expert health-care clinical leaders with understanding of patient assessment and residential aged care management were recruited through purposive sampling. Panel consensus was established a priori at 80%. A secondary measure of panel stability was used to understand panel consensus.

RESULTS

Consensus was reached after two survey rounds. In Round 1, 105 (88%) of 119 items were accepted after reaching consensus. In Round 2, all remaining 29 items reached consensus, whereby 20 were accepted and nine rejected. Key modifications were identified for 'History', which needed to consider more comprehensive and adaptive techniques, and 'Interventions' and 'Diagnostics', where differences arose in the scope of practice of aged care nurses compared to their acute care counterparts.

CONCLUSION

The study demonstrated how a small expert multidisciplinary health-care panel can be stable and reach consensus to adapt and contextualise an emergency care framework to the aged care setting. These findings will form the content to scaffold educational resources to support learning and practice change.

Defining minimum workforce standards for intensive care physiotherapy in Australia and New Zealand: A Delphi study

BACKGROUND

Intensive care staffing guidelines provide recommendations for the safe and effective delivery of health care while recognising professional requirements of the workforce. To guide recommendations for physiotherapy staffing guidelines, profession-specific consultation is needed.

OBJECTIVES

The objective of this study was to develop consensus-based recommendations for minimum workforce standards for physiotherapy in intensive care.

METHODS

A Delphi survey process was conducted involving physiotherapists from Australia and New Zealand.

RESULTS

The panel consisted of 65 physiotherapists in the first round and 60 in the second round (92% retention). Respondents were from both Australia (49, 76%) and New Zealand (16, 24%) who had been physiotherapists for an average of 18.8 ± 9.0 years and were primarily senior intensive care physiotherapists (44, 68%). Respondents had experience across level 3 (50, 77%), level 2 (18, 28%), and level 1 (5, 8%) adult intensive care units (ICUs), adult high-dependency units (27, 42%), and paediatric intensive care (6, 9%). A total of 42 statements were presented, with 37 reaching consensus after two rounds. After two rounds, consensus was achieved for a minimum staffing ratio in paediatric ICUs of one physiotherapist per six (1:6) beds. For adult ICUs, use of the median value of the participant's responses was supported to establish minimum staffing ratios of 1:8, 1:7, 1:6, and 1:8 for levels 1, 2, and 3 ICUs and high-dependency units, respectively. The requirement for an additional allocation for senior physiotherapist staffing for each ICU level was also established. Statements that also gained consensus included recommendations for access to on-call and weekend services for all ICU settings and the consideration of evening shifts specifically for level 3 and paediatric ICUs.

CONCLUSIONS

Recommendations for minimum staffing for physiotherapy in intensive care settings were achieved and supported requirements for clinical service delivery, supervision, and training.

A Framework for the Analysis of Communication Errors in Health Care

OBJECTIVES

The goal of this study was to develop a systematic method to identify and classify different types of communication failures leading to patient safety events. We aimed to develop a taxonomy code sheet for identifying communication errors and provide a framework tool to classify the communication error types.

METHODS

This observational study used the Delphi method to develop a taxonomy code sheet for identifying communication errors reported in the Veterans Health Administration patient safety databases between April 2018 and March 2021. We also used Natural Language Processing to create a framework tool to classify the 9 types of communication errors using this taxonomy. Finally, analysis was done to identify affected clinical locations.

RESULTS

We identified 9 types of communication failures that impacted clinical outcomes using the taxonomy code sheet developed. The top 3 errors were related to nonadherence to facility standard operating procedures (993, 37.6%), followed by written errors (e.g., unclear documentation or not using plain language) (587, 22.3%) and no communication (347, 13.2%). The remaining categories of communication types are electronic (253, 9.6%), verbal (205, 7.8%), hand-off (124, 4.7%), visual (76, 2.9%), listening (41, 1.6%), and nonverbal (12, 0.5%). A cognitive aide was developed to demonstrate the step-by-step method for using the framework tool to classify the communication errors.

CONCLUSIONS

The cognitive aide and the framework tool developed in this study can be used in any healthcare setting to identify and classify communication failures and mitigate potential risks contributing to safety events.

