Delphi methodology in healthcare research: How to decide its appropriateness

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.

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.

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.

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.

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.

Development and validation of the national High-Risk Medicine Classification using the Delphi method

BACKGROUND

High-risk medicines (HRMs) are medicines that have a higher risk of causing severe consequences for the patient when used in error.

OBJECTIVE

This study aimed to develop a Finnish High-risk Medicine Classification (FIN-RiskMeds) to support healthcare professionals in HRM risk management.

METHODS

The development of FIN-RiskMeds was coordinated by the Finnish Medicines Agency (Fimea) using the Delphi consensus method. The preliminary list of HRMs was based on an inventory of existing HRM lists, literature, and the expertise of the working group (WG). A three-round Delphi survey with 60 panelists and a public hearing were used to achieve consensus on the content of the classification. The consensus threshold was set at 70 %.

RESULTS

The expert panel agreed on 42 medicines or medicine classes (later 'items') to be included in the FIN-RiskMeds. A 70 % consensus was reached on 30 out of 60 items in Round 1 and on 13 out of 31 items in Round 2a. The strongest consensus was reached for warfarin, methotrexate, and opioids. The serious consequences and key risks of medicines and the medication process were described for all items after Rounds 2b and 3. Based on the WG's decision after a public hearing, the final classification consists of 38 items.

CONCLUSION

This study produced expert consensus-based classifications of HRMs and a comprehensive list of their key risks. HRMs and their risks should be identified across health and social care to prevent potential medication errors. It is necessary to develop medication processes to minimize the risks associated with HRMs.

Defining terminology and outcome measures for evaluating overdose response technology: An international Delphi study

INTRODUCTION

Various novel harm reduction services leverage technology to reduce the rising number of drug poisoning deaths, particularly among those who use drugs alone. There is significant variability in terminology and outcome measures in reporting these interventions, complicating efforts to build a comprehensive knowledge base. Thus, we conducted a Delphi study to establish consensus and heterogeneity in these metrics.

METHODS

Panellists from three stakeholder groups (people who use drugs, virtual harm reduction service operators and academics) participated in a multi-round Delphi study. The first round included open-ended questions to propose items in three categories: terminology, demographic information and outcomes. Subsequent rounds included options from a previously conducted scoping review for consideration. Likert ratings were used to achieve consensus, with a 70% threshold. Final rounds involved ranking terminology that reached a consensus.

RESULTS

Of 23 initial participants, 14 completed the fourth survey round. "Overdose response technology" was identified as the most appropriate term for these harm reduction technologies. This definition includes drug contamination alerts, overdose response hotlines and applications, wearable overdose detection technology and overdose detection tools. Fourteen demographic outcomes reached a consensus for data collection, including name or handle, neighbourhood, age, gender, past overdose experience, substance used, amount and route of use. Six service use outcomes were recommended: response type, service outcomes, morbidity and mortality, overdose events, responder arrival time and post-rescue care.

DISCUSSION AND CONCLUSIONS

The study results are recommended to standardise terminology and guide future research and knowledge dissemination in the field, ensuring clear communication with a shared language.

Entrustable professional activities for physiotherapists to demonstrate digital health competency: an international delphi study

BACKGROUND

The physiotherapy workforce is going through a staggering period of change, amidst an evolving technological landscape. Whilst the profession has cautiously begun to embrace digital physiotherapy practice, there remains a lack of clear, evidence-based standardized guidance regarding tangible activities that demonstrate relevant clinical competence with digital health technologies in practice.

OBJECTIVE

Establish the world's first international consensus on entrustable professional activities (EPAs) for digital physiotherapy practice.

METHODS

International Delphi study of experts over three rounds, to establish consensus on digital physiotherapy practice EPAs and associated specifications.

RESULTS

Fifty-five participants completed the study (which was an 83.3% retention rate from round 1). Participants represented 16 countries. Over 50% were academics, and over 30% were clinicians. The final framework consisted of nine EPAs and 56 specifications for digital physiotherapy practice. The highest percentage rated specification was for "obtaining informed consent" for using digital health.

CONCLUSIONS

This Delphi study is a seminal international consensus on the core EPAs for digital physiotherapy practice. These EPAs materialize competency. As global attention to digital health continues to increase, our workforce will need to continue to mature in this space. This international consensus will support employers, universities, peak bodies, and individual physiotherapists alike to develop alongside technology. With greater evidence and the establishment of international standards, confidence in the outcomes of digital physiotherapy practice will increase.

Key strategies to reduce the global burden of myopia: consensus from the international myopia summit

In this paper, we describe key strategies to guide global collaborative efforts to further reduce the burden of myopia and myopia-related visual impairment. A modified Delphi method was applied as an iterative multistage process to collect expert and stakeholders' opinions and extract consensus strategies regarding myopia diagnosis, prevention and control. Anonymous pre-meeting preparation rounds, structured discussions for prioritisation and the development of key consensus areas were performed. Consensus was reached on three key areas to collaborate and complement existing frameworks: (1) Myopia defined not only as a refractive error but also as a disease with phenotypic features allowing for risk stratification of significant visual impairment. (2) In addition to preventive strategies, a focus is needed on preventing progression to high myopia (HM). (3) A focus on preventing and treating pathologic myopia (PM), that is, end-stage of myopia disease with irreversible visual impairment. In conclusion, the workgroup suggests a global, collaborative strategy that is needed across public health, healthcare and advocacy sectors to support efforts in reducing visual impairment from myopia. Complementary to existing preventive public health efforts, additional focus on defining myopia as a disease with risk stratification for visual impairment and an emphasis on reducing visual impairment associated with HM and PM should be considered.

Operating Department Practitioner's research priorities: A Delphi study

With the 2022 Allied Health Professions' Research and Innovation Strategy and the College of Operating Department Practitioners joining the Council for Allied Health Professions Research, understanding the Operating Department Practitioner profession's vision for research and innovation and identifying its research priorities has become important. This Delphi study aimed to establish research priorities for the Operating Department Practitioner profession. Questionnaires were distributed to Operating Department Practitioners using College of Operating Department Practitioners and social media networks. Round 1 saw 49 eligible responses; this reduced to 21 in Round 2 and 17 in Round 3. Thirty-one research priorities were identified by consensus. Priority rank was determined by mean score, percentage agreement, and coefficient of variance. By reaching a consensus, Operating Department Practitioners co-created research priorities and identified several themes that will contribute to professional development and patient care and support funding opportunities. The five key themes were Workforce Transformation, Education, Patient Safety and Experience, Innovation and Technology, and Theatre Culture.

