Delphi methodology in healthcare research: How to decide its appropriateness

Development of an instrument to measure the attitudes and skills of undergraduate nursing students in caring for family caregivers: An international multi-method study

BACKGROUND

The increasing demands on family caregivers due to the shortage of healthcare professionals and the rising prevalence of chronic conditions underscore the need for adequate nursing support to enhance family caregivers' abilities and reduce their burden. No instrument exists to measure undergraduate nursing students' attitudes and skills in involving family caregivers. This study aimed to develop a questionnaire to evaluate undergraduate nursing students' attitudes and skills in caring for family caregivers.

METHODS

A three-phase multi-method study was conducted involving a consortium of five universities in Italy, Denmark, India, Spain, and Sweden. Theoretical models and literature analysis and review informed initial item generation. Then, a Delphi process with purposefully selected international experts across three rounds refined the item list based on clarity, essentiality, and relevance, achieving consensus on a final set of items. Finally, pilot testing with purposefully selected 25 students assessed face validity and clarity.

RESULTS

The preliminary phase led to 130 items. Delphi rounds reduced the initial 130 items to a refined set of 39 (13 items on attitudes, 26 on skills). Content Validity Index (CVI) scores for clarity and relevance were high (S-CVI/Ave = 0.93 for clarity, 1.0 for relevance). From the pilot test among 25 students, items scored an average clarity of 0.84 (I-CVI). Two items were removed, resulting in a final 37-item questionnaire (12 attitudes, 25 skills).

DISCUSSION

The developed questionnaire bridges a gap in nursing education assessment. Emphasizing attitudes and skills, it addresses key areas such as understanding family dynamics, emotional support, and collaborative planning with caregivers, aligning with nursing education needs across diverse cultural contexts. The use of this instrument will support educational programs in enhancing family-centered care competencies of undergraduate nursing students, ultimately improving support for family caregivers in healthcare settings.

Defining Clinical Remission in Severe Asthma: Expert Opinion From the Gulf Region Using the Modified Delphi Method

The introduction of biologics into the asthma management landscape and the adoption of patient-centricity and outcomes principles drive the need to revise clinical goals and targets while treating asthma patients. This necessitates a deeper understanding of asthma phenotypes, endotypes, pathophysiology, and clinical cutoff points depicting an operational definition of clinical remission in asthma. This publication represents a step in this direction, through systemically gathering and analyzing insights from experts in pulmonology and immunology from the Gulf Countries. A pre-workshop survey, scientific workshop, and two rounds of Delphi surveys constituted the analysis process and resulted in agreed-upon comprehensive criteria defining clinical remission in severe asthma. While constructing the Delphi expert opinion addressing the concept of on treatment remission, the following factors were agreed to be the main defining criteria: The sustained absence of asthma symptoms, the sustained absence of asthma exacerbations, stable lung function, and zero systemic corticosteroids for the treatment of asthma for at least 12 months.

Establishing a Research Agenda for Physiotherapy in Portugal: A Delphi Study

BACKGROUND

As physiotherapy research advances, identifying knowledge gaps and setting priorities is crucial for enhancing its efficiency in national and international collaborations. This study aimed to establish a physiotherapy research agenda in Portugal by integrating perspectives from physiotherapists and users of physiotherapy services.

METHODS

An online two-round Delphi study was conducted from April to August 2024 with two panels: physiotherapists and users of physiotherapy services. Participants rated 66 research priorities in the two rounds using a four-point Likert scale (1 = not important, 4 = very important), with 13 new priorities introduced in the second round. These priorities were organized into nine research categories identified from a prior scoping review: (1) (cost)effectiveness; (2) service delivery; (3) education, professional development and quality; (4) measurement instruments; (5) mechanisms behind disability, physiotherapy treatments and patient classification; (6) patients' needs, expectations, experience and context; (7) prognostic outcomes and responses to therapy; (8) decision-making strategies; and (9) technology and big data. Consensus was defined as a cut-off median score of ≥ 3.25.

RESULTS

A total of 479 physiotherapists and 70 users of physiotherapy services participated in Round 1 with final retention rates of 64% and 43%, respectively. The final 'Top 10' priorities focused on three research categories: researching optimal service delivery models, structures, and processes (n = 5); establishing the (cost)effectiveness of different physiotherapy interventions (n = 3); and exploring the best models of physiotherapy education, professional development, and quality (n = 2).

CONCLUSIONS

This study established a physiotherapy research agenda for Portugal, focusing on (cost)effectiveness, service delivery, education, professional development, and quality, integrating the perspectives of physiotherapists and users of physiotherapy services. The final priorities provide a foundation for future research and policy development.

Prescribing lithium for the management of persons suffering from bipolar disorders: expert consensus based on a Delphi study

BACKGROUND

According to international guidelines, lithium treatment represents the gold standard for the appropriate management of persons with bipolar disorder. However, prescription rates in ordinary practice are not in line with clinical guidelines' suggestions. Clinicians prefer to use drugs other than lithium, considering its low therapeutic window, the need for regular lab tests and its side effects profile. Based on these premises, a Delphi-method study focused on highly-debated aspects of lithium treatment in bipolar disorder has been promoted with the aim to reach a consensus among an expert panel of Italian psychiatrists.

METHODS

The Delphi method is a structured technique aimed to obtain a consensus from repeated rounds of questionnaires where opinion/agreement among experts are important. A Steering Committee of experts has developed a 24-items questionnaire exploring: (1) the use of lithium as first choice for treating different phases of bipolar disorder; (2) the side effect and tolerability profile of lithium treatment as hampering factors for its use in clinical practice; (3) the lithium prescribing in special target population, such as adolescents, elderly patients, and pregnant women.

RESULTS

The questionnaire was delivered to a panel of 100 Italian psychiatrists, experts in the field of managing people with bipolar disorders. An almost complete positive consensus was reached for statements dealing with the use of lithium treatment as first choice in the management of patients with bipolar disorder, and as the first choice for preventing manic/hypomanic and depressive episodes.

CONCLUSIONS

Current clinical guidelines and scientific evidence support the use of lithium as first choice treatment in patients with bipolar disorder. However, over the last decades a downward tendency in lithium's prescription has been registered worldwide. The present Delphi study confirmed the "good clinical reasons" for supporting lithium prescription in clinical practice. Our findings should be used to develop clinical practice guidelines and reduce the discrepancy between international guidelines and ordinary care.

The potential role of AI in research priority setting exercises

To help achieve the goals of accountability and research excellence, funding organisations often utilise evidence from research priority setting exercises (RPSEs), which distil, from data gathered from relevant stakeholders, a systematic and 'objective' rank-order of research priorities. RPSEs are, however, costly and labour-intensive. Also, critics of RPSEs have highlighted certain limitations: insufficient representation of difficult-to-reach stakeholders, especially in low- and middle-income countries; a lack of genuine stakeholder engagement; wide variation in the extent to which exercises are documented; a lack of specificity in the identified priorities; and minimal impact of the priorities. Artificial intelligence (AI) tools such as ChatGPT may potentially help, valuably complementing conventional RPSEs. While the opacity of AI decision-making is a limitation, advantages include speed, affordability, and highly inclusive distillation of the vastness of existing human knowledge. We encourage research identifying the extent to which AI can replicate conventional RPSEs. We suggest that AI tools could complement conventional approaches either at the initial question generation stage or in generating supplementary insights for reflection at the data analysis stage. Also, under conditions of high existing stakeholder engagement and an extant prevalence of conventional RPSEs, AI-only studies may be valuable.

Refining partial gland ablation for localised prostate cancer: the FALCON project

OBJECTIVES

To provide a contemporary statement on focal therapy (FT) for localised prostate cancer (PCa) from an international and diverse group of physicians treating localised PCa, with the aim of overcoming the limitations of previous consensus statements, which were restricted to early adopters, and to offer direction regarding the various aspects of FT application that are currently not well defined.

MATERIALS AND METHODS

The FocAL therapy CONsensus (FALCON) project began with a 154-item online survey, developed following a steering committee discussion and literature search. Invitations to participate were extended to a large, diverse group of professionals experienced in PCa management. From 2022 to 2023, a Delphi consensus study consisting of three online rounds was conducted using the Modified Delphi method. A 1-9 Likert scale was used for the survey, which was followed by an in-person expert meeting. The threshold for achieving consensus was set at 70% agreement/disagreement. Six main aspects of FT were covered: (i) patient selection; (ii) energy source selection; (iii) treatment approach; (iv) treatment evaluation and follow-up; (v) treatment cost and accessibility; and (vi) future perspectives.

RESULTS

Of 246 initial participants, 148 (60%) completed all three rounds. Based on participant feedback, 27 new statements were added in the second round, and 33 questions related to personal expertise, for which consensus was not necessary, were excluded. After the third and final round, consensus had not been reached for 69 items. These items were discussed at the in-person meeting, resulting in a consensus of 57 additional items. Consensus was finally not reached on 12 items. Given the volume of data, the voting outcomes are summarised in this article, with a detailed breakdown presented in the form of figures and tables.

CONCLUSIONS

The FALCON project delivered a significant consensus on the approach to FT for localised PCa. Additionally, it highlighted gaps in our knowledge that may provide guidance for future research.

Essential competencies of nurses working with AI-driven lifestyle monitoring in long-term care: A modified Delphi study

BACKGROUND

As more and more older adults prefer to stay in their homes as they age, there's a need for technology to support this. A relevant technology is Artificial Intelligence (AI)-driven lifestyle monitoring, utilizing data from sensors placed in the home. This technology is not intended to replace nurses but to serve as a support tool. Understanding the specific competencies that nurses require to effectively use it is crucial. The aim of this study is to identify the essential competencies nurses require to work with AI-driven lifestyle monitoring in long-term care.