Consensus on the Use of Therapeutic Interventions in Pain Management, Recovery, and Athletic Performance: A Delphi Study

Background

Therapeutic interventions are widely used in clinical practice to prepare individuals for movement, recover from exercise, and mediate pain and inflammation associated with injury. However, there has yet to be cited consensus regarding when to use such interventions.

Purpose

Using the Delphi method, this study aimed to develop consensus among physical therapists (PTs) and athletic trainers (ATs) regarding the use of percussive, vibration, infrared, heat, and cryotherapy in a variety of treatment circumstances. These included preparation and recovery from physical activity, treatment of acute and chronic joint pain, and treatment of acute and chronic soft tissue/muscle pain.

Methods

Four rounds of surveys were delivered to individuals who were licensed or certified PTs/ATs, with more than 1,000 hours of experience working with athletic populations and experience using at least one of the interventions of interest in the prior five years. Consensus was defined as a greater than 70% agreement, and consideration for use was defined as selecting "In Some Instances'' and"In Most Instances."

Results

Ninety-four individuals responded to the screening survey (n1 = 74, n2 = 68, n3 = 44, n4 = 32). The individuals who participated agreed that they would consider using the following therapeutic interventions in treatment: 1) percussive therapy, local vibration, and local heat therapy in the preparation for physical activity; 2) local cryotherapy in recovery from physical activity; 3) local cryotherapy for the treatment of acute joint pain and acute soft tissue/muscle pain; 4) local heat and local cryotherapy for the treatment of chronic joint pain; and 5) percussive, local vibration, local heat, and local cryotherapy in the treatment of chronic soft tissue/muscle pain.

Conclusion

Clinical intervention often relies on patient presentation and preference. This study provides a consensus on the use of common therapeutic interventions for the management of athletic recovery, pain, and inflammation among ATs and PTs.

Level of Evidence

3.

A consensus of European experts on the definition of ventilator-associated pneumonia recurrences obtained by the Delphi method: the RECUVAP study

BACKGROUND

There are recognized diagnostic criteria for a first ventilator-associated pneumonia (VAP) episode, but not for recurrences. Many randomized clinical trials (RCTs) have used the recurrence of VAP as a criterion for efficacy evaluation. Still, the different definitions used in RCTs make it difficult to compare studies. We aimed to develop a consensual definition of VAP recurrences and of the various types of VAP recurrences.

METHODS

Thirty-six European experts constituting a multidisciplinary group of physicians (critical care, infectious diseases, microbiology) with special interest in the management of VAP were polled using the Delphi methodology.

RESULTS

After the completion of four iterations of the DELPHI method, 94% of experts agreed that the diagnostic criteria for a first VAP episode could also be used for recurrences, except for the radiological criterion, which not all the experts considered to be mandatory. Consensus was also reached regarding the definition of four distinct entities: relapse, persistent VAP, superinfection, and new-pathogen VAP. For relapse and persistent VAP, bacteriological findings were identical for different VAP episodes, whereas they differed for superinfection and new-pathogen VAP. The distinction between relapse and persistent VAP, and between superinfection and new-pathogen VAP depended on the timing of antibiotic treatment (before or after 48-72 h after the end of antibiotic therapy) and the clinical course. Microbiological criteria were proposed to facilitate the diagnosis of persistent VAP.

CONCLUSION

This consensus by European experts proposes four different VAP recurrence entities which should facilitate the harmonization of recurrence criteria for clinical practice and future studies.

From Clinical to Non-clinical Outcomes in the Treatment of HIV: An Economic and Organizational Impact Assessment

OBJECTIVE

The aim of this study was to define the economic and organizational impacts related to a broader utilization of bictegravir/emtricitabine/alafenamide (BIC/FTC/TAF) in Italian clinical practice.