Consensus recommendations on multiple sclerosis management in Australia and New Zealand: part 1

INTRODUCTION

Multiple sclerosis (MS) is a chronic inflammatory demyelinating and degenerative disease of the central nervous system. There were 33 335 people with MS in Australia in 2021 and 2917 in New Zealand in 2006 and the prevalence and incidence are increasing with time. Although new treatments have substantially improved outcomes in recent decades, the treatment landscape has become increasingly complex due to the expanding number of disease-modifying therapies (DMTs) and associated safety considerations.

MAIN RECOMMENDATIONS

A total of 80 consensus recommendations were developed on the current best-practice management of MS in Australia and New Zealand. Part 1 of these guidelines outlines the consensus recommendations covering domains including DMT counselling and selection, pre-DMT assessments, monitoring disease activity on DMT, switching DMT, and discontinuing DMT. The remaining recommendations are outlined in Part 2, encompassing risk mitigation strategies during treatment with DMT, managing DMT in special situations (including pregnancy, postpartum, breastfeeding, active infection including COVID-19, and malignancy), general lifestyle measures, acute MS relapses, and symptomatic treatments for MS.

CHANGES IN MANAGEMENT AS A RESULT OF THE GUIDELINES

This two-part position statement provides a practical resource for clinicians on current best-practice consensus recommendations for managing adults (≥ 18 years old) with MS in the Australian and New Zealand health care settings. It outlines the 14 DMTs currently available through the Australian Pharmaceutical Benefits Scheme and eight through the New Zealand Pharmaceutical Schedule, including the unique efficacy, safety and monitoring considerations of each. Through these guidelines, we aim to support safe, timely and effective management of patients with MS in Australia and New Zealand.

Long COVID clinical evaluation, research and impact on society: a global expert consensus

BACKGROUND

Long COVID is a complex, heterogeneous syndrome affecting over four hundred million people globally. There are few recommendations, and no formal training exists for medical professionals to assist with clinical evaluation and management of patients with Long COVID. More research into the pathology, cellular, and molecular mechanisms of Long COVID, and treatments is needed. The goal of this work is to disseminate essential information about Long COVID and recommendations about definition, diagnosis, treatment, research and social issues to physicians, researchers, and policy makers to address this escalating global health crisis.

METHODS

A 3-round modified Delphi consensus methodology was distributed internationally to 179 healthcare professionals, researchers, and persons with lived experience of Long COVID in 28 countries. Statements were combined into specific areas: definition, diagnosis, treatment, research, and society.

RESULTS

The survey resulted in 187 comprehensive statements reaching consensus with the strongest areas being diagnosis and clinical assessment, and general research. We establish conditions for diagnosis of different subgroups within the Long COVID umbrella. Clear consensus was reached that the impacts of COVID-19 infection on children should be a research priority, and additionally on the need to determine the effects of Long COVID on societies and economies. The consensus on COVID and Long COVID is that it affects the nervous system and other organs and is not likely to be observed with initial symptoms. We note, biomarkers are critically needed to address these issues.

CONCLUSIONS

This work forms initial guidance to address the spectrum of Long COVID as a disease and reinforces the need for translational research and large-scale treatment trials for treatment protocols.

Development of a generalised tool for evaluating success of clinical practice guidelines implementation (A-GIST)

OBJECTIVES

To develop a generalised tool to evaluate the success of implementation of clinical practice guidelines (CPGs).

DESIGN AND SETTING

Systematic review, group brainstorming discussion and modified Delphi method.

PARTICIPANTS

A steering group (3 members) was assembled responsible for the guidance and ensuring stakeholder's involvement. A tool development group (24 members) of leading experts provided expertise in refining the frame and items during the development and participated in the Delphi process. And a secretary group (7 members) was responsible for the organization and coordination, systematic reviewing, drafting of the preliminary list of items, documenting and revising the tool according to the suggestions of the development group.

INTERVENTIONS

Four process stages were employed. First, the project was launched with core groups formed for the development. Second, based on the Reach Effectiveness Adoption Implementation Maintenance framework, a systematic review of existing methods for evaluating the success of CPGs implementation and a brainstorming discussion were conducted to form a preliminary list. Third, a modified Delphi method was organised, integrating a multidisciplinary face-to-face consultation meeting with two rounds of online Delphi consultations. Fourth, the tool was revised and finalised incorporating all expert suggestions.

RESULTS

Development teams comprising multidisciplinary experts were formed. In the systematic review, 7 biomedical literature databases were searched, and 208 pieces of literature were included. After three rounds of brainstorming discussions on items identified in the literature, a 23-item preliminary list was produced. In the modified Delphi method, 14 experts made 23 main suggestions in the face-to-face meeting on the list. 13 experts participated in the first round of Delphi consultation, reached agreement on 20 items, removed 4 items and added 1 new item. 11 experts attended the second-round consultation and had an agreement to include 20 items after revision.

CONCLUSIONS

The Guideline Implementation Success Assessment Tool (A-GIST) was systematically developed as a comprehensive tool to assess the success of CPGs implementation. It comprises 5 dimensions, Reach, Adoption, Implementation, Effectiveness and Maintenance, encompassing 20 items that integrate perspectives from both clinicians and patients. A-GIST is designed to facilitate evaluating, benchmarking and cross-comparison of implementation success between guidelines, facilities and regions. Additionally, it provides evidence-based insights to inform the development of targeted strategies for optimising guideline implementation practices.

A structured framework for standardized 3D leg alignment analysis: an international Delphi consensus study

PURPOSE

To reach consensus among international experts on a structured framework for standardized 3D leg alignment analysis based on 3D bone models, ensuring consistency and improving clinical applicability.

METHODS

A Delphi study was performed in four rounds. Rounds 1 and 2 involved a steering and rating group that developed statements based on principles preserving the 3D complexity of anatomical structures, identified through a systematic review. These statements encompassed approaches for deriving joint centres and joint orientations, and defining coordinate systems using 3D bone models. In Rounds 3 and 4, a panel of 35 international experts, including clinicians (54%) and engineers (46%), with participants from Europe (80%), Oceania (9%), Asia (6%), and the Americas (6%), evaluated these statements. Consensus was defined as ≥80% agreement.

RESULTS

Rounds 1 and 2 resulted in 31 statements to be included in the survey. Of these, 26 achieved consensus in Round 3, with the five remaining statements refined and reaching consensus in Round 4. Experts agreed on utilising all available relevant surface data to define joint centres, joint orientations, and individual femoral and tibial coordinate systems alongside a combined leg coordinate system, and adopting central 3D axes for femoral version and tibial torsion.