METHODS

A three round modified Delphi study was conducted, consisting of two online questionnaires and one focus group. A group of 48 experts participated in the study: nurses, innovators, developers, researchers, managers and educators. In the first two rounds experts assessed clarity and relevance on a proposed list of competencies, with the opportunity to provide suggestions for adjustments or inclusion of new competencies. In the third round the items without consensus were bespoken in a focus group.

FINDINGS

After the first round consensus was reached on relevance and clarity on n = 46 (72 %) of the competencies, after the second round on n = 54 (83 %) of the competencies. After the third round a final list of 10 competency domains and 61 sub-competencies was finalized. The 10 competency domains are: Fundamentals of AI, Participation in AI design, Patient-centered needs assessment, Personalisation of AI to patients' situation, Data reporting, Interpretation of AI output, Integration of AI output into clinical practice, Communication about AI use, Implementation of AI and Evaluation of AI use. These competencies span from basic understanding of AI-driven lifestyle monitoring, to being able to integrate it in daily work, being able to evaluate it and communicate its use to other stakeholders, including patients and informal caregivers.

CONCLUSION

Our study introduces a novel framework highlighting the (sub)competencies, required for nurses to work with AI-driven lifestyle monitoring in long-term care. These findings provide a foundation for developing initial educational programs and lifelong learning activities for nurses in this evolving field. Moreover, the importance that experts attach to AI competencies calls for a broader discussion about a potential shift in nursing responsibilities and tasks as healthcare becomes increasingly technologically advanced and data-driven, possibly leading to new roles within nursing.

Modification of the Adjustment Disorder New Module20 (ADNM-20) for Use in Military Environments (ADNM-20-MIL): A Delphi and Pilot Study

OBJECTIVES

Despite its high prevalence and strong linkages with dangerous health outcomes, research on Adjustment Disorder (AjD) is hindered by lack of diagnostic clarity. AjD is categorized as a stress-related disorder, highlighting the important role of the stressor(s) on AjD symptom onset and severity. The military community shows increased risk for AjD, and existing tools do not capture the stressors most relevant and appropriate to this unique community. A diagnostic assessment tool developed specifically for this specialized population may provide critical capability to clinical assessment.

METHODS

A Delphi method was used to create a military-specific version of the standard assessment for Adjustment Disorders (ADNM-20), named ADNM-20-MIL. This tool was pilot-tested in a sample of U.S. Active Duty Service Members (ADSMs) with AjD diagnoses.

RESULTS

Throughout the Delphi process, military-specific stressors were identified and integrated into the ADNM-20-MIL, then refined and validated, ensuring their applicability and relevance to the military context.

CONCLUSIONS

The ADNM-20-MIL will enable timely diagnosis and targeted treatment for AjD, which remains a highly prevalent and destabilizing diagnosis in ADSMs.

Consensus Recommendations for Sustainable and Equitable Neonatology Staffing: A Delphi Approach

BACKGROUND AND OBJECTIVE

The specialty of neonatology faces significant and growing challenges related to patient safety, physician well-being, and workforce sustainability that highlight the necessity for innovative work models. Our objective was to develop consensus recommendations to improve neonatologist staffing practices in the United States.

METHODS

We used a modified Delphi process with 32 diverse subject-matter expert stakeholders to reach consensus. We derived 60 initial potential recommendations for improved staffing from the literature and our 2 previous studies of physician leaders. We defined consensus as 80% or higher agreement and strong consensus as 90% or higher agreement. We ultimately eliminated statements that achieved less than 80% consensus from the recommendations.

RESULTS

Fifty-one individual statements reached consensus and were grouped into 24 final recommendations to improve neonatology staffing. Topics of focus included clinical allocations (eg, clinic work is counted in hours/year), shift characteristics (eg, clinical work after 24 hours is minimized), allocation of nonclinical work (eg, nonclinical work is accounted for in full-time equivalent), and staffing flexibility (eg, options to restructure clinical work are provided for specific circumstances such as aging and pregnancy). Significant discussion on many statements focused on ensuring that recommendations were both feasible and not overly prescriptive for individual institutions.

CONCLUSIONS

We reached consensus on a set of neonatologist staffing recommendations that emphasize the critical issues related to patient safety and physician well-being. Future work will focus on advocating for widespread implementation of these recommendations and evaluating their effect on patient safety, physician well-being, and sustainability of the neonatal workforce.

Developing a Prototype Home-Based Toothbrushing Support Tool for Families in Scotland: A Mixed-Methods Study With Modified Delphi Survey and Semi-Structured Interviews

BACKGROUND

Scotland's National Oral Health Programme for Children, Childsmile, provides targeted home toothbrushing support for families of young children (0-3 years) in the home setting. The study describes the adaptation of an existing dental practice-based intervention from the Netherlands using pictorial cards (Uitblinkers) for use in the programme. The aims were to modify Uitblinkers for the setting and context in Scotland by: (1) identifying the barriers that parents/carers in need of extra support face in implementing supervised toothbrushing; (2) explore consensus about behaviour change techniques that are appropriate and valid to address these; and (3) making recommendations for the design of a co-produced home-support tool and identifying facilitators for implementation in practice.

METHODS

A modified Delphi study was carried out consisting of two survey rounds with a purposively recruited expert panel (n = 21) to develop consensus on home toothbrushing barriers (aim 1), behaviour change techniques (aim 2) and considerations for implementation (aim 3). Proposition statements for the Delphi were derived from literature, discussions with project advisors and from Uitblinkers, an existing behaviour change intervention for parents developed by the Academic Centre for Dentistry Amsterdam (ACTA) and delivered in dental practice. Then 12 in-depth, semi-structured interviews were conducted with Dental Health Support Workers in Scotland (delivering the home support toothbrushing intervention) to gather the views on the proposed toothbrushing barriers, behaviour change techniques and considerations for implementation (aim 1 to 3). Delphi results are presented descriptively in terms of percentage agreement and priority ratings. Interview transcripts were analysed using Template Analysis.

RESULTS

From the Delphi study, a final set of 11 overlapping child, parent and environmental/social toothbrushing barriers was agreed upon (aim 1), to be addressed through a tool based on applied Motivational Interviewing, and a combination of Operant Conditioning, Stimulus Control and Goal-Setting techniques (aim 2). Experts supported the tool as realistic for delivery in the home setting, provided staff were trained. A physical 'paper' tool was preferred to a proposed electronic version (aim 3). Themes from interviews were: (1) the barriers present an exhaustive set and are valid from staff experience with families; (2) Motivational interviewing is appropriate and fits with usual practice; (3) the included behaviour change techniques are workable; (4) the tool is generally feasible within the operation of Childsmile home visits; (5) the tool is not less applicable for children with additional support needs.

CONCLUSIONS

A card-based conversational intervention to provide targeted home toothbrushing support for families of young children (0-3 years) in the home setting in Scotland, drawing from a template from the Netherlands, has been deemed worthy of further testing based on expert consensus and staff views on barriers faced, appropriate behaviour change techniques to address these and the design of a physical tool.

Principles of the superior labrum and biceps complex: an expert consensus from the NEER Circle

BACKGROUND

The superior labrum and biceps complex is commonly implicated in shoulder pain and there remains discordance regarding the surgical management of superior labrum anterior to posterior (SLAP) tears. The purpose of this study was to establish an expert consensus regarding the management of superior labrum and biceps complex pathology.

METHODS

The NEER Circle is an organization of shoulder experts recognized for their service to the American Shoulder and Elbow Surgeons (ASES) society. Consensus among 92 identified experts was sought with a series of surveys pertaining to the management of superior labrum and biceps complex (SBC) pathology. The initial survey featured questions crafted to determine the experience of the panel in treating SBC pathology. The second survey was designed to elicit opinions concerning the diagnosis and treatment of SBC pathology. The third survey aimed to establish consensus across 48 scenarios, tasking panelists with categorizing 4 surgical modalities as either preferred, acceptable, or not acceptable. The available options included débridement, SLAP repair, biceps treatment, or a combined repair and biceps treatment. In the final survey, the panelists were tasked with diagnosing SBC pathologies by assessing arthroscopic footage and evaluating treatment options within 45 scenarios. A minimum of 80% agreement was required to attain consensus, designating a treatment as either preferred or unacceptable.

RESULTS

Response rates ranged from 52.2% to 58.7%. Discordance exists regarding aspects of the physical examination, patient history, imaging, nonoperative management, and the surgical approach in SBC injuries. Of the 78 clinical scenarios, 26 reached consensus agreement. Treating the biceps was the favored approach in older, more sedentary patients with evidence of biceps tendinopathy. Performing a SLAP repair was favored in scenarios depicting younger, more active patients with signs of an unstable biceps anchor or mechanical symptoms. A SLAP repair was typically contraindicated in the setting of an older patient, concomitant rotator cuff tear, and/or a prior failed SLAP repair. The management of overhead throwing athletes, particularly those that are professionals, remained controversial, although SLAP repair is generally favored in younger pitchers.

CONCLUSION

The optimal management of superior labrum and biceps complex pathology requires a systematic approach based on the individual's age, occupational demands, and functional requirements. Age was the predominant factor influencing surgical decision making. SLAP repairs are generally favored in younger, active patients, whereas treating the biceps is preferred in lower-demand patients aged >30 years. Little consensus was observed regarding the management of competitive athletes.

The participation of lifeworld experts in Delphi processes: A reflection on method and practice

Delphi studies have established themselves in the health sciences as a means to systematically and, ideally, synthesize expert opinions into a consensus on concrete issues. As participatory health research increases in relevance, lifeworld experts (e.g., patients, caregiving relatives) are being included in Delphi surveys and their opinions placed alongside those of professional and scientific experts. Looking at the theory and methodology, we discuss the opportunities and challenges concerning result quality and derive practical implications for conducting Delphi studies involving lifeworld experts alongside scientific and/or professional experts. Delphi techniques are understood here to be social interaction processes whose outcomes are a result of the participating experts' conscious, cognitive judgment processes, and also shaped by individual, situational and cultural factors. The more heterogeneous the expert panel, in particular when lifeworld experts are participating, the more these influences vary. Expert panel composition and how diversity is handled prove significant to Delphi study results. Our argument is based on an in-depth analysis of a systematic review of Delphi studies with lifeworld experts. We found that the inclusion of lifeworld experts in Delphi studies usually occurs relatively unsystematically and, furthermore, that results are not analysed separately according to expert group, although there would be good reasons for this. We have oriented the reporting here on PRISMA. To enhance the outcomes of Delphi studies that incorporate lifeworld experts alongside scientific and/or professional experts, we put forward specific recommendations that address potential biases arising from the participation of lifeworld experts.