METHODS

A budget impact analysis-representing the evolution of the Italian National Healthcare Service (NHS) healthcare expenditure over 3 years-was developed, considering the overall Italian population treated for human immunodeficiency virus (HIV). Model input variables were treatment history, therapeutic regimen, development of adverse events, achievement of an undetectable viral load and total direct healthcare costs. Besides the BIA, an organizational impact assessment was conducted to determine the impact on the use of healthcare resources, assessing the release of organizational hospital assets, focusing on the management of drug-related adverse events. Data were collected from scientific evidence, Italian national and regional legislations and healthcare professionals' reports. To verify the robustness of the economic and organizational impact assessment, sensitivity analyses were performed.

RESULTS

Results demonstrate economic savings of about 26 million euros in total health spending, assuming a higher penetration rate for BIC/FTC/TAF. This change in the current case mix would lead to a reduction in the specific costs related to adverse event management (0.9 million euros; - 2.09%) and in the medical management of patients (38 million euros; - 7.79%), with a positive impact on the achievement of virological control. From an organizational perspective, a wider use of BIC/FTC/TAF generates a reduction in the utilization of healthcare resources due to a decrease in adverse events and complications. The model estimated a 19.64% reduction in HIV-related inpatient days, which freed up healthcare professional time.

CONCLUSIONS

Capable of improving both economic and organizational sustainability for the entire HIV care continuum, BIC/FTC/TAF is an efficient therapeutic strategy for people with HIV.

Food Allergy Test-Guided Dietary Advice for Children With Atopic Dermatitis: A Consensus Study

BACKGROUND

The use of blood specific IgE or skin prick tests (SPT) to guide dietary exclusions for disease control in children with atopic dermatitis (AD) is controversial. We undertook a consensus exercise on how to interpret SPT results and dietary history for cow's milk, hen's egg, wheat, and soy in children < 2 years old with AD.

METHODS

Fourteen clinicians from general practice, pediatrics, pediatric dermatology, pediatric allergy, and pediatric dietetics from UK and Ireland took part in an online modified Delphi study. Over three rounds, participants gave their anonymous opinions and received individualized and group feedback, based on the premise that all children had SPTs. The findings were discussed in an online workshop.

RESULTS

Of 18 symptoms, 12 were identified as relevant to immediate and 7 to delayed allergy. Regarding SPTs, there was consensus over which allergens to use for wheat and soy but not cow's milk or hen's egg; for all study foods, wheal size was determined as 0-1 mm negative, ≥ 5 mm sensitized, but between 2 and 4 mm, categorization varied by food. During the final workshop, consensus was reached on dietary advice for nine combinations of SPT results and dietary history.

CONCLUSION

We attained consensus on how SPTs and dietary history for four common food allergens should be interpreted in young children under 2 years of age with AD. These pragmatic recommendations may support clinician education, consistency of decision-making, and future research.

Developing a Competency Assessment Index System for Hematology Nurses in China: Delphi Study Insights

PURPOSE

Patient management, care, and education are influenced by the core competencies of hematology nurses. Nurse specialists enhance patient safety and nursing care quality. However, no study has constructed an index of core competence assessment for hematology nurses.

DESIGN

In this study, a literature review, theoretical analysis, and group discussion were performed to construct the core competency evaluation index system for hematology nurses.

METHODS

Twenty-six experts from 7 provinces and cities across China were selected by purposive sampling for 2 rounds of Delphi expert consultation, and the indicators were selected based on the mean importance score >3.5 and coefficient of variation <0.25. A precedence chart determined the indicator weights at all levels.

RESULTS

The evaluation index included 6 primary, 18 secondary, and 70 tertiary indicators. The positive coefficients of the questionnaire on the 2 rounds were 100% and 92.86%. The Kendall's harmony coefficients for indicators at all levels were 0.176 to 0.461 and 0.197 to 0.220. Experts' familiarity, judgment, and authority coefficients were 0.892, 0.871, and 0.882, respectively.

CONCLUSIONS

The evaluation index system may provide references for the training, curriculum setting, assessment, and qualification certification of hematology nurses.

Establishing Research Priorities in Geriatric Nephrology: A Delphi Study of Clinicians and Researchers

RATIONALE & OBJECTIVE

Despite substantial growth of the population of older adults with kidney disease, there remains a lack of evidence to guide clinical care for this group. The Kidney Disease and Aging Research Collaborative conducted a Delphi study to build consensus on research priorities for clinical geriatric nephrology.