CONCLUSIONS

This international Delphi consensus study provides a structured framework for a standardized 3D leg alignment analysis based on 3D bone models. This framework aims to enhance clinical applicability for preoperative planning and execution of uni- and multiplanar correction osteotomies around the knee, reduce the methodological variability in 3D leg alignment analysis literature, and improve cross-study comparability.

LEVEL OF EVIDENCE

Level V.

How to Refine and Prioritize Key Performance Indicators for Digital Health Interventions: Tutorial on Using Consensus Methodology to Enable Meaningful Evaluation of Novel Digital Health Interventions

Digital health interventions (DHIs) have the potential to improve health care and health promotion. However, there is a lack of guidance in the literature for the development, refinement, and prioritization of key performance indicators (KPIs) for the evaluation of DHIs. This paper presents a 4-stage process used in the Gravitate Health project based on stakeholder consultation and consensus for this purpose. The Gravitate Health consortium, which comprises private and public partners from across Europe and the United States, is developing innovative digital health solutions in the form of Federated Open-Source Platform and G-lens to present users with individualized digital information about their medicines. The first stage of this was the consultative process for the development of KPIs involving stakeholder (Gravitate Health project leads) consultations at the planning stages of the project. This resulted in the formation of an extensive list of KPIs organized into 7 categories. The second stage was conducting a scoping review, which confirmed the need for extensive stakeholder consultation in all stages of the KPI development, refinement, and prioritization process. The third stage was a period of further consultation with all consortium members, which resulted in the elimination of 1 category of KPIs. The fourth stage involved using the Delphi technique for refining and prioritizing the remaining 6 categories of KPIs. It is unusual to use this methodology in a nonresearch exercise, but it provided a clear consultative framework and structure that facilitated the achievement of consensus within a large consortium of 250 members on a substantial list of KPIs for the project. Consortium members ranked the relevance and importance of each KPI. The final list of KPIs provides substantial indicators sensitive to the needs of a broad group of stakeholders that are being used to capture real-world data in developing and evaluating DHIs.

A Delphi study of current practices and establishing consensus regarding assessment of fitness to drive among patients with brain tumours

PURPOSE

Evaluating fitness to drive among patients with brain tumours remains a challenge for clinicians. Due to difficulties in conducting prospective driving studies in this patient cohort, a Delphi study was performed to formulate new driving guidelines for patients with brain tumours.

METHODS

The survey questions, which were designed by utilising Australian driving guidelines and previous Delphi studies, established panelists' expertise, and then used a 9-point Likert scale to formulate new driving guidelines. An expert group of panelists comprising medical oncologists, radiation oncologists, neurosurgeons, and neurologists were chosen based on membership to professional societies with validation in part one of the survey. Two rounds of anonymised surveys were performed using REDCap for data entry, and a novel automated methodology on R for data analysis.

RESULTS

46 statements regarding fitness to drive were developed. Among the 37 surveys distributed, there were 26 responses (70.3% response rate) from round one, and 17 responses (65.4% response rate) for round two. Among the 46 statements, 19 (41.3%) achieved consensus. In addition to establishing a framework for assessing patients, there was notable consensus agreement for stable imaging required as part of evaluation and the need for continual reassessment.

CONCLUSION

Despite clinicians being aware of driving guidelines, determining fitness to drive among patients with brain tumours remains a challenge. This Delphi study identified consensus agreement for the need for stable imaging, and continually reassessing fitness to drive. These novel findings could be translated into future driving guidelines and consensus statements can be integrated into clinical practice.

User requirements for quantitative radiological reports in multiple sclerosis

OBJECTIVES

Quantitative radiological reports (QReports) can enhance clinical management of multiple sclerosis (MS) by including quantitative data from MRI scans. However, the lack of consensus on the specific information to include, on and clinicians' preferences, hinders the adoption of these imaging analysis tools. This study aims to facilitate the clinical implementation of QReports by determining clinicians' requirements regarding their use in MS management.

MATERIALS AND METHODS

A four-phase Delphi panel approach was employed, involving neurologists and (neuro)radiologists across Europe. Initial interviews with experts helped develop a questionnaire addressing various QReport aspects. This questionnaire underwent refinement based on feedback and was distributed through the MAGNIMS network. A second questionnaire, incorporating additional questions, was circulated following a plenary discussion at the MAGNIMS workshop in Milan in November 2023. Responses from both questionnaire iterations were collected and analyzed, with adjustments made based on participant feedback.

RESULTS

The study achieved a 49.6% response rate, involving 78 respondents. Key preferences and barriers to QReport adoption were identified, highlighting the importance of integration into clinical workflows, cost-effectiveness, educational support for interpretation, and validation standards. Strong consensus emerged on including detailed lesion information and specific brain and spinal cord volume measurements. Concerns regarding report generation time, data protection, and reliability were also raised.

CONCLUSION

While QReports show potential for improving MS management, incorporation of the key metrics and addressing the identified barriers related to cost, validation, integration, and clinician education is crucial for practical implementation. These recommendations for developers to refine QReports could enhance their utility and adoption in clinical practice.

KEY POINTS

Question A lack of consensus on essential features for quantitative magnetic resonance imaging reports limits their integration into multiple sclerosis management. Findings This study identified key preferences, including detailed lesion information, specific brain and spinal cord measurements, and rigorous validation for effective quantitative reports. Clinical relevance This study identified essential features and barriers for implementing quantitative radiological reports in multiple sclerosis management, aiming to enhance clinical workflows, improve disease monitoring, and ultimately provide better, data-driven care for patients through tailored imaging solutions.

Core functions and forms in home-delivered meal programs: a stakeholder-driven approach to identifying essential practices

BACKGROUND

The rapid growth of the aging population underscores the need for programs tailored to older adults' complex health needs. Home-delivered meal programs are critical, providing nutrition and socialization support to older adults with greatest economic and social need. However, variations in local implementation complicate our understanding of how specific program practices influence older adult outcomes. This present study applies the core functions and forms framework to identify and prioritize essential home-delivered meal practices-or forms-that can be replicated by other meal programs.

METHODS

This study was conducted within a pragmatic randomized effectiveness trial comparing two home-delivered meal models and their impacts on health outcomes among older adults. The study involved nine meal programs across the United States and used a three-phase approach characterized by the following: (1) core functions of home-delivered meal programs were identified based on Title III of the Older Americans Act; (2) the full spectrum of program "forms" was gathered through site visits, surveys, and listening sessions; and (3) a modified e-Delphi process was conducted with stakeholders to determine consensus on the most essential forms of home-delivered meal programming.

RESULTS

Three core functions were identified from Title III of the Older Americans Act: provide meals to reduce hunger and malnutrition, provide opportunities for socialization, and provide opportunities to promote health and well-being. Out of 103 identified program forms, 25 were deemed essential for achieving the core functions of home-delivered meal programs. Essential practices included dietary customization, emergency meal provision, and meaningful client-driver interactions, as examples.

