Consensus Threshold Research Articles

Guidance for Canadian Breast Cancer Practice: National Consensus Recommendations for Clinical Staging of Patients Newly Diagnosed with Breast Cancer

The accurate staging of breast cancer is fundamental for guiding treatment decisions and predicting patient outcomes. However, there can be considerable variation in routine clinical practice based on individual interpretation of guidelines and depending on the healthcare provider initially involved in working up patients newly diagnosed with breast cancer, ranging from primary care providers, triage nurses, surgeons, and/or oncologists. The optimal approach for clinical staging, particularly in asymptomatic patients presenting with intermediate-risk disease, remains a topic of dialogue among clinicians. Given this area of uncertainty, the Research Excellence, Active Leadership (REAL) Canadian Breast Cancer Alliance conducted a modified Delphi process to assess the level of agreement among Canadian expert clinicians on various staging recommendations. In total, 20 items were drafted covering staging based on biological status, the utilization of localization clips, both for the axilla during diagnosis and primary surgical site for margins and radiation therapy planning, and the use of advanced imaging for the investigation of distant metastases. Overall, the consensus threshold among all participants (i.e., ≥75% agreement) was reached in 20/20 items. Differences in clinical practice and recent findings from the literature are provided in the discussion. These consensus recommendations are meant to help standardize breast cancer staging practices in Canada, ensuring accurate diagnosis and optimal treatment planning.

Consensus-driven protocol for transanal irrigation in patients with low anterior resection syndrome and functional constipation.

This study aims to establish a consensus-based standard protocol for transanal irrigation (TAI) in patients with low anterior resection syndrome (LARS) and functional constipation. The Delphi method was utilized to reach a consensus among clinicians and nurses expert in the field of colorectal surgery and gastroenterology. To address various uncertainties concerning technical aspects, difficulties, and prescription of TAI, two questionnaires were developed and analyzed in two rounds. A binary approach was employed, setting a consensus threshold of 75% agreement. In the first round, nurses achieved consensus on all statements, while clinicians required a second round to reach consensus, particularly regarding prescription and technical aspects. Clinicians reached consensus on prescribing TAI as a second-line treatment for LARS and functional constipation, following the failure of conservative measures such as dietary and lifestyle interventions. Timing considerations for patients with LARS encompass avoiding TAI within 1month of stoma closure and waiting a minimum of 3months. For functional constipation, TAI is recommended for slow transit constipation, emphasizing its preference over surgical options. Consensus was also reached on the choice of catheter for patients with LARS, training requirements for patients and caregivers, preparation of the patient's intestine before TAI, and recommended irrigations. This consensus study successfully developed a standardized TAI protocol for LARS and functional constipation. It provides comprehensive guidelines for prescription and technical aspects, addressing the challenges encountered by healthcare professionals. The protocol aims to enhance patient care, improve treatment outcomes, and contribute to the advancement of TAI.

Asia-Pacific consensus recommendations on the management of generalized pustular psoriasis.

Generalized pustular psoriasis (GPP) is a rare, chronic, heterogeneous, and potentially life-threatening disease characterized by primary, sterile, and macroscopically visible pustules with or without systemic symptoms. There are ethnic differences in the genetic mutations associated with GPP that might affect the clinical manifestations and treatment responses. Currently, there is limited evidence from the patient population in the Asia-Pacific (APAC) region, resulting in a general paucity of information on the effective management of patients with GPP in this region. This modified Delphi panel study aimed to identify current evidence and gain advanced insights to facilitate the development of a regionally tailored APAC consensus on the management of GPP. A systematic literature review (SLR) was conducted to identify published literature and develop consensus statements on (i) definition and clinical course, (ii) diagnosis of GPP, (iii) treatment outcomes, goals, and monitoring measures, and (iv) optimal management strategies and clinical practices. Statements were rated by a panel of dermatologists in two rounds, with the threshold for consensus at ≥80% agreement. Twenty experts from the APAC region reached consensus on 106 statements that were developed based on the SLR and experts' collective expertise. The experts agreed that GPP is a rare, severe, and potentially life-threatening condition that is distinct from plaque psoriasis. This consensus emphasized the importance of a tailored treatment strategy taking into account the GPP flare severity and each patient's unique clinical circumstances. The experts reached consensus on the severity classification of GPP flares and recommended first-line and maintenance treatment options for adult GPP, childhood GPP, and GPP in pregnancy. These consensus outcomes have been synthesized into treatment algorithms to guide dermatologists in the APAC region in their clinical decision-making processes.