Promoting Patient Safety Through Patient Engagement at the Organisational Level: A Delphi-Based Needs Assessment Among Patient and Family Advisory Councils

BACKGROUND

Patient and family advisory councils (PFACs) are increasingly recognised as a promising approach for improving patient safety (PS) through patient engagement (PE) at the organisational level. However, PFAC stakeholders often lack the necessary knowledge and competence to engage effectively in PS-related issues with healthcare organisations. Moreover, evidence on specific needs for knowledge and competence improvement remains limited, hindering the development of future interventions.

OBJECTIVE

This study aimed (a) to identify needs for PS-related competency and knowledge improvement among PFAC stakeholders and (b) to assess current and desired levels of PFAC engagement, roles and factors influencing PFACs' work.

DESIGN

We established an exploratory mixed-methods design with a modified, two-round Delphi approach. We first used qualitative content analysis to analyse interview data (Round 1) and then consolidated statements for a quantitative questionnaire (Round 2). Responses were analysed descriptively and for consensus (criterion: 85% agreement). Mixed-methods analysis was conducted sequentially and convergently.

SETTING AND PARTICIPANTS

PFAC stakeholders are affiliated with German healthcare organisations, including patient representatives and professionals from healthcare organisations. MAIN VARIABLE AND OUTCOME STUDIED: (a) Needs for competency improvement on PS and communication, self-assessed knowledge and preferred training formats and (b) PFAC engagement levels, roles and factors influencing PFACs' work.

RESULTS

Across 6 different oncology-focused PFACs from German university hospitals, 19 stakeholders participated across both rounds. Seventeen needs for competency improvement in PS and communication were identified. After establishing consensus, 10 distinct domains of need were agreed upon (e.g., PS fundamentals, legal basis for PE and respectful communication). While PFAC engagement in PS was inconsistent, participants expressed a strong desire for further involvement. Key implementation factors included limited access to organisational processes, lack of resources and unequal conditions between research- and care-oriented councils.

DISCUSSION AND CONCLUSION

This study highlights the need for targeted training and structural support to strengthen PFACs' role in PS. Competency improvement and role clarity were deemed essential for effective collaboration. Enhancing PFAC engagement in PS requires tailored educational programmes, transparent structures and institutional support. This study provides an empirical basis for interventions to improve PE in PS at the organisational level.

PATIENT OR PUBLIC CONTRIBUTION

A patient representative was actively involved throughout the research process, contributing to the development of study materials and providing independent feedback on interview guides and questionnaires. Her input helped to shape the materials, improve their accessibility to lay audiences and ensure the inclusion of patient-relevant issues. The research team discussed her feedback in detail and revised study materials accordingly. Beyond the content presented in this manuscript, she contributed to shaping a subsequent intervention that emerged from the study's needs assessment, which was designed as a participatory approach to incorporate patient and stakeholder perspectives from the outset. In addition, she and participating stakeholders of the patient advisory councils are committed to disseminating project findings and developing recommendations to help translate research into practice from a patient perspective.

CLINICAL TRIAL REGISTRATION

The study was pre-registered in the German Clinical Trials Register (ID: DRKS00034733).

Best practice recommendations for physiotherapists providing telerehabilitation to First Nations people: a modified Delphi study

OBJECTIVES

This study aimed to develop best practice recommendations for physiotherapists providing telerehabilitation to First Nations people.

DESIGN

Modified Delphi study.

PARTICIPANTS

Eighteen experts from four groups were selected: (a) physiotherapists who provide telerehabilitation to First Nations people, (b) Carrier Sekani Family Services leaders (CSFS, First Nations-led health organization/research partners), (c) telehealth experts from British Columbia (BC), Canada, and (d) First Nations individuals (end users) with experience in telerehabilitation.

METHODS

Panelists rated recommendations on telehealth best practices in two rounds using an online questionnaire. Recommendations were synthesized from a scoping review and two qualitative studies. Each statement was rated on a four-point Likert scale indicating whether it was essential, useful, not useful, or unnecessary for inclusion in the best practices. Statements endorsed by ≥80% of panel members were considered for inclusion in the final document.

RESULTS

Following the Delphi process, 77 recommendations covering foundational components, information technology utilization, professional expertise, therapeutic relationships, cultural safety, and the telehealth visit were validated for inclusion in the policy document. Participants also validated the methodology.

CONCLUSION

The recommendations offer a valuable resource for continuing education and professional development, empowering physiotherapists to enhance their skills and competencies in delivering culturally competent telerehabilitation to the First Nations population. The adoption of these best practices ensures that First Nations people are getting the best standard of care, potentially enhancing uptake and experiences with telehealth. It also enables healthcare organizations and policymakers to monitor adherence to established standards and identify areas for improvement. CONTRIBUTION OF THE PAPER.

Use of the Delphi method as an instrument of community participation in health needs assessment

We conducted a comprehensive analysis of the usefulness of the Delphi technique for facilitating community participation in local health needs assessments within the Andalusian Local Health Action Network, Spain. We developed an ad hoc online questionnaire based on the Social Determinants of Health model and applied it to a panel of experts in two municipalities in the province of Seville (Andalusia, Spain) between May and June 2021. Our results reflected good panelist participation. The questionnaire successfully enabled the prioritization of both new and original items, some of which were incorporated into local health policies. We concluded that the Delphi method was effective for facilitating participation in local health needs assessments offering a replicable, cost-effective approach that accelerated local policy development and supported the implementation of Health in All Policies within local government.

Developing an evaluation framework for public health environmental surveillance: Protocol for an international, multidisciplinary Delphi consensus study

INTRODUCTION

Public health environmental surveillance has evolved, especially during the coronavirus pandemic, with wastewater-based surveillance being a prominent example. As surveillance methods expand, it is important to have a robust evaluation of surveillance systems. This consensus study will develop an evaluation framework for public health environmental surveillance, informed by the expanding practice of wastewater-based surveillance during the pandemic.

METHODS

The public health environmental surveillance evaluation framework will be developed in five steps. In Step 1, a multinational and multidisciplinary executive group will be formed to guide the framework development process. In Step 2, candidate items will be generated by conducting relevant scoping reviews and consultation with the study executive group. In Step 3, an international electronic Delphi will be conducted over two rounds to develop consensus on items for the framework. In Step 4, the executive group will reconvene to finalize the evaluation framework, discuss standout items, and determine the dissemination strategies. Lastly, Step 5 will focus on disseminating the evaluation framework to all parties involved with or affected by wastewater-based surveillance using traditional and public-oriented methods.

DISCUSSION

The Delphi consensus study will provide multidisciplinary and multinational consensus for the evaluation framework, by providing a set of minimum criteria required for the evaluation of public health environmental surveillance systems. The evaluation framework is intended to support the sustainability of environmental surveillance and improve its implementation, reliability, credibility, and value.

Agile Implementation of a Digital Cognitive Assessment for Dementia in Primary Care

PURPOSE

This study aimed to assess how agile implementation-driven iterative processes and tailored workflows can facilitate the implementation of a digital cognitive assessment (DCA) tool for patients aged 65 years or older into primary care practices.

METHODS

We used agile implementation principles to integrate a DCA tool into routine workflows across 7 primary care clinics. The intervention involved a structured selection process for identifying an appropriate DCA tool, stakeholder engagement through iterative sprints (structured, time-bound cycles), and development of tailored workflows to meet clinic-specific needs. A brain health navigator role was established to support patients with positive or borderline screenings, and assist primary care clinicians with follow-up assessment. We used the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework to evaluate the intervention's performance over a 12-month period.

RESULTS

The intervention engaged 69 (63.8%) of 108 clinicians across the 7 clinics. DCA screening was completed in 1,808 (10.8%) of 16,708 eligible visits. We selected the Linus Health Core Cognitive Evaluation tool as our DCA tool based on stakeholder evaluations. Screening workflows were tailored to each clinic. The brain health navigator received 447 referrals for further assessment of a positive or borderline screening result. Four clinics fully adopted the intervention, achieving a DCA completion rate of at least 20%, and 5 clinics were still routinely using the DCA tool at 12 months.

CONCLUSIONS

Agile implementation effectively helped integrate the DCA tool into primary care workflows. Customized workflows, stakeholder engagement, and iterative improvements were crucial for adoption and sustainability. These insights can guide future efforts for early detection and management of cognitive impairment in primary care, ultimately improving patient outcomes and easing the burden on health care professionals.

Training and Assessing Teamwork in Interprofessional Virtual Reality-Based Simulation Using the TeamSTEPPS Framework: Protocol for Randomized Pre-Post Intervention Study

BACKGROUND

Interprofessional teamwork is essential for patient outcomes in emergency medicine; yet, effective training in this area is scarce. Virtual reality (VR) provides a promising, resource-efficient solution for simulating emergency scenarios and facilitating interprofessional collaboration. While VR-based training has shown benefits for medical skill and knowledge acquisition, assessing teamwork within such environments remains a challenge due to the lack of validated measurement tools. Existing teamwork assessment instruments, developed for physical simulations, may not fully apply to VR due to differences in communication modalities, interaction mechanics, and observer perspectives.

OBJECTIVE

This study aims to adapt and validate the TeamSTEPPS framework to assess teamwork in VR-based training. Subsequently, these adapted instruments will enable the investigation of whether interprofessional teamwork can be successfully trained in VR scenarios.