DISCUSSION

This study demonstrates that while program variability allows flexibility to meet local client needs, establishing core functions and essential forms provides a foundation for evaluating home-delivered meal program effectiveness. The findings inform home-delivered meal program improvements at the national level, emphasizing a balance between standardized practices and local adaptations. This work serves as a model for characterizing complex interventions in community-based settings, advancing the science of implementation and the impact of home-delivered meals on older adult populations.

TRIAL REGISTRATION

NCT registration: NCT05357261 ; April 27, 2022.

Delphi Consensus on the Distinct Clinical and Histopathological Features of Lichen Planopilaris and Frontal Fibrosing Alopecia: Insights From the Hair Diseases EADV Task Force

BACKGROUND

Frontal fibrosing alopecia (FFA) has been defined as a lichen planopilaris (LPP) variant, and both are characterized by lymphocytic scarring alopecia. Despite histopathological similarities, they differ clinically, suggesting potentially different pathogenetic factors. This Delphi study aimed to collect expert opinions to clarify the relationship between FFA and LPP.

METHODS

The Delphi method was employed via an anonymous survey among experts in hair disorders from the Hair Diseases Task Force of the European Academy of Dermatology and Venereology (EADV), ensuring broad international representation. Two rounds of online questionnaires assessed the definition, clinical presentation, diagnosis, and management of LPP and FFA. The statements, developed based on an extensive literature review, were validated by the core expert panel. A 5-point Likert scale was utilized to quantify agreement levels, with strong consensus defined as ≥ 75% agreement or disagreement. Statements lacking strong consensus in the first round were revised and merged for inclusion in the second round.

RESULTS

Seventeen experts from seven countries joined the Delphi consensus process. In the first round, 65 statements underwent qualitative content analysis, yielding strong consensus in 30.7% of cases. Participants provided written justifications for their assessments. In the second round, an increased consensus rate (53.7%) was reached after the expert panel statement's revision.

CONCLUSIONS

This study confirms that FFA and LPP are clinical variants within the same lichenoid spectrum. While moderate consensus supports FFA as a variant of LPP, uncertainties remain regarding its demographic distribution, the presence of vellus hairs, and blue-gray dots. The study refines diagnostic and management approaches but is limited by the absence of dermatopathologists and basic researchers.

Adult glioblastoma in England: Incidence, treatment, and outcomes with novel population-based strata

INTRODUCTION

Malignant brain tumours are the leading cause of cancer death in the under 40's and they have the highest average-years of life lost. England has a long-running system for national cancer data collection. In this work we present data on incidence, treatment and survival in all adult glioblastoma patients in England diagnosed between 2013 and 2018.

METHODS

GlioCova uses a linked pseudo-anonymised data set of all adult patients in England diagnosed with a primary brain tumour between 2013 and 2018. We identified all patients with a glioblastoma (GBM) based on ICD-10 diagnosis and tumour morphology.

RESULTS

In the 6-year period of the study (2013-2018 inclusive), 15,181 patients were diagnosed with a GBM in England. The national age-standardised incidence was 4.98 adult glioblastoma patients per 100,000 per year, with men having a higher incidence than women (6.3 and 3.8 respectively). Overall, 79 % of patients received treatment (76 % female vs. 81 % male, p = 0.22), with younger patients more likely to be treated than older patients. Median overall survival was 16 months in those receiving aggressive treatment, but 7 months in the whole cohort. 21 % of patients received no treatment, and 17 % of patients underwent surgery or biopsy alone.

CONCLUSION

Age-adjusted incidence of GBM is stable, although absolute numbers are rising, and prognosis remains poor. Only 29 % of patients receive aggressive multi-modality treatment, and we suggest that taking a population-level approach to GBM reveals significant areas for improvement.

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.

Identification of essential topics and procedural skills for inclusion in a contextualised undergraduate anaesthesia and critical care clerkship in Rwanda: results of a modified Delphi process

INTRODUCTION

Low anaesthesia workforce numbers contribute to shortfalls in access to surgical care globally. Investment in contextualised education and training can help address this issue by inspiring graduates to enter into training and imparting important knowledge and skills to non-specialists. We undertook a modified Delphi study to identify physician anaesthesiologist consensus on themes, topics, and skills for inclusion in undergraduate anaesthesia and critical care (ACC) medical school curricula in sub-Saharan Africa (SSA) and Rwanda.

METHODS

A list of ACC topics/skills was compiled through grey literature review, guiding survey development for a 3-round Delphi process. The first two rounds solicited responses from physician anaesthesiologists across SSA. The final round included only Rwandan physician anaesthesiologists. Respondents rated topics/skills on a 4-point Likert scale from 1 ("exclude from the curriculum") through 4 ("essential for inclusion"). Item-level Content Validity Index (I-CVI, the proportion of respondents rating a topic/skill as 3 or 4) was used for stratification. A first-round I-CVI threshold of 80% and 70% for subsequent rounds was used to define consensus for inclusion. Excluded topics/skills were considered for re-inclusion in subsequent rounds; 50% agreement was set as threshold for re-inclusion. The first round also sought consensus regarding aims, objectives, and delivery methodology.

RESULTS

A total of 147 topics/skills across 12 domains were identified for initial survey inclusion. Fifty-one respondents from 12 countries completed round one. Ninety-six (65.3%) topics/skills met consensus threshold. One additional skill ("pain assessment") was incorporated into round two following suggestions from respondents. The clerkship outcome ranked as most important and achievable was to 'inspire students to undertake anaesthesia specialty training' (n = 25, 49.0% and n = 26, 51.0% respectively). Thirty-six respondents from 12 countries completed round two. Eighty (82.5%) topics/skills met consensus threshold. Seventeen Rwandan specialists completed round three. Seventy-eight (97.5%) topics/skills met consensus threshold. From 67 previously excluded topics/skills, 14 (20.9%) met re-inclusion threshold.

DISCUSSION AND CONCLUSION

A modified Delphi process identified 92 essential topics/skills for inclusion in a Rwandan undergraduate ACC clerkship. Experts prioritised 'inspiring students' over 'achieving clinical competence' for undergraduates. A similar Delphi approach may be useful for educational content development in other settings across the African continent and for other specialties.

TRIAL REGISTRATION

Not applicable (study described is not a clinical trial). UGHE IRB protocol number: 194.