Optimal planning and management strategies for minimally invasive lung segmentectomies: an international Delphi consensus report.

CALGB140503/JCOG0802 RCTs comparing lobectomy with sublobar resection in stage IA NSCLC have confirmed the non-inferiority of segmentectomy. Additional insight is needed to improve preoperative work-up and intraoperative strategies to increase safety and promote the dissemination of minimally invasive segmentectomy (MIS). A Delphi panel study assessed the level of consensus among surgeons for the planning and management of MIS. Twenty-one expert lung surgeons represented academic institutions, major teaching hospitals, and community hospitals from Europe, North America, and Asia. A 3-round Delphi methodology was used to analyse the answers of each panellist. Recognizing that questions with fewer response options have a higher consensus probability due to limited variability, weighted consensus thresholds were modified based on the number of response options. The 21 panellists responded to all 3 rounds of questions. Based on the most robust consensus (94.4%), 3D chest CT reconstructions are recommended only when planning complex segmentectomies. Surgeons should perform 3D reconstructions chest CT scans (consensus = 83.3%). The most effective and safest technique is image-guided VATS in a hybrid operating room (consensus = 83.3%). Dyes with intravenous administration are the safest technique for identifying the intersegmental plane during MIS (consensus = 72.2%). Augmented/mixed reality will probably not immediately help reduce perioperative complications (consensus = 72.2%). This Delphi consensus supports 3D reconstructions and preoperative pulmonary nodule localization before complex MIS. These recommendations should be considered when allocating resources to improve MIS's safety and oncologic efficacy for patients with small, early-stage lung cancers.

Development of theoretical framework and digital competence assessment checklist (DCAC) for nursing students

BackgroundThe rapid development of digital technology impacts all aspects, including nursing education. Nursing programs are tasked with equipping graduates with both clinical skills and digital competence. However, inconsistencies in the conceptual understanding of digital competence in nursing literature, underscore the need to refine the concept. DesignThis study involved two phases including a modified Delphi approach and psychometric testing. In Phase 1, the panel of experts in nursing was invited to evaluate the theoretical framework, domain, and item of assessment checklist. In Phase 2, the psychometric properties of the assessment checklist were tested using a quantitative survey. SettingThe study was conducted in Taiwan, Indonesia, and Vietnam. ParticipantParticipants included 12 nursing experts from Taiwan, Indonesia, and Vietnam during the development phase and 417 nursing students from these countries in the validation phase. MethodsPhase 1 utilized a modified Delphi approach establishing a theoretical framework and assessment checklist. Experts provided feedback on a Likert scale, aiming for consensus. Phase 2 involved a quantitative survey where graduate nursing students rated the DCAC. The analysis process following the recommendation of the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN). ResultsThe theoretical framework defined digital competence across four domains. In the first Delphi round, all items were rated above the consensus threshold. After two rounds, the CVI ranged from .8 to 1.0, suggesting strong agreement among experts. The second phase revealed high discriminant validity among survey items, with Cronbach's alpha indicating high internal consistency. The refined 22-item DCAC showed improved fit indices, confirming the assessment checklist's structure. ConclusionThe developed 22-item DCAC is a valid and reliable tool for measuring digital competence among nursing students. Integration of digital competence into nursing education is essential for preparing students to excel in the healthcare environment.

Critical Steps for Determining Capacity to Refuse Emergency Medical Services Transport: A Modified Delphi Study