STUDY DESIGN

Asynchronous modified Delphi study.

SETTING & PARTICIPANTS

Clinicians and researchers in the United States and Canada with clinical experience and/or research expertise in geriatric nephrology.

OUTCOME

Research priorities in geriatric nephrology.

ANALYTICAL APPROACH

In the first Delphi round, participants submitted free-text descriptions of research priorities considered important for improving the clinical care of older adults with kidney disease. Delphi moderators used inductive content analysis to group concepts into categories. In the second and third rounds, participants iteratively reviewed topics, selected their top 5 priorities, and offered comments used to revise categories.

RESULTS

Among 121 who were invited, 57 participants (47%) completed the first Delphi round and 48 (84% of enrolled participants) completed all rounds. After 3 rounds, the 5 priorities with the highest proportion of agreement were (1) communication and decision-making about treatment options for older adults with kidney failure (69% agreement), (2) quality of life, symptom management, and palliative care (67%), (3) frailty and physical function (54%), (4) tailoring therapies for kidney disease to specific needs of older adults (42%), and (5) caregiver and social support (35%). Health equity and person-centricity were identified as cross-cutting features that informed all topics.

LIMITATIONS

Relatively low response rate and limited participation by private practitioners and older clinicians and researchers.

CONCLUSIONS

Experts in geriatric nephrology identified clinical research priorities with the greatest potential to improve care for older adults with kidney disease. These findings provide a road map for the geriatric nephrology community to harmonize and maximize the impact of research efforts.

Cardio-oncology rehabilitation and exercise: evidence, priorities, and research standards from the ICOS-CORE working group

The aim of this whitepaper is to review the current state of the literature on the effects of cardio-oncology rehabilitation and exercise (CORE) programmes and provide a roadmap for improving the evidence-based to support the implementation of CORE. There is an urgent need to reinforce and extend the evidence informing the cardiovascular care of cancer survivors. CORE is an attractive model that is potentially scalable to improve the cardiovascular health of cancer survivors as it leverages many of the existing frameworks developed through decades of delivery of cardiac rehabilitation. However, there are several challenges within this burgeoning field, including limited evidence of the efficacy of this approach in patients with cancer. In this paper, a multidisciplinary team of international experts highlights priorities for future research in this field and recommends standards for the conduct of research.

A Delphi Consensus Project to Capture Greek Experts' Opinion on the Position of Triple Therapies in COPD: Why, When and to Whom

Background

In recent years, COPD treatment has become more personalized considering specific patient's characteristics.

Aim and Methods

We have performed a DELPHI consensus project to assess the level of consensus among Greek experts on the use of triple therapy in COPD as an initial and follow-up treatment. A three-round Delphi online survey was developed. The questionnaire was developed by a 6-member steering committee, included 54 statements, and divided into 3 domains: (A) triple therapy as initial treatment (divided into subdomains examining the impact of exacerbations based on lung function, bronchodilation reversibility and/or blood eosinophil count, smoking, symptoms, and comorbidities), (B) escalation to triple therapy from dual bronchodilation and (C) de-escalation from triple therapy to dual bronchodilation. The survey was funded by AstraZeneca and was hosted and analysed by an independent external company.

Results

Consensus was reached in 84.8%, 63% and 80% of statements for domains A, B and C, respectively. Experts agreed that initial treatment with triple therapy is a reasonable option for specific patients, while escalation from dual bronchodilation to triple therapy could be considered, besides frequent exacerbators, also in patients with a history of one moderate exacerbation, mainly in the presence of marked bronchodilator reversibility or high blood eosinophil count. Finally, there was a consensus that de-escalation from triple therapy to dual bronchodilation was inappropriate in patients who had experienced one moderate exacerbation in the previous year.

Conclusion

Although consensus was generated in several statements, panelists failed to reach consensus in many aspects of the use of triple therapy, identifying areas for further research.