Determining the Prioritization of Behavior Change Techniques for Long-Term Stroke Rehabilitation: Delphi Survey Study

Background

Stroke results in both physical disability and psychological distress. The impact can be minimized through rehabilitation, but it is a long-term process, making it difficult for patients to adhere to treatment. Thus, a better understanding of long-term behavior change interventions for patients with stroke is needed as well as how such interventions can support not only rehabilitation of motoric functions but also mental well-being.

Objective

The aim of this study is to understand both the most important behavior change technique (BCT) clusters for long-term stroke rehabilitation in general as well as which are most relevant for each aspect of stroke rehabilitation: behavioral, cognitive, and emotional.

Methods

We applied the 16 BCT clusters. The study used a 2-round Delphi survey, as reliable consensus was obtained among a group of 12 international experts. Experts represented three main backgrounds involved in behavioral intervention in the health context: (1) specialists in behavioral science (n=4), (2) behavioral designers (n=4), and (3) expert health care professionals (n=4). Experts were brought together in this way for the first time. In the first round, web-based questionnaires were used to collect data from the experts. This was followed by a personalized second round. Consensus was determined by statistically aggregating the responses and evaluating IQR and percentage consensus. BCT clusters reaching consensus (IQR ≤1 and percentage ≥50%) were then ranked.

Results

In total, 12 of 16 BCT clusters reached consensus for general importance in stroke rehabilitation, with 11, 9, and 6 BCT clusters achieving consensus for, respectively, the behavioral, cognitive, and emotional aspects of rehabilitation. The overall most relevant BCT clusters were repetition and substitution, social support, feedback and monitoring, and self-belief, with similar outcomes for behavioral and cognitive rehabilitation. For emotional rehabilitation, social support and identity were emphasized. The least relevant BCT clusters were natural consequences, covert learning, and comparison of behavior.

Conclusions

This expert panel study using a 2-round Delphi survey ranked the importance of BCT clusters for long-term stroke rehabilitation. The process yielded a number of novel insights highlighting differences in importance between general rehabilitation and that specifically focused on the behavioral, cognitive, and emotional aspects of stroke recovery. This provides a first but important step toward unlocking the prioritization of BCT clusters for long-term intervention contexts such as stroke rehabilitation and enables effective intervention mapping addressing long-term behavior change and treatment adherence.

Prioritizing gaps in stroke care: A two-round Delphi process

BACKGROUND

Despite international recognition of stroke as a significant health priority, discrepancies persist between the target values for stroke quality measures and the actual values that are achieved in clinical practice, referred to as gaps. This study aimed to reach consensus among international experts on prioritizing gaps in stroke care.

METHODS

A two-round Delphi process was conducted, surveying an international expert panel in the field of stroke care and cerebrovascular medicine, including patient representatives, healthcare professionals, researchers, policymakers, and medical directors. Experts scored the importance and required effort to close 13 gaps throughout the stroke care continuum and proposed potential solutions. Data were analyzed using descriptive statistics and qualitative analysis methods.

RESULTS

In the first and second Delphi rounds, 35 and 30 experts participated, respectively. Expert consensus was reached on the high importance of closing 11 out of 13 gaps. Two out of 13 gaps were considered moderately important to close, with expert consensus for one of these two gaps. Expert consensus indicated that only one gap, related to the prevention of complications after stroke, requires moderate effort to close, whereas the others were considered to require high effort to close. Key focus areas for potential solutions included: "Care infrastructure," "Geographic disparities," "Interdisciplinary collaboration," and "Advocacy and funding."

CONCLUSIONS

While closing gaps in stroke care primarily requires high effort and substantial resources, targeted interventions in the identified key focus areas may provide feasible and clinically meaningful improvements.

Methodology used to develop the minimum common data elements for surveillance and Reporting of Musculoskeletal Injuries in the MILitary (ROMMIL) statement

Background

The objective was to summarize the methodology used to develop the international minimum data elements for surveillance and Reporting of Musculoskeletal Injuries in the MILitary (ROMMIL) statement. This is a recommended list of elements to be collected and reported when conducting injury surveillance research in military settings.

Methods

A Delphi methodology was employed to reach consensus. Preliminary steps included conducting a literature review and surveying a convenience sample of military stakeholders to 1) identify barriers and facilitators of military musculoskeletal injury (MSKI) prevention programs, 2) identify relevant knowledge gaps, and 3) establish future research priorities. A sequential three-round Delphi consensus survey followed, including relevant stakeholders from militaries around the world, using results to conduct an asynchronous knowledge user meeting (mixture of in-person and live video conference and recording) to explore the level of agreement among subject matter experts. Knowledge users, including former and current military service members, civilian practitioners working in military health networks, and international subject matter experts having experience with policy, execution, or clinical investigation of MSKI mitigation programs, MSKI diagnoses, and MSKI risk factors in military settings. For each round, participants scored questions on a Likert scale of 1-5. Scores ranged from No Importance (1) to Strong Importance (5).

Results

Literature review and surveys helped inform the scope of potential variables. Three rounds were necessary to reach minimum consensus. Ninety-five, 65, and 42 respondents participated in the first, second and third rounds, respectively.

Conclusions

Achieving consensus across relevant knowledge users representing military organizations globally can be challenging. This paper details the methodology employed to reach consensus for a core minimum data elements checklist for conducting MSKI research in military settings and improve data harmonization and scalability efforts. These methods can be used as a resource to assist in future consensus endeavors of similar nature.

The road to successful implementation of innovation in radiotherapy: A research-based implementation protocol

BACKGROUND AND PURPOSE

Radiotherapy (RT) is rapidly advancing, yet only 50 % of innovations are implemented promptly. Despite the availability of Implementation Science (ImpSci) theories, models, and frameworks (TMFs), a theory-practice gap persists in effectively applying these insights in RT clinical practice. This study aims to develop a consensus-based implementation protocol for RT innovations using validated ImpSci knowledge.

MATERIAL AND METHODS

A literature review of TMFs (May-August 2023) and 20 semi-structured interviews with Dutch RT professionals (August-December 2023) identified key RT components for implementation. These insights informed a draft RT implementation protocol, which was refined through a three-round international Delphi study (March-September 2024) involving 11 RT and 5 ImpSci experts. Consensus was determined using a 5-point Likert scale, analysing medians, interquartile ranges (IQRs), and percentage scoring.

RESULTS

The Knowledge-to-Action (KTA) Framework and input from expert interviews were used to draft the protocol. Delphi response rates were 100 %, 93.8 %, and 88.9 % across rounds. In round 1, 88.9 % of elements achieved consensus (median = 4.0, IQR = 0.0-1.3); only the application of a prediction model for timely implementation (step 3c) needed revision after rounds 1 and 2. In round 3, also for step 3c consensus was reached (median = 4.0, IQR = 0.3). The protocol includes defining innovation types, stakeholder analysis, tailored implementation strategies, and a phased evaluation plan to ensure sustainability.