ABSTRACT OBJECTIVES Emergency physicians without specialized Emergency Medical Services (EMS) training are often required to provide online medical oversight. One common ethical question faced by these physicians is the assessment for decision-making capacity in a patient who does not accept EMS transport to the hospital. We sought expert consensus for a standardized set of guiding questions and recommendations to ensure a rigorous and feasible capacity assessment. METHODS A modified Delphi method approach was used to achieve group consensus among expert individuals. Nineteen physician experts were recruited from across the country, representing populations totaling over 22 million and a variety of urban, suburban, and rural practice environments. Experts completed a Round 1 survey that included 19 questions surrounding best practices for capacity evaluation among patients refusing transport. The threshold for consensus was predefined as 80% agreement. Participants gathered virtually meeting where the results from the first round were shared with the group. Discussion generated new items and refined the language of existing items. Following the virtual meeting, a Round 2 survey was conducted, and voted on by the panel for the items that did not meet consensus in Round 1. RESULTS After the first round, 15 of 19 items reached consensus. Three of the items that met consensus were universally noted to require language modification for clarification. A large portion of the discussion involved the proper method of integrating patient concerns around ambulance transport (e.g., cost of transport, financial concerns, social barriers) into the capacity assessment and whether alternate care options should be discussed. After the second round of voting, one additional item was reversed to meet consensus, resulting in a total of 16 items. CONCLUSIONS A consensus expert panel was able to agree upon 16 standardized steps to guide best practices and assist emergency physicians in real-time evaluation of patients that refuse EMS transport.

Validity of a Smartphone App to Objectively Monitor Performance Outcomes in Degenerative Cervical Myelopathy: Preliminary Findings From a Longitudinal Observational Study

Background Developing new clinical measures for degenerative cervical myelopathy (DCM) is an AO Spine RECODE-DCM research priority. Difficulties detecting DCM, and changes in DCM, cause diagnostic and treatment delays in clinical settings and heightened costs in clinical trials due to elevated recruitment targets. Digital outcome measures can tackle these challenges due to their ability to measure disease remotely, repeatedly, and more economically. Objective The study aims to assess the validity of MoveMed, a battery of performance outcome measures performed using a smartphone app, in the measurement of DCM. Methods A prospective observational study in decentralized secondary care was performed in England, United Kingdom. Validity and risk of bias were assessed using criteria from the COSMIN (Consensus-Based Standards for the Selection of Health Measurement Instruments) manual. Each MoveMed outcome was compared with 2 patient-reported comparators, with a priori hypotheses of convergence or divergence tested against consensus thresholds. The primary outcome was the correlation coefficient between the MoveMed outcome and the patient-reported comparators. The secondary outcome was the percentage of correlations that aligned with the a priori hypotheses. The comparators used were the patient-derived modified Japanese Orthopaedic Association score and the World Health Organization Quality of Life Brief Version questionnaire. Thresholds for convergence or divergence were set at ≥0.3 for convergence, <0.3 for divergence, and >0/<0 for directionality. Results A total of 27 adults aged 60 (SD 11) years who live with DCM and possess an approved smartphone were included in a preliminary analysis. As expected, MoveMed tests of neuromuscular function correlated most with questionnaires of neuromuscular function (≥0.3) and least with questionnaires of quality of life (<0.3). Furthermore, directly related constructs correlated positively to each other (>0), while inversely related constructs correlated negatively (<0). Overall, 74% (67/90) and 47% (8/17) of correlations (unidimensional and multidimensional, respectively) were in accordance with hypotheses. No risk-of-bias factors from the COSMIN Risk of Bias checklist were recorded. Overall, this was equivalent to “very good” quality evidence of sufficient construct validity in DCM. Conclusions MoveMed outcomes and patient-reported questionnaires converge and diverge in accordance with expectations. These findings support the validity of the MoveMed tests in an adult population living with DCM. Criteria from COSMIN provide “very good” quality evidence to support this.

Development of an evidence-based nursing practice course framework for undergraduate nursing students from a perspective of academic-practice partnerships: A Delphi study

AimTo develop an evidence-based nursing practice course framework for undergraduate nursing students from a perspective of academic-practice partnerships. BackgroundAcademic-practice partnerships could play a crucial role in bridging theory-practice gap in evidence-based nursing education. However, there is a lack of evidence-based nursing practice course framework for undergraduate nursing students from a perspective of academic-practice partnerships. DesignA Delphi study. MethodsThe Delphi study was conducted by literature analysis, qualitative interview and Delphi expert consultation to develop this course framework. 15 and 12 experts were involved in round one and round two of Delphi expert consultation, respectively. The consensus threshold of two-round Delphi expert consultation was described by expert's positive coefficient (≥ 50 %), positive coefficient (≥ 70 %), expert authority coefficient (≥ 0.7), coefficient of variation (<0.25) and full score frequency (>20 %). ResultsThe final course framework includes learning objectives (17 items); teaching chapters of theoretical classes (five items); teaching contents (30 items), methods (12 items) and class hours (9 items) of theoretical classes; and the responsibilities of academic teachers (11 items) and clinical teachers (11 items) in practical classes. ConclusionThe course framework developed by this study could provide guidance for evidence-based nursing education of undergraduate nursing students. The effectiveness of this course framework should be verified through further experimental studies in the future.

