Delphi Survey Of Experts Research Articles

The benefits and harms of open notes in mental health: A Delphi survey of international experts.

As of April 5, 2021, as part of the 21st Century Cures Act, new federal rules in the U.S. mandate that providers offer patients access to their online clinical records. To solicit the view of an international panel of experts on the effects on mental health patients, including possible benefits and harms, of accessing their clinical notes. An online 3-round Delphi poll. Online. International experts identified as clinicians, chief medical information officers, patient advocates, and informaticians with extensive experience and/or research knowledge about patient access to mental health notes. An expert-generated consensus on the benefits and risks of sharing mental health notes with patients. A total of 70 of 92 (76%) experts from 6 countries responded to Round 1. A qualitative review of responses yielded 88 distinct items: 42 potential benefits, and 48 potential harms. A total of 56 of 70 (80%) experts responded to Round 2, and 52 of 56 (93%) responded to Round 3. Consensus was reached on 65 of 88 (74%) of survey items. There was consensus that offering online access to mental health notes could enhance patients' understanding about their diagnosis, care plan, and rationale for treatments, and that access could enhance patient recall and sense of empowerment. Experts also agreed that blocking mental health notes could lead to greater harms including increased feelings of stigmatization. However, panelists predicted there could be an increase in patients demanding changes to their clinical notes, and that mental health clinicians would be less detailed/accurate in documentation. This iterative process of survey responses and ratings yielded consensus that there would be multiple benefits and few harms to patients from accessing their mental health notes. Questions remain about the impact of open notes on professional autonomy, and further empirical work into this practice innovation is warranted.

Management of women with pregnancy-related pelvic girdle pain: an international Delphi study

ObjectivesPregnancy-related pelvic girdle pain (PPGP) contributes to significant prenatal and postpartum impairments; however, various clinical practices exist around the conservative treatment of this condition. This study sought to reach a consensus on the essential components of PPGP management through an international Delphi survey of experts in women's health. Design and participantsEighty-seven international experts in the field of PPGP were invited to participate and surveyed over three rounds. Round 1 of the survey utilised open-ended questions to gain feedback on 16 components of PPGP management previously identified by a focus group. Feedback from panel members guided modification and refinement of questions for Rounds 2 and 3. A 5-point Likert scale was used to rate level of agreement, with a minimum threshold for consensus of ≥75% agreement set across all survey rounds. ResultsForty-four of the 87 (50%) invited professionals agreed to participate in the panel, with 77% (34/44) of panellists contributing to all three rounds. Of the 16 initial components, 15 were included in Round 2. The final consensus was reached on 10 important components of assessment and management after Round 3: pain education, postural and ergonomic advice, social and lifestyle factors, psychological factors, cultural considerations, strengthening exercise, other exercise, exercise precautions, manual therapy and the use of crutches. ConclusionThis study identified 10 key components that should be considered in the management of PPGP. In addition, these components provide a potential framework for future research around the conservative management of PPGP.

Development of a competency model for general practitioners after standardized residency training in China by a modified Delphi method

BackgroundThe “5 + 3” residency training is the main stream general practitioner training program in China. However, a competency model is absent for evaluating the clinical competence attained by general practitioners after training. This study was conducted to develop a consensus set of competencies for general practitioners after standardized residency training in China.MethodsA modified Delphi process was deployed to develop the competency model, including two stages: (1) generation of an initial set of competencies derived from literature review, behavioral observation of GP–patient consultations, and critical incidents interview of GPs; (2) a 2-round, web-based Delphi survey of experts in general practice, selected using purposive sampling, to prioritize and gain consensus on the essential competencies of GPs.ResultsFrom literature review, behavioral observation, and critical incidents interview, 46 competencies in 7 domains were identified. After two rounds of Delphi survey of 28 participants (the mean age was 47.9 [9.3] years and 64.3% were women) representing a range of health professionals (GPs, managers, and researchers), a consensus was reached on 50 competencies categorized into 7 domains.ConclusionA consensus-based competency model for general practitioners in China has been identified which may be used to evaluate the general practitioners’ clinical competence after standardized training.