CONCLUSION

This is the first consensus-based RT innovation implementation protocol, addressing the theory-practice gap with a structured clinical approach. Future research should validate the protocol and assess the impact of preparation on implementation success.

Development and validation of the social frailty scale for the older adult in China

Objectives

Existing social frailty instruments are not tailored to the linguistic and cultural characteristics of Chinese-speaking patients; a version addressing this gap will increase clinical understanding of their healthcare experience and may help guide social frailty. To develop a Chinese version of a Social Frailty Scale (CVSFS) for the older adult and to examine the psychometric properties of this instrument.

Method

Based on the recommendations of the COSMIN guidelines, the scale development inclued three phases: development of the initial scale, optimisation of scale items, and validation test for scale. The initial CVSFS 1.0 version was developed through literature review, semi-structured interviews, research team discussion, and Delphi method. Then, cross-sectional survey was conducted (n = 265) and scale items were optimized based on the survey results using item analysis and exploratory factor analysis (EFA) to form CVSFS 2.0 version. Lastly, the cross-sectional survey (n = 287) was repeated using CVSFS 2.0 version, and the reliability and validity of the scale's measurement properties were tested.

Results

The initial scale stage of development formed a 42-item CVSFS 1.0 version. After item analysis and EFA, six items were excluded to form a four-dimension with 36-item CVSFS 2.0 version including individual level, family level, interpersonal level, community and social level. The CVSFS 2.0 version demonstrated good reliability and validity, with a Cronbach's α coefficient of 0.926 and a McDonald's ω estimate of 0.931, split-half reliability of 0.928, and test-retest reliability of 0.978. The I-CVI of the scale was calculated to be 0.889~1.000, and the S-CVI/Ave was 0.930. Confirmatory factor analysis results indicated satisfactory fit indices: χ2/df = 2.17, GFI = 0.813, TLI = 0.932, CFI = 0.937, RMSEA = 0.064.

Conclusions

The CVSFS 2.0 version developed in this study based on a social-ecological framework has high reliability and validity, making it a suitable instrument for evaluating social frailty among the older adult in China.

Prevention strategies against academic burnout: the perspective of Romanian health sciences students in the aftermath of the COVID-19 pandemic

Background

Burnout in academia can have important long-term consequences. This study aimed to investigate academic burnout and the perception of its prevention strategies among Romanian health sciences students.

Methods

Three hundred and five health sciences students (from General Medicine, Dental Medicine, Pharmacy, and Midwifery and Nursing) (36 men, 269 women, mean age 21.9, standard deviation 1.911) self-rated their burnout using the Burnout Assessment Tool (BAT) and a visual analog scale, and answered a survey with open and closed questions about the most effective coping strategies to prevent burnout.

Results

Above average scores (mean = 3.05; SD = 0.67) on burnout were met (with the highest scores on exhaustion and psychological distress and the lowest on mental distance and psychosomatic symptoms). Women were more affected than men by burnout and associated emotional impairment and secondary symptoms. Participants rated supportive relationships as the most effective in preventing burnout (mean = 3.75; SD = 0.55), followed by relaxation-meditation (mean = 3.32; SD = 0.85), while they also positively valued cognitive-behavioral therapy (those with high burnout scores), and physical activity (those with low burnout scores). Organizational strategies have included re-evaluating the university curriculum (mean = 3.83; SD = 0.48) and increasing access to psychological support programs (mean = 3.72; SD = 0.58) and to programs that increase self-efficacy and resilience (mean = 3.65; SD = 0.61). The qualitative analysis showed that freely chosen individual strategies included, in descending order, detachment, active actions, healthy lifestyle, and specialist help, while the most preferred organizational were better academic organization and program optimization.

Conclusion

These results may be useful in designing more sustainable and effective burnout prevention strategies in health sciences academic settings.

Adaptation and modification of the professional identity formation scale for postgraduate trainees in basic health science: a mixed method study

BACKGROUND

The professional identity formation (PIF) of postgraduate trainees in basic health sciences is critical to their educational journey. Yet, appropriate measurement tools are lacking. This research aimed to adapt and modify an existing PIF scale to assess the professional identities of postgraduate basic health sciences trainees.

METHODS

A mixed-method study was conducted to validate a modified PIF scale. An instrument was developed following AMEE Guide 87 (A. R. Artino et al.) (1). Seven medical educationalists and basic health science postgraduate supervisors established its content validity and reliability. Cognitive interviews were conducted with 15 participants, and the tool was validated through the Delphi technique. Piloting was undertaken on a simple random sample of 500 postgraduate trainees. Psychometric analyses, including structure factor analysis, internal consistency testing, and qualitative content analysis, were used to evaluate the modified scale.

RESULTS

Five factors related to professional identity formation were identified: "Commitment to Professional Identity, belonging and Values," "Pursuit of Knowledge and Excellence," "Professional Growth and Collaboration," Personal Growth and Reflection," and "Confidence and impact." The modified PIF scale demonstrated robust psychometric properties, including a well-defined factor structure, significant reliability, and high internal consistency. With a Cronbach alpha 0.97, the PIF scale's five kept variables accounted for 99.99% of the variance.

CONCLUSIONS

The study found the modified PIF scale to be a reliable tool for assessing the professional identities of postgraduate trainees in basic health sciences. It developed a 50-item tool with five valid factors to evaluate professional identity for postgraduate trainees.

Development of a classification system for potential sources of error in robotic-assisted spine surgery

PURPOSE

Robotic-assisted spine surgery (RASS) has increased in prevalence over recent years, and while much work has been done to analyze differences in outcomes when compared to the freehand technique, little has been done to characterize the potential pitfalls associated with using robotics. This study's goal was to leverage expert opinion to develop a classification system of potential sources of error that may be encountered when using robotics in spine surgery. This not only provides practitioners, particularly those in the early stages of robotic adoption, with insight into possible sources of error but also provides the community at large with a more standardized language through which to communicate.

METHODS

The Delphi method, which is a validated system of developing consensus, was utilized. The method employed an iterative presentation of classification categories that were then edited, removed, or elaborated upon during several rounds of discussion. Voting took place to accept or reject the individual classification categories with consensus defined as ≥ 80% agreement.

RESULTS

After a three-round iterative survey and video conference Delphi process, followed by an in-person meeting at the Safety in Spine Surgery Summit, consensus was achieved on a classification system that includes four key types of potential sources of error in RASS as well as a list of the most commonly identified sources within each category. Initial sources of error that were considered included: cannula skidding/skive, penetration, screw misplacement, registration failure, and frame shift. After completion of the Delphi process, the final classification included four major types of pitfalls including: Reference/Navigation, Patient Factors, Technique, and Equipment Factors (available at https://safetyinspinesurgery.com/ ).