Preferences for Text Messaging Supports During Youth Transition to Adult Mental Health Services: Theory-Informed Modified e-Delphi Study.

For many young people, the transition from child to adult mental health services is a vulnerable time associated with treatment disengagement and illness progression. Providing service information and options to youth, appealing to them, and tailoring to their needs during this period could help overcome systematic barriers to a successful transition. We know little about how SMS text message-based interventions might be leveraged to support the motivational, informational, and behavioral needs of youth during this time. Ascertaining youth preferences for the content and functionality of an SMS text message service could inform prototype development. This study investigated consensus preferences among youth on important content, technology features, and engagement supports to inform a transition-focused SMS text message service. A modified e-Delphi survey design was used to collect demographics, current levels of technology use, importance ratings on message content, preferred technical features, and barriers and enablers to engagement for youth in Canada aged 16-26 years who have accessed mental health services within the past 5 years. Survey items on content were categorized according to the information-motivation-behavioral skills (IMB) model. Survey items on technical features were categorized according to the persuasive system design (PSD) model. A predefined consensus rating matrix and descriptive statistics were used to characterize the sample. The high consensus threshold was 70%. A total of 100 participants, predominantly non-White (n=47, 47%), aged 20-26 years (n=59, 59%), and who had first accessed mental health services between the ages of 13 and 19 years (n=60, 60%), were selected. The majority (n=90, 90%) identified as daily SMS text message users. A high level of consensus on importance ratings was reported in 45% (9/20) of content items based on the IMB model. There were higher levels of consensus on importance ratings related to behavior domain items (3/3, 100%) than information domain items (4/9, 44%) or motivation domain items (2/8, 25%). A high level of consensus on importance ratings was reported in only 19% (4/21) of feature and functionality items based on the PSD model. Among PSD model categories, there was a high level of consensus on importance ratings in 8% (1/12) of the primary task support domain items and 100% (3/3) of the system credibility support domain items. None of the dialogue-support and social-support domain items met the high level of consensus thresholds. In total, 27% (27/100) of youth indicated that the most significant enabler for engaging with a transition-focused SMS text message intervention was the personalization of text messages. Scientists developing next-generation SMS text messaging interventions for this population need to consider how levels of consensus on different features may impact feasibility and personalization efforts. Youth can (and should) play an integral role in the development of these interventions.

Publisher preferences for a journal transparency tool: A modified three-round Delphi study

Background We propose the creation of a journal transparency tool (JTT), which will allow users to obtain information about a given scholarly journal’s operations and policies. We are obtaining preferences from different stakeholders to inform the development of this tool. This study aimed to identify the publishing community’s preferences for the JTT. Methods We conducted a modified three-round Delphi survey. Representatives from publishing houses and journal publishers were recruited through purposeful and snowball sampling. The first two Delphi rounds involved an online survey with items about JTT metrics and user features. During the third round, participants discussed and voted on JTT metric items that did not reach consensus after round 2 within a virtual consensus meeting. We defined consensus as 80% agreement to include or exclude an item in the JTT. Results Eighty-six participants completed the round 1 survey, and 43 participants (50% of round 1) completed the round 2 survey. In both rounds, respondents voted on JTT user feature and JTT metric item preferences and answered open-ended survey questions regarding the JTT. In round 3, a total of 21 participants discussed and voted on JTT metric items that did not reach consensus after round 2 during an online consensus group meeting. Fifteen out of 30 JTT metric items and none of the four JTT user feature items reached the 80% consensus threshold after all rounds of voting. Analysis of the round 3 online consensus group transcript resulted in two themes: ‘factors impacting support for JTT metrics’ and ‘suggestions for user clarity.’ Conclusions Participants suggested that the publishing community’s primary concerns for a JTT are to ensure that the tool is relevant, user-friendly, accessible, and equitable. The outcomes of this research will contribute to developing and refining the tool in accordance with publishing preferences.