METHODS

Prior to the study, measurement instruments for subjective (Teamwork Perceptions Questionnaire) and objective teamwork quality (Team Performance Observation Tool, TPOT) will be adapted and validated for use in VR scenarios. Validation of the adapted version of the Team Performance Observation Tool includes expert consensus via a modified Delphi method as well as validity and reliability testing using recorded VR teamwork sessions. The study itself is designed as a prospective pre-post study with a planned enrollment of 65 nursing and 65 medical students working in randomly assigned interprofessional teams. On 3 timepoints (day 1, day 8, and day 15), participants engage in a VR scenario simulating 1 out of 3 different emergency medical conditions (esophageal variceal bleeding, exacerbated chronic obstructive pulmonary disease, and atrial fibrillation due to urinary tract infection). As an intervention, a structured training video on successful teamwork according to the TeamSTEPPS concept is shown on day 8 immediately before the second VR scenario. Teamwork is assessed objectively with the adapted version of the Team Performance Observation Tool and subjectively with the adapted Teamwork Perceptions Questionnaire. Medical performance will be recorded automatically by the VR software based on the medical measures conducted by the team.

RESULTS

As of May 2024, a total of 28 interprofessional teams have been enrolled. Data analysis will begin in late 2025.

CONCLUSIONS

This study addresses the challenge of adapting teamwork assessment tools to VR environments and may provide insights into the potential of VR-based training for improving interprofessional collaboration in medical education. Future research could include a control group to measure the effects of team training more rigorously or use more enhanced technologies (eg, natural language processing) to capture the full range of teamwork behavior.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/68705.

A Delphi study to identify and prioritize research areas in sickle cell disease in India

Sickle Cell Disease (SCD) poses a significant health burden in India, necessitating comprehensive research to address its complex challenges. This Delphi study engaged a diverse panel of experts and stakeholders to identify and prioritize critical research questions on SCD in India. A total of 74 experts participated in the process of prioritizing research questions in SCD. In the first Delphi round, 52 participants, including scientists, clinicians, policymakers, and representatives from governmental and non-governmental organizations, attended this meeting, where 163 SCD research areas were generated. These areas were refined by the Delphi team in consultation with the core working group, and 16 priority questions were circulated to 81 experts (of which 65 responded) for rating 3 top priority questions. The study revealed three key research priorities: implementation research considering community perceptions addressing stigma, improving diagnostic methods, and developing affordable treatment options. Experts also emphasized the need for patient-centered research, addressing psychosocial challenges, and incorporating innovative treatments and diagnostic tools. The findings provide important insights for advancing SCD research and inform the direction of future SCD research in India, focusing on early detection, innovative treatments, and patient-centered care.

Development of quality indicators for a community pharmacy setting

OBJECTIVES

Community pharmacies in Norway offer accessible healthcare services that require monitoring. Relevant and realistic quality indicators (QIs) must be developed to establish standards. This study aimed to establish consensus on healthcare quality measures in a community pharmacy setting by implementing two distinct approaches.

METHODS

A comprehensive multi-phase research design was implemented to identify, define, and select potential QIs for community pharmacies. Potential QIs were identified and nominated from workshops, focus groups, and literature. Thirteen panellists were recruited for a modified Delphi study over two rounds. We used the RAND/UCLA Appropriateness Method (RAM) panel median ratings and disagreement index (DI) to assess appropriateness and disagreement and define consensus.

KEY FINDINGS

We identified 192 QIs from workshops, focus groups and literature searches. After duplicates were removed and QIs with similar wording were merged, 137 QIs were nominated for the first Delphi round. The panellists deemed 61 appropriate, two inappropriate and excluded six QIs in the first round. The remaining 68 QIs were assessed in Round 2, where 23 achieved consensus as appropriate without disagreement. After DI was calculated, the number of QIs categorized as appropriate without disagreement after Round 1 and 2 was 34 and 10, respectively.

CONCLUSION

This study demonstrates the use of the RAM combined with the DI to establish consensus on healthcare quality measures, i.e. QIs for community pharmacy services. Our findings indicate that the number of QIs considered acceptable is strongly impacted by the method chosen to handle disagreement in the ratings. Incorporating DI and conventional RAM disagreement calculations reduced the number of QIs deemed acceptable by half.

Defining Reablement in the Dutch Context: A Modified Delphi Study

Introduction

For the past decade, the Netherlands has been developing and implementing reablement programs to promote independence and to empower older adults' autonomy. However, a key challenge remains the lack of clarity around the definition of reablement and its relations to usual care practices. Existing international definitions lack specificity to account for contextual differences, such as variations in healthcare systems and cultural norms. An operational definition is needed that not only fits the Dutch health and social care system and incorporates context-specific elements. This study extends the original conceptual definition by integrating these elements, offering clearer, more practical guidance for real-world application.

Materials and methods

A modified Delphi study was performed to develop a definition of reablement that fits the Dutch health and social care system, extending beyond conceptual understanding. The study comprised three expert rounds and three Delphi survey rounds.

Results

A total of 139 participants from Dutch health and social care, education, research, and representatives of clients and informal caregivers, participated. They evaluated statements in four sections: the target group, aims, type of care or support, and characteristics of reablement programs. Key discussions during the expert rounds focused mainly on 1) the target group, emphasizing the importance of involving individuals and their families, and 2) the characteristics of reablement, such as coordinating roles, team composition, and size. Input from the Delphi surveys and expert rounds led to the development of an operational definition for the Dutch context, agreed upon by 81% of stakeholders.

Conclusion

The Delphi methodology proved valuable in identifying context-specific elements and incorporating expert perspectives, creating a culturally and contextually sensitive definition. This definition distinguishes itself from the international version by offering practical guidance on areas of application and interventions, with a focus on promoting social participation, well-being, and the involvement of the individual's social network.

Using a modified Delphi approach to develop and validate a digital self-management support checklist in bariatric surgery aftercare

INTRODUCTION

Current clinical practice in bariatric surgery follow-up care is highly heterogeneous, and patients have reported needing more and extended personalised support. Especially, they want more support on how to self-manage and cope with the changes and challenges of living with the chronic aspects of obesity and a changing body following surgery. The overall aim of this study protocol is to develop and validate a digital self-management support checklist in bariatric surgery aftercare.

METHODS

We propose a protocol for a modified, electronic Delphi study design using qualitative and quantitative methods to develop and validate the content of the checklist. The study is divided into two phases: (1) generation of candidate checklist attributes and (2) validation of candidate checklist attributes. In Phase 1, two qualitative studies involving individual interviews with patients and focus groups with healthcare professionals will be conducted to derive context-specific knowledge. This knowledge will be combined with best-practice evidence and stakeholder input to generate candidate checklist attributes, that is, principles, items and features. In Phase 2, a two-round electronic Delphi survey with an expert panel will be conducted to assess the relevance, comprehensibility and comprehensiveness of candidate checklist attributes and to determine the final checklist attributes based on content validity results from the Delphi process. Reflexive thematic analysis will be used on qualitative data and descriptive statistics on quantitative data.

ETHICS AND DISSEMINATION

The study has been approved by the Regional Committee for Medical and Health Research Ethics, Region West (2023/676367). The Data Protection Officer at Førde Hospital Trust and collaborating hospital trusts have approved the project (4386-4386). The results will be presented at scientific conferences, published and open-accessed in international peer-reviewed journals.

Developing consensus for upper limb rehabilitation, physical preparation and return to climbing in adults: protocol for an international e-Delphi study

Climbing has grown into a grassroots participation sport and Olympic discipline. The high loads expressed through the upper limb may increase the risk of injury in this population. This may also affect rehabilitation and return to sport (RTS) considerations after injury. Treatment, management, rehabilitation and RTS parameters after injury are poorly documented. The aim of this study is to reach international expert consensus on the postinjury and surgical rehabilitation, physical preparation and RTS strategies in a range of climbers. This will provide a framework for the safe RTS of climbers. The study will be reported in accordance with guidance on conducting and reporting Delphi Studies guidelines. Panel members will be recruited with expertise in either the delivery of healthcare and/or physical preparation of climbers. The electronic Delphi is anticipated to consist of three irritative rounds. Round 1 will consist of open and closed questions to generate a broad range of statements on the rehabilitation, RTS and outcome measures used after climbing injury. In round 2, all participants will be provided with a summary of the current literature of the rehabilitation and RTS strategies for upper limb sports injuries. Rounds 2 and 3 will consist of a summary of the results from the previous round including any dissonance. Participants will be asked to anonymously rate responses on a 5-point Likert scale. The study steering group and patient public involvement representatives will be involved from conceptualisation until final dissemination.

A decision-making model for public health authorities in circumstances of potentially high public risk

BACKGROUND

An expert multidisciplinary panel was commissioned by a UK Health Security Agency led incident management team (IMT) to support decision making in the case of an individual with extensively drug-resistant tuberculosis. The behaviour and stated intentions of the individual were potentially a significant risk to public health, and the regional IMT felt unable to adequately balance the rights of the individual, versus the public health risk, within current processes and legal powers.

METHOD

We describe the composition, organization, implementation, and conclusions of a national, expert, multidisciplinary panel.

RESULTS

The national panel convened over three structured virtual meetings to consider the balance between the rights of the individual to an unrestricted life, and the duty to protect the public's health. Evidence included briefs from the regional IMT and input from a public consultation group. Following the first two meetings the need for a literature review examining the success of surgical interventions was identified and conducted.

CONCLUSIONS

Evidence and conclusions were mapped onto a custom-designed risk assessment template. The panel provided authoritative advice regarding the case, and developed a review methodology that is transferable to similar complex public health scenarios both in the UK and internationally.

Classification of trauma-related preventable death; a Delphi procedure in The Netherlands

INTRODUCTION

Trauma-related preventable death is considered death as a consequence of moderate to severe injury under (sub)optimal trauma care conditions and is used as a criterion to evaluate the management and quality of trauma care worldwide. A validated definition of trauma-related preventable death is still lacking due to differences in classification. To reach consensus on a definition and assess the necessity of an additional trauma prediction algorithm, a Delphi procedure was performed.