Development of the elderly lifestyle profile: A Delphi survey of multidisciplinary health care experts

AbstractBackgroundLifestyle has been considered as a crucial key factor which effect on one's health and quality of life and it has become a focus of increasing research interest worldwide. As research shown that lifestyle is reconsidered an important health determinant in preventive health care. However, lifestyle is a multifaceted construct and there was a limited evident regarding lifestyle assessment which is able to evaluate individual's multi‐domain lifestyle factors. This study attempt to develop evaluation items used to measure a multifaceted lifestyle profile for community‐dwelling elders in order to prevent chronic disease and improve their health and quality of life.MethodOpinions from 21 Delphi panels who have experience with elderly and lifestyle research were collected from December 2019 to January 2020. A Delphi survey was carried out three times, and based on previous research. The first Delphi survey gathered opinions using a mix of open‐ended questions and closed‐ended questions reconstructed regarding the evaluation items of elderly's multifaceted lifestyle profile. The second Delphi survey was conducted after the processes of deleting and modifying several items based on the first Delphi survey. In the third Delphi survey after the results of second Delphi survey were presented to expert panels, final opinions from experts were converged. Ethics approval was granted by the Yonsei University(YUWIRB‐1041849‐201901‐BM‐012‐01)Result65 items were selected as the first Delphi results, and as the second Delphi result, 62 items were analyzed after the processes of deleting and modifying the values below a content validity ratio of .42. Finally, in the third Delphi survey, 62 items were analyzed as appropriate items. The average content validity ratio of the final Delphi survey was .92 stability .18, and consensus .80, which were highConclusionThis study verified the content validity of the evaluation items for community‐dwelling older' multifaceted lifestyle profile. In the future, it is expected that through verifying validity and reliability, there will be used as a standardized assessment tool in the clinical environment.

Development of the Korean Community Health Determinants Index (K-CHDI).

This study developed and validated a Korean community health determinants index (K-CHDI), which can be used to assess the health status of the community. To develop composite indicators, we followed the guidelines of the Joint Research Centre of the Organization for Economic Cooperation and Development. We reviewed previous studies and formed a theoretical framework to systematize our domains and indicators, which were decided through a Delphi survey of healthcare experts. Data on indicators were obtained from the Korean Statistics and Community Health Survey. We applied the Min-Max normalization method and measured weights by the analytic hierarchy process. Health outcomes were estimated using mortality, years of life lost, years lived with disability, and disability-adjusted life years by standardizing sex and age. The value of the index is between 0 and 1; higher values indicate more positive health determinants. K-CHDI for 250 subnational regions (cities, counties, and districts, or Si·Gun·Gu) were correlated with health outcomes. The correlation coefficient was stronger in large cities than in medium-sized areas and small areas, and the higher the K-CHDI group, the higher the coefficient. The K-CHDI represents a reference standard for estimating health status using health determinants as composite indicators at the subnational level.

Valuing public transport customer experience infrastructure–A review of methods & application

One of the most significant contemporary trends in public transport systems internationally has been the refocussing of planning and operations on improving the customer experience. This has been matched by the work of transport economists who have been advancing the field of economic appraisals using willingness to pay methodologies to place a value on customer experience infrastructure so as to better represent customer valuation of these amenities in project evaluation. This paper provides an international review of this field by reporting on a major international research program on this topic. The first phase of the program assembled the results of over 500 valuations to assess the general range and values for a range of amenity infrastructure including Information, Environment, Access, Customer Facilities and Security amenities. Values were normalized between currencies of the countries where they were measured and adjusted to create present value estimates. The second phase of the program sought to understand authority practices in using customer experience infrastructure valuations in practice using a survey of 12 cities in Australia, Europe, North America and Asia. This established patterns of use by breadth of modes evaluated, types of methods used and the degree of sophistication which valuations were undertaken. The third and final phase of the research program involved an international expert Delphi survey of researchers and practitioners involved in measuring values of customer experience infrastructure. The main focus of the expert survey was problems and issues in measurement methods and best practices in approaches to measurement. The paper presents an overview of all the phases of the research program and provides a view on best practices for industry in providing methods and estimates for valuing customer amenities in public transport into the future.