Dynamic trust network-driven consensus modeling with endogenous adjustment and exogenous modification under a quasi-Z-number environment

The Z-number is widely used in decision-making because of its unique dual ability to capture human knowledge and facilitate judgments on realistic issues. To improve the applicability of Z-numbers, this paper puts forward the concept of quasi-Z-number and studies the social network and consensus models with quasi-Z-information to address multi-attribute group decision-making problems. First, a dynamic trust network among decision makers (DMs) is constructed. The endogenous adjustment mechanism is presented due to the interaction among DMs. Second, a feedback mechanism for non-consensus opinions is established. In the feedback, an exogenous modification mechanism is constructed through the minimal modification consensus model to help non-consensus DMs improve their consensus level. Furthermore, a minimum tolerance increment consensus model is proposed to cope with the situation where the consensus threshold is not reached within a specified number of iterations. Third, the practicability of the proposed decision-making system is illustrated by the case of a green energy investment in which all technicalities are shown. Its comprehensive performance is exhibited in the sensitivity analysis. The validity of the information form and methodology is demonstrated in the comparative analysis.

Early major fracture care in polytrauma-priorities in the context of concomitant injuries: A Delphi consensus process and systematic review.

The timing of major fracture care in polytrauma patients has a relevant impact on outcomes. Yet, standardized treatment strategies with respect to concomitant injuries are rare. This study aims to provide expert recommendations regarding the timing of major fracture care in the presence of concomitant injuries to the brain, thorax, abdomen, spine/spinal cord, and vasculature, as well as multiple fractures. This study used the Delphi method supported by a systematic review. The review was conducted in the Medline and EMBASE databases to identify relevant literature on the timing of fracture care for patients with the aforementioned injury patterns. Then, consensus statements were developed by 17 international multidisciplinary experts based on the available evidence. The statements underwent repeated adjustments in online- and in-person meetings and were finally voted on. An agreement of ≥75% was set as the threshold for consensus. The level of evidence of the identified publications was rated using the GRADE approach. A total of 12,476 publications were identified, and 73 were included. The majority of publications recommended early surgery (47/73). The threshold for early surgery was set within 24 hours in 45 publications. The expert panel developed 20 consensus statements and consensus >90% was achieved for all, with 15 reaching 100%. These statements define conditions and exceptions for early definitive fracture care in the presence of traumatic brain injury (n = 5), abdominal trauma (n = 4), thoracic trauma (n = 3), multiple extremity fractures (n = 3), spinal (cord) injuries (n = 3), and vascular injuries (n = 2). A total of 20 statements were developed on the timing of fracture fixation in patients with associated injuries. All statements agree that major fracture care should be initiated within 24 hours of admission and completed within that timeframe unless the clinical status or severe associated issues prevent the patient from going to the operating room. Systematic Review/Meta-Analysis; Level IV.

Social network group decision-making method based on stochastic multi-criteria acceptability analysis for probabilistic linguistic term sets

In social network group decision-making (SNGDM) problems, decision-makers (DMs) often express their opinions or preferences using probabilistic linguistic term sets (PLTSs). In this paper, a novel SNGDM method for probabilistic linguistic information is proposed. Firstly, to obtain the prioritization of DMs in the clustering process, a DM clustering method for SNGDM is developed considering the influence of trust relationships and opinions similarity among DMs. Then, to satisfy the requirements of the consensus reaching process in SNGDM, a dynamic consensus threshold calculation method based on an optimization model is introduced. Furthermore, in the consensus measure stage, a novel consensus measure method for both DMs and subgroups is proposed, using a stochastic multi-criteria acceptability analysis (SMAA) method. Based on the consensus measure method, a novel SNGDM method based on SMAA for PLTSs is proposed. Finally, a case study of service quality evaluation in institutional pensions is used to illustrate the effectiveness of the proposed method. The results of case show that the proposed method can adjust consensus thresholds dynamically based on each round of collective opinions, and can solve the SNGDM problems when DMs can not provide their preferences for criteria weights.

An international delphi survey and consensus meeting to define the risk factors for ureteral stricture after endoscopic treatment for urolithiasis.