METHODS

A digital three-round Delphi procedure was performed. Trauma surgeons, neurosurgeons, forensic medicine physicians, anesthesiologists, and emergency care physicians working at a Level 1 or affiliated trauma center in the Netherlands were invited to participate. An electronic questionnaire was administered to assess the most suitable category of trauma-related preventable death (clinical definition, trauma prediction algorithm, clinical definition and trauma prediction algorithm or other) and the additional benefit of a trauma prediction algorithm.

RESULTS

Fifty-four panelists completed the study: 23 trauma surgeons, 13 emergency care physicians, 10 anesthesiologists, 4 neurosurgeons and 4 forensic medicine physicians. In the first round, a clinical definition and a clinical definition and trauma prediction algorithm (Trauma Score and Injury Severity Score and a combination of algorithms) were favored. The results were fed back to the panelists. In the final round, there was a tendency towards group consensus in favor of a clinical definition and trauma prediction algorithm (63 %). Consensus was reached on the most suitable algorithm: the Trauma Score and Injury Severity Score combined with the Probability of survival.

CONCLUSION

The identification of trauma-related preventable death is essential in the evaluation of trauma care. This study elucidates the difficulty of multidisciplinary consensus. However, a propensity towards consensus on a clinical definition, and consensus on the additional benefit of the PS, based on the TRISS, seems to be present.

Latin American Consensus on Ocular Lubricants and Dry Eye Disease (LUBOS): A Report on Severity Classification, Diagnosis, and Therapy

PURPOSE

This consensus aims to establish a practical severity classification for applying a tailored stepladder treatment algorithm helpful to any clinician.

METHODS

A modified Delphi methodology was used to establish a consensus on the definition, diagnosis, severity classification, and treatment algorithms for dry eye disease (DED) adapted to the needs of Latin America. The consensus focused on promoting the effective use of lubricants and providing straightforward, practical guidance for ophthalmologists treating dry eyes. Twenty-eight corneal specialists from representative Latin American countries reviewed the scientific evidence and drew on their expertise to answer specifically designed open-ended questions.

RESULTS

A simple diagnostic algorithm (clinical history, DED questionnaire, and dry eye clinical tests) identified patients with the disease. A practical severity classification system of four grades: mild, moderate, severe, and LUBOS plus DED was based on four criteria: OSDI, film break-up time, Sjögren International Collaborative Clinical Alliance ocular surface staining score, and international workshop on meibomian gland dysfunction meibomian gland functionality test. For classification, ≥2 criteria of the highest severity grade from the worse eye were considered. A stepladder therapeutic algorithm aligned with disease severity consisted of 5 steps, each with proposed and recommended treatment alternatives. Patient education, lifestyle recommendations, adverse environment avoidance, lubricants, and eyelid therapy were reinforced during the therapy period.

CONCLUSIONS

The LUBOS expert panel consensus considered the diverse geoenvironmental, socioeconomic, cultural, and ethnic factors pertinent to Latin America. This consensus offers an accessible and cost-effective tool, enabling professionals to detect, evaluate, and grade the severity of dry eye disease effectively for planning adequate therapeutic strategies that can be monitored with confidence.

Revisiting the Delphi technique - Research thinking and practice: A discussion paper

The Delphi technique is a research methodology which has traditionally been used to gain consensus among experts on complex issues characterised by uncertainty. Pioneered by the Rand Corporation in the 1950s for military applications, it has since been widely adopted across various fields, including nursing, health and social sciences and information systems on an array of multifaceted real-world issues. However, since its inception, the Delphi technique has undergone substantial methodological development and its use has now gone beyond its initial rationale. In the last two decades there has been a growing body of work illustrating an increasing methodological diversity of the method. While such diversity presents possibilities, it also challenges traditional application and methodological rigour. In an attempt to preserve the integrity of the method, generic and discipline specific guidelines have emerged providing general principles and standards. The aim of this paper is to present a much-needed critical reflection on the current application of the Delphi technique and its methodological development and to build on our paper from 2001 (Keeney et al., 2001). While the development of the Delphi method and its evolution are well recognised and reported in the literature, some controversies surrounding the approach remain and it is timely to revisit the method with a critical eye. Ultimately, the Delphi technique's flexibility is its significant strength, enabling the exploration of novel lines of inquiry, but it also presents a challenge. Striking the right balance between flexibility and rigour can lead to more meaningful insights and actionable outcomes from a Delphi study. Yet to achieve this, some level of consensus may need to be reached on the Delphi technique itself. In recognition of its 60th birthday, it is an opportune time to re-examine its key aspects and methodological advances and reflect on 'when is a Delphi not a Delphi?'

Development of a Core Outcome Set for Intervention Studies in Adults With Laryngotracheal Stenosis

OBJECTIVE

Adult acquired laryngotracheal stenosis (LTS) is a chronic condition with heterogeneous treatment options and a significant symptom burden. Synthesis of data across research studies to guide clinical decision-making is challenging due to inconsistent outcome selection and use of unvalidated measures. Our objective was to establish a core outcome set (COS) for studies of LTS interventions in adults.

METHODS

We conducted a two-round modified e-Delphi study. We reviewed published systematic reviews and qualitative studies to inform the inclusion of 42 outcomes in the first e-Delphi round, with 10 additional outcomes added by participants for the second voting round. The international expert panel included clinicians, researchers, and people living with LTS. We held two consensus meetings and a final voting round.

RESULTS

The first e-Delphi round involved 1067 participants from multiple stakeholder groups, with 575 participants voting in the second. Seventeen participants participated in the consensus meetings. The final COS included seven outcomes: (1) Level of breathlessness, (2) Ability to generate audible voice, (3) Ability to manage/clear mucus, (4) Ability to eat and drink, (5) Health-related quality of life, (6) Emotional and mental health symptoms, and (7) Frequency of treatment.

CONCLUSION

By using a rigorous Delphi process informed by multiple stakeholder groups, we gained consensus on seven core outcomes for inclusion in future research relating to LTS. Use of this COS will standardize outcomes measured in future research studies, ensuring they are comparable. Future work is required to identify the best way to measure these outcomes to fully operationalize this COS.

LEVEL OF EVIDENCE

Level V.

Transition Care for Young Persons with Rare Bone Mineral Conditions: A Consensus Recommendation from the ECTS Rare Bone Disease Action Group

Transition care (TC) is crucial for young persons with rare bone and mineral conditions (RBMCs) as they move from pediatric to adult healthcare. Effective TC prevents care disruptions and supports medical and psychosocial needs. However, gaps in communication, a shortage of adult RBMC specialists, and challenges in navigating adult healthcare necessitate standardized care. This study aimed to develop consensus-based recommendations for TC in RBMCs, focusing on best practices for seamless transition and patient empowerment. A two-round Delphi survey (September 2023-April 2024) was conducted among European RBMC experts, including 3 pediatric and 8 adult clinicians and 3 patient representatives from the European Calcified Tissue Society (ECTS). The panel formulated and refined statements through literature review and iterative scoring. Statements reaching ≥ 70% consensus were retained. A total of 81 statements were finalized across seven domains: initiation and planning, TC requirements, patient empowerment, organization and communication, service infrastructure and funding, and clinical care. Consensus was achieved on 64 out of 81 statements, with strong agreement on general and RBMC-specific recommendations. Key priorities included structured coordination among healthcare providers and a patient-centered approach that fosters self-advocacy and self-management. This Delphi consensus provides a structured framework for TC in young persons with RBMCs, emphasizing multidisciplinary care and patient empowerment. Future studies should assess the feasibility and impact of these guidelines across diverse healthcare systems.

The innovation of traditional handicrafts and cultural identity: A multidimensional value analysis using the DEMATEL-ISM method

This study aims to explore how cultural identity influences the protection and innovation of traditional crafts through multidimensional pathways. Using the examples of macau shipbuilding and portuguese tile painting, 14 influencing factors were extracted from three dimensions-culture and expression, aesthetics and creation, and cognition and emotion-through the Delphi method and expert feedback. The decision-making trial and evaluation laboratory (DEMATEL) method was used to analyze causal relationships, and interpretive structural modelling (ISM) was employed to construct a hierarchical model consisting of core, direct, and indirect factors. The results indicate that historical continuity, knowledge transmission, and the integration of tradition and modernity are core factors, forming the cultural foundation for traditional craft innovation. Direct factors, such as creative expression, local culture, and emotional communication, play a pivotal role in connecting the core and indirect layers, while indirect factors like visual appeal, design originality, and craft education reflect the multidimensional value of traditional crafts. The study provides a clear, hierarchical pathway that explains the systematic process from cultural identity to innovation practice, offering valuable insights for sustainable craft innovation in the context of globalization.

Red flags for remote cognitive diagnostic assessment: A Delphi expert consensus study by the Canadian Consortium on Neurodegeneration in Aging

Despite the potential benefits of remote cognitive assessment for dementia, it is not appropriate for all clinical encounters. Our aim was to develop guidance on determining a patient's suitability for comprehensive remote cognitive diagnostic assessment for dementia. A multidisciplinary expert workgroup was convened under the auspices of the Canadian Consortium on Neurodegeneration in Aging. We applied the Delphi method to determine 'red flags' for remote cognitive assessment of dementia. This resulted in 14 red flags that met the predetermined consensus criteria. We then developed a novel clinical decision-making infographic that integrated these findings to support multidisciplinary clinicians in determining a patient's readiness to undergo comprehensive remote cognitive assessment.