Criteria for medication reconciliation in major orthopedic surgery in high-risk patients: A consensus based on the Delphi method

BACKGROUND

Medication reconciliation is relevant in transitional care, however, given limited resources, it is necessary to identify the patients who benefit most from this activity.

AIM

To validate criteria to identify patients at high risk of medication errors undergoing major orthopedic surgery.

METHOD

Delphi Method in 3 phases, April to June 2023, to obtain consensus on the inclusion criteria, previously defined. Each expert rated criteria according to a 5-point Likert scale. Consensus was assumed in round 1 if the rate average was more than 4 (inclusion) or less than 2 (exclusion) and in round 2 and 3 if 50% of the responses were more than 4 (inclusion) or less than 2 (exclusion). It was possible to suggest the inclusion of new criteria.

RESULTS

10 experts from Faculties of Pharmacy and Medicine participated. In the first phase, consensus was reached on 18 criteria: polypharmacy, anticoagulants, oral chemotherapy (not hormone), immunosuppressants, antiretrovirals, antimyasthenics, insulin, corticoids, neuroleptics, antiarrhythmics, digoxin, carbamazepine, phenytoin, valproate, thyroid drugs, anti-glaucoma, anti-aggregants, and urgent surgery. Systemic antifungals and opioids were suggested. In the second phase, consensus was reached on eleven criteria: anti-parkinsonics, beta-blockers, age more than65 years, length of stay more than 5 days, lamotrigine, diuretics, antidepressants, angiotensin converting enzyme inhibitors, angiotensin II receptor antagonists, anxiolytics, opioids, and systemic antifungals. In the last phase, one criterion reached consensus (sulfonylureas) and one criterion did not reach consensus (calcium channel blockers).

CONCLUSIONS

We develop and validate a list of 30 criteria to identify patients at high risk of experiencing medication errors undergoing major orthopedic surgery. These may help improve human resource management for clinical pharmacy activities by prioritizing patients who would benefit most.

Group exercise in long-term care facilities, alignment with World Health Organization recommendations: a cross-sectional survey

BACKGROUND

Maintaining functional status in institutionalized older people is a challenge for long-term care (LTC) institutions. In this regard, exercise may have positive effects. The World Health Organization (WHO) has issued guidelines which include recommendations of exercise for each population group. Nonetheless, the literature shows that the levels of exercise among institutionalized population are still low.

AIMS

This study sought to determine: (1) the characteristics of exercise programs for older people performed by health professionals in LTC facilities, (2) the knowledge and use of the WHO recommendations and guidelines for exercising among older people in LTC facilities; (3) the limitations identified by health professionals regarding the application of the WHO guidelines.

MATERIALS AND METHODS

A cross-sectional national survey following STROBE guideline was performed.

SAMPLE

professionals developing exercise programs for institutionalized older people. A Delphi study was conducted to create the survey which included sociodemographic data, exercise characteristics, knowledge about WHO recommendations and limitations regarding their application. Descriptive statistics were used on the data, such as Pearson's χ2 and independent t- test.

RESULTS

Many professionals do not know (27,5%) or do not follow (52%) the guidelines proposed by the WHO. There is a low weekly frequency for strength exercises (30%) and aerobic exercise (51%). The professional contract influences the weekly frequency of exercise. Most identified limitations for using the WHO recommendations were the lack of time and large groups.

DISCUSSION AND CONCLUSIONS

Recommendations of WHO guidelines are familiar to many professionals, however, some are difficult to implement in exercise programs in LTC facilities.

Factors influencing clinically trained pharmacists to pursue management roles: A modified Delphi survey

PURPOSE

This study aimed to establish consensus among a sample of pharmacist clinicians on factors that would make them more or less likely to transition from a position primarily in direct patient care to a management position that included direct reports.