Iatrogenic ureteral strictures (US) after endoscopic treatment for urolithiasis represent a significant healthcare concern. However, high-quality evidence on the risk factors associated with US is currently lacking. We aimed to develop a consensus statement addressing the definition, risk factors, and follow-up management of iatrogenic US after endoscopic treatment for urolithiasis. Utilizing a modified Delphi method, a steering committee developed survey statements based on a systematic literature review. Then, a two-round online survey was submitted to 25 experts, offering voting options to assess agreement levels. A consensus panel meeting was held for unresolved statements. The predetermined consensus threshold was set at 70%. The steering committee formulated 73 statements. In the initial survey, consensus was reached on 56 (77%) statements. Following in-depth discussions and refinement of 17 (23%) statements in a consensus meeting, the second survey achieved consensus on 63 (86%) statements. This process underscored agreement on pivotal factors influencing US in endoscopic urolithiasis treatments. This study provides a comprehensive list of categorized risk factors for US following endoscopic urolithiasis treatments. The objectives include enhancing uniformity in research, minimizing redundancy in outcome assessments, and effectively addressing risk factors associated with US. These findings are crucial for designing future clinical trials and guiding endoscopic surgeons in mitigating the risk of US.

Recommendations for Implementing the INTERACT3 Care Bundle for Intracerebral Hemorrhage in Latin America: Results of a Delphi Method

Introduction: The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT3) showed that the implementation of a care bundle improves outcomes after acute intracerebral hemorrhage (ICH). We aimed to establish consensus-based recommendations for the broader integration of the care bundle across Latin American countries (LAC). Methods: A 3-phase Delphi study allowed a panel of 32 healthcare workers from 14 LAC to sequentially rank statements relevant to 7 domains (training, resources/infrastructure, patient education, blood pressure, temperature, glycemic control, and anticoagulation reversal). The pre-defined consensus threshold was 75%. Results: A total of 43 statements reached consensus by the third round, with 12 new statements emerging through rounds. The highest-ranked statements in each domain emphasized critical aspects, but successful implementation requires appropriate resourcing. Key priorities were continuous training of all healthcare workers in ICH management, establishing protocols aligned with available resources, and collaborative interdisciplinary care supported by institutional networks. Statements related to anticoagulation reversal had the highest priority. Conclusions: Consensus statements are provided to facilitate integration of the INTERACT3 care bundle to reduce disparities in ICH outcomes in LAC.

Pathogen prioritisation for wastewater surveillance ahead of the Paris 2024 Olympic and Paralympic Games, France.

BackgroundWastewater surveillance is an effective approach to monitor population health, as exemplified by its role throughout the COVID-19 pandemic.AimThis study explores the possibility of extending wastewater surveillance to the Paris 2024 Olympic and Paralympic Games, focusing on identifying priority pathogen targets that are relevant and feasible to monitor in wastewater for these events.MethodsA list of 60 pathogens of interest for general public health surveillance for the Games was compiled. Each pathogen was evaluated against three inclusion criteria: (A) analytical feasibility; (B) relevance, i.e. with regards to the specificities of the event and the characteristics of the pathogen; and (C) added value to inform public health decision-making. Analytical feasibility was assessed through evidence from peer-reviewed publications demonstrating the detectability of pathogens in sewage, refining the initial list to 25 pathogens. Criteria B and C were evaluated via expert opinion using the Delphi method. The panel consisting of some 30 experts proposed five additional pathogens meeting criterion A, totalling 30 pathogens assessed throughout the three-round iterative questionnaire. Pathogens failing to reach 70% group consensus threshold underwent further deliberation by a subgroup of experts.ResultsSix priority targets suitable for wastewater surveillance during the Games were successfully identified: poliovirus, influenza A virus, influenza B virus, mpox virus, SARS-CoV-2 and measles virus.ConclusionThis study introduced a model framework for identifying context-specific wastewater surveillance targets for a mass gathering. Successful implementation of a wastewater surveillance plan for Paris 2024 could incentivise similar monitoring efforts for other mass gatherings globally.