Comparing Artificial Intelligence-Generated and Clinician-Created Personalized Self-Management Guidance for Patients With Knee Osteoarthritis: Blinded Observational Study

BACKGROUND

Knee osteoarthritis is a prevalent, chronic musculoskeletal disorder that impairs mobility and quality of life. Personalized patient education aims to improve self-management and adherence; yet, its delivery is often limited by time constraints, clinician workload, and the heterogeneity of patient needs. Recent advances in large language models offer potential solutions. GPT-4 (OpenAI), distinguished by its long-context reasoning and adoption in clinical artificial intelligence research, emerged as a leading candidate for personalized health communication. However, its application in generating condition-specific educational guidance remains underexplored, and concerns about misinformation, personalization limits, and ethical oversight remain.

OBJECTIVE

We evaluated GPT-4's ability to generate individualized self-management guidance for patients with knee osteoarthritis in comparison with clinician-created content.

METHODS

This 2-phase, double-blind, observational study used data from 50 patients previously enrolled in a registered randomized trial. In phase 1, 2 orthopedic clinicians each generated personalized education materials for 25 patient profiles using anonymized clinical data, including history, symptoms, and lifestyle. In phase 2, the same datasets were processed by GPT-4 using standardized prompts. All content was anonymized and evaluated by 2 independent, blinded clinical experts using validated scoring systems. Evaluation criteria included efficiency, readability (Flesch-Kincaid, Gunning Fog, Coleman-Liau, and Simple Measure of Gobbledygook), accuracy, personalization, and comprehensiveness and safety. Disagreements between reviewers were resolved through consensus or third-party adjudication.

RESULTS

GPT-4 outperformed clinicians in content generation speed (530.03 vs 37.29 words per min, P<.001). Readability was better on the Flesch-Kincaid (mean 11.56, SD 1.08 vs mean 12.67 SD 0.95), Gunning Fog (mean 12.47, SD 1.36 vs mean 14.56, SD 0.93), and Simple Measure of Gobbledygook (mean 13.33, SD 1.00 vs mean 13.81 SD 0.69) indices (all P<.001), though GPT-4 scored slightly higher on the Coleman-Liau Index (mean 15.90, SD 1.03 vs mean 15.15, SD 0.91). GPT-4 also outperformed clinicians in accuracy (mean 5.31, SD 1.73 vs mean 4.76, SD 1.10; P=.05, personalization (mean 54.32, SD 6.21 vs mean 33.20, SD 5.40; P<.001), comprehensiveness (mean 51.74, SD 6.47 vs mean 35.26, SD 6.66; P<.001), and safety (median 61, IQR 58-66 vs median 50, IQR 47-55.25; P<.001).

CONCLUSIONS

GPT-4 could generate personalized self-management guidance for knee osteoarthritis with greater efficiency, accuracy, personalization, comprehensiveness, and safety than clinician-generated content, as assessed using standardized, guideline-aligned evaluation frameworks. These findings underscore the potential of large language models to support scalable, high-quality patient education in chronic disease management. The observed lexical complexity suggests the need to refine outputs for populations with limited health literacy. As an exploratory, single-center study, these results warrant confirmation in larger, multicenter cohorts with diverse demographic profiles. Future implementation should be guided by ethical and operational safeguards, including data privacy, transparency, and the delineation of clinical responsibility. Hybrid models integrating artificial intelligence-generated content with clinician oversight may offer a pragmatic path forward.

A Proposed Universal "Home Time" Quality of Life Measure for Older Adults

BACKGROUND

Researchers and insurers use "home time," or an individual's time at home compared to time in different health care settings, as a population-level quality of life (QoL) or quality of care measure. With varying definitions, it is unknown which components of a home time measure most closely reflect QoL. Our objective is to develop a person-centered universal home time measure agnostic to condition.

METHODS

We used an iterative, structured approach based on Delphi methods to obtain expert input on what a measure should include, using qualitative and quantitative evidence from prior work. A total of 28 expert panelists, including Veterans Affairs (VA) leaders, clinician researchers, and non-clinician researchers, participated. In the first round, panelists voted on components (settings, weights, timeframes) to include in a home time measure. In the second round, panelists discussed results. The third round was final voting and explanations of choices and caveats.

RESULTS

Qualitative and quantitative data suggested that emergency department, inpatient care, and post-acute care settings all affect older adults' QoL in different ways, supporting inclusion; 75% of the experts endorsed all settings, and discussion suggested that future work should limit ED days to visits resulting in an inpatient admission. Our data did not reveal a clear indication for weighting settings: 56% of the expert panel suggested continuing to explore the use of weights to arrive at values that would reflect qualitative differences in settings, and 44% did not support the use of any weights. Our 6-month models resulted in QoL outcomes for all settings, and 30% of experts endorsed a 6-month timeframe, while 65% said that timeframe would depend on the situation.

CONCLUSION

A "1.0" universal person-centered home time measure that reflects QoL should include days in the emergency department, inpatient care, and post-acute care. Expert input revealed domains of agreement and disagreement. Future validation efforts that incorporate expert input are needed to iterate and arrive at the optimal measure.

End-of-Life Care Competency in Long-term Care Facilities for Care Providers in Thailand: A Delphi Study

The global shift toward an aging population, evident in Thailand, highlights the critical need for end-of-life care (EOLC) competencies among care providers in long-term care facilities (LTCFs). As the number of older people requiring complex and compassionate care at the end of life continues to rise, the competencies required for care providers in Thai LTCFs remain underexplored. This study aimed to identify the key competencies required to deliver effective EOLC in Thai LTCFs. A Delphi method was used, engaging a panel of 12 experts, including nurses, academics, and LTCF managers. The study achieved consensus on 7 core competencies, encompassing 32 subcompetencies essential for high-quality EOLC. These competencies include knowledge of EOLC, caregiving skills, communication, leadership, innovation, ethical decision-making, and professional development. This study provides a culturally relevant framework for EOLC competencies in Thai LTCFs, emphasizing the importance of integrating technical and interpersonal skills to enhance the quality of care for older people in their final stages of life. These findings can inform educational programs and policy development, ensuring that care providers are adequately prepared to meet the complex needs of this vulnerable population.

Applying a Modified Version of the Prediction of Alcohol Withdrawal Severity Scale in a Canadian Community Withdrawal Management Setting

INTRODUCTION

Severe alcohol withdrawal syndrome (SAWS) can lead to significant morbidity and mortality. The Prediction of Alcohol Withdrawal Severity Scale (PAWSS) has been validated in general acute care environments, but its efficacy in withdrawal management settings remains underexplored. This study aimed to assess the utility of a modified PAWSS and identify appropriate cutoff scores in a community withdrawal management setting in Vancouver, Canada.

METHODS

From October 2019 to September 2022, we reviewed charts at Vancouver Detox Centre. Modified PAWSS versions replaced question 9 on the original PAWSS with: (i) breath analysis readings; (ii) alcohol consumption in the previous 24 h; and (iii) clinical assessments. We performed receiver operating characteristic analysis and used Youden's index to determine modified PAWSS' diagnostic accuracy against SAWS presentation, defined by a score of 15 or greater on the Clinical Institute Withdrawal Assessment Alcohol, Revised, seizures or delirium tremens and/or benzodiazepine administration.

RESULTS

Among 228 individuals (165 male, 63 female), 175 (75%) met SAWS criteria during admission. For breath analysis readings, an optimal PAWSS cutoff score had 55% sensitivity (95% confidence interval [CI] 46%-63%) and 74% specificity (95% CI 54%-87%). For alcohol consumption in the last 24 h, a cutoff score of 7 had 44% sensitivity (95% CI 36%-51%) and 85% specificity (95% CI 70%-93%). For clinical assessment, a cutoff score of 6 had 53% sensitivity (95% CI 45%-61%) and 71% specificity (95% CI 58%-85%).

DISCUSSION AND CONCLUSIONS

Within a community withdrawal setting, the prevalence of SAWS was high, rendering the modified PAWSS less valuable. Although higher cutoff scores improved specificity, poor sensitivity hindered identification of low-risk SAWS individuals.

Inducing and measuring positive affective state in domesticated equines: A Delphi consultation

Over the last twenty years the definition of good animal welfare has advanced from the 'absence of negative welfare states' to the aim of identifying the presence of positive welfare states; however, research on positive animal welfare is relatively new. Consequently, through expert consultation, this study aimed to synthesise knowledge regarding domesticated equine emotional state, specifically methods to induce and measure positive affective states, which could be of significant benefit to equine welfare across sectors. A Delphi consultation of experts in the field of equine behaviour, welfare and affective state was undertaken to derive consensus agreement on definitions used when considering positive affective state in equines and methods suitable for inducing and measuring these states within experimental investigations. Ninety-three international experts participated in a robust three-round Delphi consultation with data gathered analysed qualitatively (thematic analysis) and quantitatively (ranking data, consensus benchmarks and Content Validity Index (CVI) / Content Validity Ratio (CVR) analyses). Retention rates were high (78 %), and consensus (minimum 70 % agreement) was reached within Round three of the consultation. Nineteen methods for inducing positive affect reached consensus (provision of high value food, an affiliative companion and a substrate to roll in where the highest ranked), and twelve behavioural (assessment of body language, facial actions and horse-horse interactions were ranked highest) and three physiological (evaluation of heart rate, heart rate variability and respiratory rate) variables for measuring positive affect also reached consensus. This consultation highlights several important considerations surrounding the induction and measurement of positive affective state in equines, including consideration of the individual's personality and individual preference within any measures of affective state. We therefore recommend that establishing individual preference should be a prerequisite of research into positive affective states. It is anticipated that the results of this study can be used to provide new direction for research on positive affective states by providing expert agreed methods and measures for policy and practice through expert agreed approaches to induce positive affect in horses.

Cervical Disc Replacement in Athletes: A Modified Delphi Consensus Survey of Expert Opinion

BACKGROUND CONTEXT

The safety and efficacy of cervical disc replacement (CDR) for spinal disorders in contact sport athletes is not clear. Current research is limited and highlights mixed results regarding return-to-sport (RTS) among athletes with CDR.

PURPOSE

We sought to perform a modified Delphi consensus survey of expert opinion on CDR in athletes.