METHODS

A 3-round modified Delphi survey was conducted. Pharmacists were selected as panelists to gain further information on the transition from a clinician to a managerial role. Study investigators utilized their professional network of pharmacy leaders nationwide who may have had staff who met the inclusion criteria. Participating pharmacy leaders emailed staff an interest survey, and participant email addresses were collected. During the round 1 survey, 2 open-ended questions were used to identify both positive and negative factors influencing pursuit of a managerial roles and responses were analyzed for factor development. In round 2, factors that met or exceeded a predetermined consensus agreement threshold of 70% were included in the round 3 survey. In round 3, a 4-point Likert scale was utilized for respondents to indicate agreement with each factor remaining.

RESULTS

For each consecutive round, the survey response rate was 63% (96/152), 83% (79/96), and 87% (69/79), respectively. A total of 595 factor terms submitted by panelists in round 1 were consolidated into 30 "more likely" and 27 "less likely" factors by round 3. In round 3, the 70% agreement threshold was met across all factors. One less likely factor regarding workload expectations reached 100% total agreement.

CONCLUSION

The survey results may assist pharmacy administrative leaders in optimizing transitions to managerial roles by considering clinician perspectives.

Improving awareness of rabies and free-roaming dogs in schools of Guwahati, Assam, India: exploring the educators' perspective

BACKGROUND

Rabies poses a significant threat to public health in India, with schoolchildren comprising approximately 40% of mortality due to this zoonotic disease. Despite ongoing interventions in schools to increase awareness about rabies and free-roaming dogs (FRD), the incidence of dog bites and rabies cases among schoolchildren continues to rise. This study addresses the limitations of existing awareness programs by exploring educators' perspectives and proposing innovative, feasible, and cost-effective interventions in schools.

METHODS

A three-day workshop involving 19 teachers from seven schools representing diverse socio-economic backgrounds by adopting a modified Delphi method to achieve consensus on interventions identified during the process.

RESULTS

The workshop recommends (a) promoting awareness in morning assemblies, (b) starting a wall magazine on One Health, (c) distributing and displaying information, education, and communication (IEC) materials, (d) encouraging infographics, paintings, sketches, and reels, (e) integrating rabies-related topics in co-curricular activities, (f) initiating interdisciplinary projects focusing on rabies awareness (g) displaying in rabies awareness stalls during exhibitions/school functions, and (h) discussing in parent-teachers meets.

CONCLUSIONS

This study identifies sustainable and pedagogically sound interventions to raise awareness about rabies and FRD in schools, contributing to the broader goal of reducing rabies-related mortality among school children.

Identifying Research Priorities in Digital Education for Health Care: Umbrella Review and Modified Delphi Method Study

BACKGROUND

In recent years, the use of digital technology in the education of health care professionals has surged, partly driven by the COVID-19 pandemic. However, there is still a need for focused research to establish evidence of its effectiveness.

OBJECTIVE

This study aimed to define the gaps in the evidence for the efficacy of digital education and to identify priority areas where future research has the potential to contribute to our understanding and use of digital education.

METHODS

We used a 2-stage approach to identify research priorities. First, an umbrella review of the recent literature (published between 2020 and 2023) was performed to identify and build on existing work. Second, expert consensus on the priority research questions was obtained using a modified Delphi method.

RESULTS

A total of 8857 potentially relevant papers were identified. Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology, we included 217 papers for full review. All papers were either systematic reviews or meta-analyses. A total of 151 research recommendations were extracted from the 217 papers. These were analyzed, recategorized, and consolidated to create a final list of 63 questions. From these, a modified Delphi process with 42 experts was used to produce the top-five rated research priorities: (1) How do we measure the learning transfer from digital education into the clinical setting? (2) How can we optimize the use of artificial intelligence, machine learning, and deep learning to facilitate education and training? (3) What are the methodological requirements for high-quality rigorous studies assessing the outcomes of digital health education? (4) How does the design of digital education interventions (eg, format and modality) in health professionals' education and training curriculum affect learning outcomes? and (5) How should learning outcomes in the field of health professions' digital education be defined and standardized?

CONCLUSIONS

This review provides a prioritized list of research gaps in digital education in health care, which will be of use to researchers, educators, education providers, and funding agencies. Additional proposals are discussed regarding the next steps needed to advance this agenda, aiming to promote meaningful and practical research on the use of digital technologies and drive excellence in health care education.