CONCLUSION

This work provides expert insight into potential sources of error in the setting of robotic spine surgery. The working group established four discrete categories while providing a standardized language to unify communication.

Baby steps to mastery: building blocks for novices in pediatric regional anesthesia

Pediatric regional anesthesia offers significant benefits, yet its adoption faces barriers, including perceived overcomplexity. This study aimed to identify and establish a set of core, high-value, low-complexity nerve blocks to improve perioperative pain management in pediatric patients. A four-round modified Delphi consensus study was conducted with an international panel of pediatric and regional anesthesia experts. An initial long list of regional techniques was compiled by the Steering Committee and refined through iterative input. Panelists rated each technique on a 10-point Likert scale for importance. Consensus was defined as ≥75% of panelists assigning a mean importance score of ≥8. Techniques receiving 50%-74% agreement were categorized as having strong agreement and considered for inclusion. The final selection was confirmed through a virtual roundtable discussion. Thirty-three experts representing 12 pediatric and regional societies participated. Consensus was reached on six regional techniques, with strong agreement (*) on two additional techniques, identifying eight core pediatric regional anesthesia blocks: supraclavicular brachial plexus block, rectus sheath block, transverse abdominis plane block*, suprainguinal fascia iliaca block*, femoral nerve block, adductor canal block, popliteal sciatic nerve block, and landmark-based caudal block. This consensus-driven framework defines a core set of pediatric regional anesthesia techniques that balance clinical effectiveness, feasibility, and accessibility. These findings provide a practical entry point for practitioners looking to incorporate pediatric regional anesthesia into their practice, regardless of prior experience. Future efforts should focus on standardized training, implementation research, and policy initiatives to support widespread adoption and improve perioperative pain management in children globally.

International consensus on research priorities in hypospadias using a Delphi study approach

INTRODUCTION

Hypospadias is a common congenital anomaly of the male genitalia that poses significant management and treatment challenges. Gaining a comprehensive understanding of priority research questions in hypospadiology will be essential to reach agreement on the optimal approach to assessment, treatment, and outcome prediction for affected patients.

METHODS

We employed a consensus-building Delphi method to identify and prioritize research questions in the hypospadias field. Additionally, we integrated questions sourced from the artificial intelligence platform ChatGPT to capture multiple perspectives. Engaging a diverse panel of experts including clinicians, researchers, and patient advocates from across the globe, the Delphi process aimed to distill collective expertise and insights through iterative rounds of structured questionnaires and feedback.

RESULTS

The analysis identified key themes in hypospadias research, covering etiology, tissue engineering, pre-clinical models, device/technology evaluation, phenotyping, surgical techniques, surgical training and postoperative outcomes. These themes highlight crucial areas for future investigation to improve understanding of hypospadias, treatment options, and patient outcomes, thereby guiding both research and clinical practice.

DISCUSSION

By harnessing the collective wisdom and perspectives of multiple stakeholders, this Delphi study establishes a roadmap for prioritizing research initiatives to effectively unravel the complexities of hypospadias. Integration of ChatGPT outputs into our Delphi-based approach also outlined how future studies can harness the collective wisdom of human experts together with artificial intelligence methods. The outcomes of this novel endeavor hold promise for shaping future research agendas, informing clinical practice guidelines, and fostering multidisciplinary collaborations to drive innovation and ultimately improve outcomes for hypospadias patients worldwide.

Setting the foundation for a national collaborative learning health system in acute TBI rehabilitation: CARE4TBI Year 1 experience

Introduction

A learning health system (LHS) approach is a collaborative model that continuously examines, evaluates, and re-evaluates data eventually transforming it into knowledge. High quantity of high-quality data are needed to establish this model. The purpose of this article is to describe the collaborative discovery process used to identify and standardize clinical data documented during daily multidisciplinary inpatient rehabilitation that would then allow access to these data to conduct comparative effectiveness research.

Methods

CARE4TBI is a prospective observational research study designed to capture clinical data within the standard inpatient rehabilitation documentation workflow at 15 TBI Model Systems Centers in the US. Three groups of stakeholders guided project development: therapy representative work group (TRWG) consisting of frontline therapists from occupational, physical, speech-language, and recreational therapies; rehabilitation leader representative group (RLRG); and informatics and information technology team (IIT). Over a 12-month period, the three work groups and research leadership team identified the therapeutic components captured within daily documentation throughout the duration of inpatient TBI rehabilitation.

Results

Data brainstorming among the groups created 98 distinct categories of data with each containing a range of data elements comprising a total of 850 discrete data elements. The free-form data were sorted into three large categories and through review and discussion, reduced to two categories of prospective data collection-session-level and therapy activity-level data. Twelve session data elements were identified, and 54 therapy activities were identified, with each activity containing discrete sub-categories for activity components, method of delivery, and equipment or supplies. A total of 561 distinct meaningful data elements were identified across the 54 activities.

Discussion

The CARE4TBI data discovery process demonstrated feasibility in identifying and capturing meaningful high quantity and high-quality treatment data across multiple disciplines and rehabilitation sites, setting the foundation for a LHS coalition for acute traumatic brain injury rehabilitation.

Structured Exercise Program for Hip Arthroplasty: An Expert Consensus Using the Delphi Technique

Background

A structured exercise program following hip arthroplasty for hip fractures is crucial for improving patients' physical function and quality of life. Despite the increasing incidence of hip fractures, there is a dearth of literature on exercise programs for hip arthroplasty performed for fractures. This study aimed to obtain an expert consensus on a structured exercise program for hip arthroplasty patients.

Methods

A literature search was performed in electronic databases such as PubMed, Web of Science, PEDro, and Scopus, and evidence was pooled and formulated into items for the protocol. A three-round, online modified Delphi survey was conducted to validate the results of the framed exercise protocol which included national and international physiotherapy experts as panelists.

Results

In round 1, 59 items about rehabilitation were mailed to the panelists, and 50 items reached a consensus. Round 2 had 19 items, and 13 items reached a consensus. Consensus was sought on items for which the authors disagreed by sending them for review before the next round. In round three, a model exercise program was framed based on the results of previous rounds and was mailed to the panelists for their feedback. Based on their comments and suggestions, the framework of the structured exercise program was finalized.

Conclusions

Based on the results of the Delphi survey, the exercise protocol for hip arthroplasty was framed and validated. The validated exercise program can serve as guidance for physiotherapists in enhancing optimal recovery following hip arthroplasty.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-025-01335-3.