STUDY DESIGN/SETTING

A cross-sectional, modified Delphi consensus survey of different scenarios regarding RTS for athletes with CDR was conducted among a panel of expert spine surgeons.

PATIENT/RESPONDENT SAMPLE

An international panel of 34 spine surgeons involving both neurosurgeons and orthopaedic surgeons with sport expertise was identified.

OUTCOME MEASURES

Consensus regarding return to any level of sport as defined above was queried as the main outcome measure, with consensus defined a-priori at ≥70%.

METHODS

A 2×2 scheme was used to classify sport risk: 1=low impact/low frequency; 2=low impact/high frequency; 3=high impact/low frequency; 4=high impact/high frequency that also served as the different levels of sport that respondents could recommend returning to for the theoretical athlete. Descriptive statistics were performed with survey respondent data to generate the percentages of respondents recommending return to each level of sport for all scenarios.

RESULTS

Of the 34 sports spine surgeons invited to participate (55.9% neurosurgeons and 44.1% orthopaedic surgeons), all completed 9 questions as part of a larger survey. Regarding radiculopathy, consensus was achieved that CDR is an acceptable treatment for cervical radiculopathy in a high impact/high frequency athlete for 1-level disease (73.5%). However, only 58.8% responded that they would offer a CDR in this scenario. Regarding spinal cord compression, consensus was not achieved that CDR is an acceptable treatment for a high impact/high frequency forces athlete for 1-level disease with cord compression with/without myelopathy (47.1%). The most common reasons behind not offering a CDR included certainty of the anterior cervical discectomy and fusion (ACDF), safety concerns (e.g., adequacy, efficacy, stability), and lack of data/evidence. Postoperatively, following a 1-level CDR for myelopathy or radiculopathy, 57.6% of participants responded that they would advise the athlete may return to high impact/high frequency sport, whereases following a 2-level CDR, only 23.5% of all participants responded they would advise the same. For 1-level CDR, the most endorsed timelines for return to practice were 6 weeks (26.5%) and 3 months (26.5%) and for games was 3 months (41.2%). For 2-level CDR, the most endorsed timeline for return to practice was 3 months (26.5%) and for games was 3 months (41.2%).

CONCLUSIONS

Consensus was achieved that CDR is an acceptable treatment for radiculopathy (74%) but not myelopathy (47%) in high impact/high frequency athletes; however, only 59% of surgeons would offer a CDR for athletes with radiculopathy. Reasons for CDR hesitancy were certainty of outcomes with ACDF, safety concerns, and lack of long-term data. Although consensus was reached for some indications herein, this study highlights ongoing heterogeneity in the use of CDR for contact sport athletes and concerns regarding its safety. Future research should focus on gathering primary data on safety, durability, and long-term efficacy of CDR among athletes of different sports.

Criteria For Agreement When Conducting Local Consensus Discussions: A Qualitative Study

Purpose

Healthcare is a complex, multi-layered team environment where effective change often requires reaching consensus among relatively autonomous stakeholders. Although conducting informal consensus discussions is a frequently used implementation strategy in real-world clinical settings, limited information exists about what defines consensus when using these methods. Specifying the criteria for consensus is important, as it can shape the design of consensus-building strategies. This study aimed to identify and define the key domains of consensus used in local consensus discussions to standardise healthcare practices.

Patients and Methods

A qualitative study was conducted in one private hospital in Australia using a modified, grounded theory methodology. Clinical, non-clinical and leadership staff involved in developing standardised perioperative pathways using informal consensus discussions were recruited. Data were collected via semi-structured interviews and naturalistic participant observations between February 2023 and May 2024. Data collection and analysis occurred concurrently until theoretical saturation was achieved. Data were analysed using open coding with constant comparison, focussed and theoretical coding to develop theoretical concepts.

Results

Sixteen hours of observations with 31 participants and nine semi-structured interviews were conducted. Analysis identified four distinct consensus criteria: i) unanimous consensus, ii) delegated consensus, iii) assumed consensus and iv) concessional consensus. While unanimity was the preferred outcome, other consensus types emerged as viable alternatives when unanimous agreement was challenging to achieve. Each criterion had differing factors and mechanisms which influenced reaching the consensus criterion, underpinning assumptions, and considerations for practice, which formed four domains of consensus.

Conclusion

These domains provide a structured framework for classifying consensus criteria when conducting local consensus discussions in healthcare. The findings broaden our understanding of consensus in local healthcare discussions, moving beyond a singular focus on unanimity. By clearly defining consensus types, organisations can strategically select consensus methods that best support decision-making and intervention implementation.

Off-label drug use in palliative medicine: Delphi study for the consensus of evidence-based treatment recommendations

BACKGROUND

Off-label use of drugs is an integral part of everyday clinical practice in palliative medicine. However, it is associated with many uncertainties, that is, drug therapy safety or legal issues including cost coverage. Healthcare professionals often lack time and resources for comprehensive literature search and patient-specific risk-benefit analyses.

AIM

The aim of this project is to develop, evaluate and rate agreement/disagreement on treatment recommendations for off-label use in adult palliative medicine.

DESIGN

Online Delphi study with two rounds each to rate agreement/disagreement with treatment recommendations for off-label use in adult palliative medicine. An international expert panel consisting of physicians, pharmacists and nurses working in palliative care evaluated previously developed recommendations based on the best available evidence.

SETTING

/participants:Professionals (physicians, pharmacists, nursing staff) working in inpatient and home palliative care involved in the medication process were recruited as experts to participate. Between 64 and 75 experts participated in the first two Delphi studies.

RESULTS

A total of 64/68 recommendations on 21 drugs and 14 applications were agreed upon. Topics related to routes of administration as well as indications for sialorrhea, bronchorrhea, xerostomia, pruritus, singultus, fistula, gastroparesis and hot flashes. Recommendations that reached consensus are available to health care professionals via a free of charge database.

CONCLUSION

For many off-label use applications, it is likely that there will be no registration studies and therefore no drug approvals in the future. The consensus-based recommendations are intended to facilitate individual treatment planning for prescribers and to enable a more reflected handling of off-label use.

Identifying Research Priorities for Cognition in CKD: A Delphi Study

Key Points

Background

Cognition is a research priority for people living with CKD, but identification of critical research questions is lacking. This study aimed to determine which cognition-related research questions are most important to CKD stakeholders.

Methods

A modified Delphi technique with three survey rounds was used. The study sample included three panels (People with lived CKD experience, Researchers, and Clinicians) recruited through international patient and kidney research networks, kidney societies, and snowball sampling with email invitations. Survey rounds were distributed electronically through Research Electronic Data Capture. In round 1 (October 2021–May 2022), respondents contributed three important research questions regarding cognition in CKD (free text). After deduplication and qualitative synthesis, respondents ranked the importance of these questions on a nine-point Likert scale in round 2 (February–April 2023). Questions with mean and median ratings of >7 by at least two respondent panels or rated critically important by the lived experience panel were reranked in round 3 (August–September 2023) and assessed for consensus to identify the final list of priority research questions.

Results

Respondents (n=152) identified 125 and 44 discrete questions after rounds 1 and 2, respectively. The final shortlist included 27 questions in eight categories. The most critical research question identified was “What factors prevent cognitive impairment in people receiving dialysis?” Overall, respondents prioritized questions focusing on prevention and treatment of cognitive impairment. Scores between the panels were significantly different for 16 questions. Those with lived CKD experience prioritized quality of life, researchers emphasized developing interventions to mitigate cognitive impairment, and clinicians prioritized the effect of CKD treatment on cognitive impairment.

Conclusions

Through an established consensus methodology involving key stakeholder groups, we identified 27 critical research questions about cognition in CKD. These questions should guide future study design and outcome selection.

Preventing pneumococcal infections in patients with hematological malignancies: a review of evidence and recommendations based on modified Delphi consensus

Introduction

Individuals with hematological malignancies (HMs) are at a high risk of invasive pneumococcal disease due to underlying malignancy and subsequent immunosuppressive anticancer therapy. Early management of pneumococcal infections is crucial for reducing morbidity and mortality in this vulnerable patient subgroup. In this study, we aim to review the current evidence and recommendations regarding the use of pneumococcal conjugate vaccines (PCVs) in patients with HMs and develop a consensus document on the optimal timing and patient profiles who can benefit from them.

Methods

The modified Delphi consensus method was used for achieving consensus. The panel comprised a scientific committee of six experts from India. Questions were drafted for discussion around: (i) the risk and consequences of pneumococcal disease in HMs; (ii) barriers to pneumococcal vaccination in the hemato-oncology clinical setting; and (iii) evidence and optimal timing of pneumococcal vaccines in HMs. The questionnaire was shared with the panel through an online survey platform (Delphi round 1). The consensus level was classified as high (≥80%), moderate (60%-79%), and low (< 60%). A Delphi round 2 meeting was conducted to discuss the questions that received near or no consensus to reach an agreement. The final draft of consensus statements was circulated among the experts for approval.

Results

Pneumonia with or without bacteremia and bacteremia without foci of infection are the most frequently reported clinical presentations of pneumococcal infections in patients with HMs. A high risk of pneumococcal disease has been observed in patients with multiple myeloma (MM), acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), and chronic lymphocytic leukemia (CLL). Priming with PCV enhances the response to pneumococcal polysaccharide vaccine 23 (PPSV23) in patients with HMs. Experts agreed that PCV is beneficial and can be strongly recommended in patients with CLL, MM, and patients undergoing hematopoietic stem cell transplantation. Children with acute lymphoblastic leukemia (ALL) would benefit from systematic revaccination with PCV after chemotherapy. The evidence is inadequate to consistently recommend pneumococcal vaccination to all patients with lymphoma, AML, and adults with ALL.

Conclusion

This expert consensus will guide clinicians on the recommended approach for administering pneumococcal vaccination to patients with HMs.