Real-world service costs for neovascular-AMD clinics in the United Kingdom: structured literature review and scenario analysis

Objective Current cost-effectiveness analyses (CEA) emphasize drug costs as the differentiator between NICE recommended anti-VEGF treatments but may neglect real-world non-drug costs of running nAMD services in the UK. To address this, this study identified real-world non-drug service cost items relevant to UK NHS nAMD clinics, including costs arising from operational strain (demand exceeding capacity). Methods Cost items were identified by a structured literature review of peer-reviewed and grey literature, and an expert panel of 10 UK-based ophthalmologists with relevance to real-world practice. These items underwent meta-synthesis and were then determined in a consensus exercise. Results Of 237 cost items identified, 217 (91.6%) met the consensus threshold of >0.51 and were included in the nAMD Service Non-Drug Cost Instrument (nAS). Sensitivity of cost items taken from UK Health Technology Assessment (HTA) using the nAS as the reference standard was low (HTAmin: 1.84%, 95% CI 0.50–4.65%; HTAmax: 70.51%, 95% CI 63.96–76.49%). False negative rates showed variable likelihood of misclassifying a service by cost burden depending on prevalence. Scenario analysis using cost magnitudes estimated annual per-patient clinic cost at £845 (within capacity) to £13,960 (under strain) compared to an HTAmin estimate of £210. Accounting for cost of strain under an assumed 50% increase in health resource utilization influenced cost-effectiveness in a hypothetical genericisation scenario. Conclusion Findings suggested that HTA underestimates UK NHS nAMD clinic cost burden with cost of strain contributing substantial additional unmeasured expense with impact on CEA. Given potential undertreatment due to strain, durability is suggested as one of the relevant factors in CEA of nAMD anti-VEGF treatments due to robustness under limited capacity conditions affecting UK ophthalmology services.

Best practice for the selection, design and implementation of UK Kidney Association guidelines: a modified Delphi consensus approach

BackgroundDespite research into how to effectively implement evidence-based recommendations into clinical practice, a lack of standardisation in the commissioning and development of clinical practice guidelines can lead to inconsistencies and...

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

Evidence-based practice (EBP) results in high-quality care and decreases unwarranted variation in practice. Few performance criteria related to EBP are included in physical therapy clinical education (CE) performance measures, despite EBP requirements in Doctor of Physical Therapy education. The purpose of this study was to develop EBP-specific competencies that may be used for Doctor of Physical Therapy students for use throughout CE. Thirteen subject matter experts (SME) participated in this study. Subject matter experts were asked to rank each core EBP competency, from a previously described framework, using a 3-point Likert scale, which included "Not Essential," "Essential," and "Not Sure." A consensus of 70% or greater for the "Essential" rating advanced the competency to the final Delphi round, whereas a consensus of 70% or greater for the "Not Essential" rating was required for competency elimination. Subject matter experts voted to either "Accept" or "Modify" the competencies that had reached the inclusion consensus threshold. All competencies that reached consensus for inclusion after all 3 rounds were included in the final EBP Domain of Competence. Consensus was achieved in round one for 38% (n = 26) of items. In round 2, a consensus was achieved for 20% (n = 8) of items. Of the items remaining after rounds 1 and 2, 6 overarching competencies were identified, and all remaining items served as descriptions and specifications in the final EBP Domain of Competence. The 6 competencies developed from this study constitute the EBP Domain of Competence and may be used throughout CE to assess students' EBP competency in clinical practice.

The Clinical Definition of Children With Medical Complexity: A Modified Delphi Study.

Children with medical complexity (CMC) comprise a subgroup of children with severe chronic diseases. A conceptual definition for CMC has been formulated, but there is no agreement on criteria to fulfill each of the 4 proposed domains: diagnostic conditions, functional limitations, health care use, and family-identified needs. Our objective with this study was to identify a standardized definition of CMC. Through a scoping review of the CMC literature, we identified potential criteria to fulfill each domain. These were incorporated into an electronic survey that was completed by a geographic and professionally varied panel of 81 American and Canadian respondents with expertise in managing CMC (response rate 70%) as part of a 4-iteration Delphi procedure. Respondents were asked to vote for the inclusion of each criterion in the definition, and for those with quantitative components (eg, hospitalization rates), to generate a consensus threshold value for meeting that criterion. The final criteria were analyzed by a committee and collapsed when situations of redundancy arose. Of 1411 studies considered, 132 informed 55 criteria for the initial survey, which was presented to 81 respondents. Consensus for inclusion was reached on 48 criteria and for exclusion on 1 criterion. The committee collapsed those 48 criteria into 39 final criteria, 1 for diagnostic conditions, 2 for functional limitations, 13 for health care use, and 23 for family needs. These results represent the first consensus-based, standardized definition of CMC. Standardized identification is needed to advance understanding of their epidemiology and outcomes, as well as to rigorously study treatment strategies and care models.