Consensus on Symptom Selection for Endometriosis Questionnaires: A Modified e-Delphi Study

OBJECTIVE

To build consensus on most important symptoms and related consequences for use in questionnaires to characterise individuals with suspected and confirmed endometriosis in the general population.

DESIGN

A questionnaire of 107 symptoms and related consequences of endometriosis was collaboratively developed by patients, medical doctors and researchers and further assessed in a two-round e-Delphi study. Participants assessed the relevance of the symptoms, and a priori it was decided that 70% was the threshold for inclusion of a symptom.

SETTING

Participants represented 7 countries, including Australia, Denmark, France, Hungary, the United Kingdom, the United States, and Turkey.

POPULATION

Individuals with endometriosis, medical doctors and researchers with expertise in endometriosis.

METHODS

A modified e-Delphi study.

MAIN OUTCOME MEASURES

Consensus-based selection of symptoms for endometriosis questionnaires.

RESULTS

Seventy-six participants completed the first Delphi round and 65 completed the second round. Four symptoms met consensus in the first round (menstrual pain, pain during sexual intercourse, cyclic pain during defecation, and infertility), with two additional symptoms reaching consensus in the second round (cyclic pain and increased doctor/health care contacts for abdominal/pelvic pain).

CONCLUSION

This study highlighted six symptoms relevant for inclusion in endometriosis research questionnaires: menstrual pain, pain during sexual intercourse, cyclic pain during defecation, cyclic pain, infertility, and a high number of doctor/health care visits due to abdominal/pelvic pain. Recognising a broad range of potential symptoms is essential for raising awareness and supporting early detection efforts.

Technical skills assessment during simulated cleft lip repair

INTRODUCTION

Cleft lip repair is a challenging procedure with a steep learning curve. A cleft lip simulator can augment the operating experience to shorten the learning curve. This study evaluated the efficacy of a high-fidelity cleft lip simulator using a newly developed cleft lip technical assessment tool.

METHODS

Four plastic surgery residents and 6 fellows performed 3 sequential cleft lip repairs. Three staff surgeons performed 1 cleft lip repair. Each procedure was video recorded and assessed by 3 staff cleft surgeons using a newly developed cleft lip technical assessment scale and a previously developed global rating scale. The reliability (intraclass correlation coefficient [ICC]) of the assessment scores was determined. The first simulation session was compared among participants to determine whether the scales and simulator could distinguish between skill level. Learning curves were determined using successive assessment scores among the trainees.

RESULTS

The average ICC for the cleft lip-specific and global scores were 0.72 (range 0.65-0.82) and 0.70 (range 0.60-0.79), respectively. All scale items demonstrated statistically significant interrater reliability. The staff surgeons significantly outperformed the trainees in the first simulation session for both assessment scores (p < 0.05). The trainees demonstrated improved performance after each session.

CONCLUSIONS

A cleft lip assessment scale was developed and found to be reliable at evaluating technical skill in simulated cleft lip repair. Repeated use of the cleft lip simulator improved performance in simulated cleft lip repair.

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

Background and Objectives

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

Methods

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

Results

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

Discussion

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

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS/FINDINGS

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

CONCLUSIONS

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

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

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

A Delphi consensus project to capture experts' opinion on hyperkalaemia management across the cardiorenal spectrum

The main purpose of this project was to capture experts' opinion on hyperkalaemia management and form best practice recommendations for cardiorenal patients in Greece. A steering committee of nephrologists and cardiologists developed 37 statements. An online questionnaire completed by 32 experts in cardiorenal management in Greece. Median score used to determine the level of agreement and disagreement index (DI) used to determine the level of consensus for each statement. Statements divided in four sectors: hyperkalaemia risk management, preventative measures, treatment and collaboration between specialties. The rate of the first round of the consensus was 94.6%. Median score was >7 for 36 of 37 statements and DI ≤ 1 for 35 of 37. Among other statements, consensus reached for recognizing levels K+ > 5.0 mEq/L as associated with elevated mortality risk; retaining renin-angiotensin-aldosterone system inhibitors (RAASi) on maximum recommended dose for cardiorenal patients; and using novel K+ binders to help enabling guideline-recommended doses of RAASi therapy. Cardiologists compared to nephrologists showed higher reluctance to discontinue down-titrate RAASi and MRA in patients with K+ levels above 5 mEq/L. Additionally, 88.9% of nephrologists and 71.4% of cardiologists agreed that cross-specialty alignment on a serum K+ concentration level (K > 5.5 mEq/L) is needed to initiate hyperkalaemia treatment. Both cardiologists and nephrologists showed disagreement with the statement on keeping titration in cardiorenal patients with K+ > 5.5 mEq/L or preserving fruit and vegetable consumption when moderate or severe hyperkalaemia exhibits. This Delphi project pointed out nephrologists' and cardiologists' agreement on hyperkalaemia management in cardiorenal patients; thus, it can help a cross-specialty optimal management of cardiorenal patients, with hyperkalaemia not being an obstacle for disease-optimizing therapy. Novel potassium binding agents can enable guideline-recommended doses of potassium-sparing medication.

Revitalising traditional Indian games: inclusive game adaptations for children with cerebral palsy

BACKGROUND

Children with cerebral palsy (CP) present unique challenges to physical activity due to various factors. Despite the benefits of inclusive approaches and adapted physical education, low- and middle-income countries face specific barriers including environmental, equipment, personal, policy, social and professional barriers. Traditional Indian games, with their cultural significance and potential therapeutic benefits, offer a promising avenue for inclusive adaptations. At present we couldn't find any studies that explore's the method of adaptation of traditional Indian games for children with cerebral palsy of varying functional levels.

PURPOSE

The aim of the study was to explore the adaptation of traditional Indian games for children with CP of varying functional levels.

METHODS

Traditional Indian games were identified through ethnographic qualitative research, and adapted using the Delphi process involving experts from various fields. A total of 10 traditional games were selected based on their health benefits using an operationalised conceptual model. The CHANGE IT model of adapted physical activity was used to systematically adapt each game. Validation of the model was then performed on children with CP [a smaller sample size, n = 10] with different levels of functioning.

RESULTS

The games varied in playing positions, surfaces and phases. Modifications included changes in game rules, play environment, equipment and time duration. The study validation through informal interview among the parents of CP children revealed that adapted traditional game protocol shown improvements in their children's activity levels and participation.

CONCLUSIONS

While this is a preliminary exploration, no firm conclusion can be drawn. The model presented in this study lays the foundation for future randomised controlled trials to validate the effects of adapted traditional Indian games on children with cerebral palsy of different functional levels.

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

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

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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