Risk Factors for Thyroid Function Test Abnormalities During Pregnancy: A Systematic Review of the Literature to Validate Current Risk Factors and Identify Novel Ones

Background: International guidelines recommend that the indication to perform thyroid function testing during pregnancy is based on the presence of risk factors for thyroid function test abnormalities. However, the discriminative ability of currently recommended risk factors is questionable. To inform on an update of the American Thyroid Association Guidelines for the Diagnosis and Management of Thyroid Disease in Preconception, Pregnancy, and the Postpartum, we aimed to systematically review the literature to evaluate evidence for current risk factors and potential novel ones for thyroid function test abnormalities in pregnancy. Methods: A systematic literature search was performed on Embase, Medline Ovid, and the Cochrane Library from inception to October 17, 2024, to identify articles on the associations of any candidate variables with thyroid function test abnormalities, thyroid antibody positivity, or results of continuous thyroid function tests in pregnancy. Additional records were identified through citation searching. Study quality was assessed using the Newcastle-Ottawa Scale. We summarized the results using a narrative synthesis. Results: A total of 81 articles were included, describing 36 candidate variables. Thyroid antibody positivity was associated with a higher risk of overt or subclinical hypothyroidism compared with antibody negativity (absolute risks: 2.4-7.0% vs. 0.1-0.2% for overt hypothyroidism and 1.9-29.0% vs. 2.0-5.7% for subclinical hypothyroidism). In cases of iodine deficiency, sufficiency, and intake above pregnancy requirements or excess, the absolute risks for subclinical hypothyroidism were 2.2-42.6%, 1.42-16.0%, and 3.8-24.3%, respectively. A limited number of studies were available for history of autoimmune diseases, family history of thyroid disease, symptoms of hypothyroidism, and history of pregnancy loss, preterm delivery, or infertility. There was little or no association of current risk factors with isolated hypothyroxinemia or (subclinical) hyperthyroidism. We did not identify novel risk factors for thyroid function test abnormalities. Conclusions: Evidence for most currently recommended risk factors remains limited and heterogeneous, and no novel risk factor was identified. While risk factors can help guide thyroid function testing in pregnancy, a clinical risk assessment cannot be replaced. Future studies are needed to detect novel risk factors that can improve the accuracy and efficiency of identifying pregnant women at high risk of thyroid function test abnormalities, in particular, overt hypothyroidism.

Toward consensus: using the Delphi method to form an international expert consensus statement on ultra-processed food addiction

The recognition of an addictive disorder relating to the harmful use of certain foods is being called for by clinicians and researchers, which evidence supports as being distinct from eating disorders (EDs) and obesity. Critics cite a lack of consensus on the validity of associating the term addiction with food, claiming that characteristics of addiction 'are not observed in the context of eating behaviors' as a reason to dispute its consideration as a novel diagnosis. It was decided to consult international scientific and clinical experts to review whether it would be possible to reach a consensus around this subject. The 12-month project, using a Delphi method, involved 40 clinicians, researchers and academics, from 10 countries and a team of four facilitators. Consensus was achieved between 37 out of the 40 participants. The discussions during the process demonstrated that it was not only possible to achieve several areas of agreement related to the clinical observation of addiction-like symptoms related to certain foods but also, that existing extensive scientific research findings confirm the biochemical, neurological and behavioral aspects of a substance-use disorder relating specifically to ultra-processed foods, exhibiting strong similarities with other acknowledged substance-use disorders. The consensus may provide a platform for future attempts for formal recognition of ultra-processed food addiction as a diagnosis. Areas for future research are discussed.

Strategies to overcome barriers to the statistical representation of femicide data-a technical note

Mortality data systems are upstream determinants of health, providing critical information on causes of death and population health trends and influencing health outcomes by shaping policies, research, and resource allocation. Moreover, the gender-related deaths of women and girls are significantly underrepresented or underrecognized in mortality data across many countries. This paper seeks to identify potential barriers and facilitators to improving the representation of femicide data. The primary barriers affecting data representation of femicide are related to definitions, data collection, coding, comparability, access, and systemic challenges. Key recommendations include establishing a nationwide consensus on the definition of femicide, updating training modules for medicolegal professionals, improving pathology reporting processes, ensuring quality assurance in documentation, refining coding practices, developing new analytic methods, and providing deidentified access to cases still under investigation.

Report on the Development of the Accreditation Council for Education in Nutrition and Dietetics' Academic "Accreditation Standards for Advanced Practice Doctoral Education in Nutrition and Dietetics"

The dietetics profession is facing a shortage of registered dietitian nutritionists (RDNs) with a terminal degree. The need for doctoral-prepared RDNs was augmented with the entry-level RDN requiring a graduate degree and exacerbated by the number of retirees from the baby-boomer generation. Advanced practice doctoral (APD) programs can assist in meeting the increased need for doctoral-prepared RDNs. The Accreditation Council for Education in Nutrition and Dietetics Board established an Expanded Standards Committee to develop the APD academic accreditation standards, which included creating and validating doctoral-level competencies in dietetics practice. The development began with a review of the literature, including a review of advanced practice standards for nondietetic, health-related professional programs and professional-doctorate accreditation standards, and focus groups to investigate the perception and need. A rigorous, iterative, Delphi research process was used to develop the academic standards, competencies, and respective performance indicators. The iterative approach resulted in 8 validated standards with 14 competencies with 34 performance indicators for the academic accreditation APD standards. The APD standards define an advanced practice professional doctorate curriculum that is distinct from the entry-level graduate degree in clinical nutrition programs, as well as the research PhD, as it incorporates advanced didactic coursework, advanced practice residency, and applied practice-based research to achieve specific practice-based competencies. Academic accreditation at the doctoral level ensures quality programs that are educating RDNs who are competent at the advanced-practice level, enhancing not only professional practice, but also advancing research supporting practice, education, and leadership.

The Attitude of Nursing Staff Towards Oral Healthcare for Care-Dependent Older Adults (ANOCO) Questionnaire: Development and Validation

AIMS

This study aims to report on the development and validation of the Attitude of Nursing staff towards Oral healthcare for Care-dependent Older adults (ANOCO) questionnaire.

METHODS

The development of the ANOCO questionnaire was performed in three stages between 2008 and 2019. In a first stage, domains related to oral healthcare attitudes were identified. Next, relevant statements per domain were formulated by a Delphi panel in two rounds, resulting in a questionnaire with 32 statements. In a final phase, this questionnaire was subjected to psychometric analysis, including an evaluation of the construct validity, an internal consistency analysis (Cronbachs alpha) and a principal component analysis.

RESULTS

The questionnaire could significantly distinguish between known groups (dentists, nurses' aides, nursing students and nurses). Regarding internal consistency, Cronbach's alpha was 0.863 in the first sample (n = 361) and 0.843 in the second sample (n = 1051). Based on principal component analysis, 22 statements were retained. Four components with an eigenvalue of more than 1 explained 45% of the total variance.

CONCLUSION

The ANOCO-22 questionnaire consists of 22 statements and is a valid tool to assess the changes or differences in the attitude of nursing staff towards oral healthcare for care-dependent older adults.

Vessel wall MRI in giant cell arteritis: standardized protocol and scoring approach developed by an international working group

OBJECTIVES

There are an increasing number of centres performing research on high-resolution vessel wall magnetic resonance imaging (VW-MRI) in GCA. However, harmonized approaches to VW-MRI in GCA are lacking and are essential to performing multicentre studies. Using a data-driven, consensus-based approach, an international expert group developed a standardized MRI protocol and scoring system to advance multi-centred research in cranial GCA.

METHODS

A targeted literature review of VW-MRI in cranial GCA was conducted. A working group comprised of radiologists, rheumatologists and ophthalmologists with expertise in VW-MRI and GCA reviewed the results of the literature search, presented relevant data and images from their respective centres, and then reached consensus on recommendations related to key MRI structures, MRI sequences, scoring system and other important considerations.

RESULTS

A total of 21 relevant articles were identified and reviewed. Based on published literature, structures to be evaluated on MRI were categorized based on anatomic location (extradural cranial, intradural cranial and orbits) and prioritization (core vs elective). Essential and elective sequences to comprehensively image cranial and orbital structures while minimizing scan time were determined along with scoring systems to grade contrast enhancement.

CONCLUSION

This report describes a standardized approach to facilitate research of VW-MRI in cranial GCA that is the result of a multidisciplinary, international collaboration of experts in VW-MRI and/or GCA.

Clinical-genomic profiling of MDS to inform allo-HCT: recommendations from an international panel on behalf of the EBMT

ABSTRACT

For patients with myelodysplastic neoplasm/syndrome (MDS), allogeneic hematopoietic cell transplantation (allo-HCT) represents the only potentially curative treatment, capable of eradicating disease-related mutant hematopoietic cells and establishing normal donor hematopoiesis. Biologic-assignment clinical trials have indicated that in eligible patients, allo-HCT is associated with superior clinical outcomes compared with nontransplant therapy. However, this therapeutic option is only available to a subset of patients, and the outcome is influenced by multiple factors inherent to the patient, the MDS subtype, and the allo-HCT procedure itself. In 2017, the European Society for Blood and Marrow Transplantation (EBMT) published recommendations for allo-HCT in MDS to guide practical decision making. In the contemporary era, genomic profiling has become routine clinical practice in many centers, and the most recent classification systems include MDS entities that are defined by genetic abnormalities. In particular, the molecular International Prognostic Scoring System offers more precise prognostication across all clinical end points and currently represents the standard tool for estimating patient survival in the absence of disease-modifying treatment. Evidence from multiple sources increasingly indicates that allo-HCT should be considered at the time of diagnosis in all eligible patients with MDS. Therefore, genomic profiling for somatic mutations and testing for germ line predisposition variants are integral to determining a patient's eligibility for transplantation. Although all patients with higher-risk MDS are potential candidates for immediate transplantation, a subset of those with lower-risk MDS may also derive benefit from this procedure at an earlier disease stage. Comprehensive recommendations on behalf of an expert international panel for clinical practice and future clinical studies of relevance are presented.