Towards a Revised Conceptualization and Theorization of Lean Supply Management

We present a novel conceptualization and theorization of lean supply management (LSM) that captures contextually specific supply challenges that firms face in fulfilling their LSM performance objectives and their contingent association with specific lean practices. We illustrate the practical relevance and application of our contextual contingent LSM conceptualization using a Delphi survey of Canadian agri-food experts to examine what specific supply challenges and lean pillars are associated with pursued LSM performance objectives, and explore what lean supply management means from a practitioner’s perspective. The theorization underlying this study’s novel LSM conceptualization is rooted in insights emanating from tenets of the practice-based view.

Development of an elderly lifestyle profile: A Delphi survey of multidisciplinary health-care experts.

Lifestyle is considered as a key factor that affects one's health and quality of life, and it has become the focus of increasing research interest worldwide. Research has shown that lifestyle is an important health determinant in preventive health care. However, lifestyle is a multifaceted construct and there is limited evidence regarding lifestyle assessment, which evaluates individuals' multi-domain lifestyle factors. This study developed evaluation items for measuring the multifaceted lifestyle profile of community-dwelling older adult to prevent chronic disease and improve their health and quality of life. Opinions from 21 experts with experience in older adults and lifestyle research were collected from December 2019 to January 2020. Three Delphi surveys were carried out, based on previous research. The first survey gathered opinions using a mix of open- and closed-ended questions regarding items of the older adults' multifaceted lifestyle profile. The second was conducted after adding and modifying several items based on the first Delphi survey. In the third survey, after the results of the second one were presented to the expert panels, final opinions from the experts were converged. In total, 59 items were selected as the first Delphi results; 62 items were selected as the second results after adding and modifying the values below a content validity ratio of .42; and 62 items were selected as the third Delphi results. The average content validity ratio of the final Delphi survey was .92, the stability was .18, and the consensus was .80, which were all high. This study verified the content validity of the evaluation items for community-dwelling older adults' multifaceted lifestyle profile. In the future, it is expected that after verifying the validity and reliability, this will be used as a standardized assessment tool in clinical environments.

Development of an Assessment Tool for the Sustainability of Community Housing : Using expert Delphi survey

The purpose of this study was to develop a sustainability assessment tool for community housing, which shows the potential of a new dwelling culture, so that it can be established with persistence. For the research method, Delphi survey was conducted three times based on preliminary assessment items derived from previous studies. The developed assessment tool consists of the final three fields, 10 areas and 35 items. The fields are derived from three fields: social, economic and physical & environmental sustainability. The social sustainability field consisted of community space, community activities, community operations and sense of community areas, while the economic sustainability field consisted of appropriate housing expenses and sharing economy areas. Finally, the physical & environmental sustainability field consisted of areas of location and transportation, spatial planning, spatial comfort, maintenance and management. Final assessment tools put the most weight on the social sustainability field, and in the physical & environmental sectors, many items were derived from the physical space side rather than the environmental side. As such, the assessment tools were approached from a differentiated perspective that reflected the characteristics of the community housing, beyond the existing items and systems for assessing sustainability.

What Research Questions Should the Next Generation of Birth Cohort Studies Address? An International Delphi Study of Experts.

Birth cohort studies (BCS) have generated a wealth of invaluable basic scientific and policy-relevant information on a wide range of issues in child health and development. This study sought to explore what research questions are currently a priority for the next generation of BCS using a 3-round Delphi survey of interdisciplinary experts. Twenty-four (Round I, N=17; Round II, N=21; Round III, N=18) experts across a wide range of fields (eg, psychology, public health, and maternal/child health) agreed to participate. In Round I, the expert panel was invited to freely respond to the question, "what are the key scientific questions future birth cohort studies should address?" Content analysis of answers was used to identify 47 questions for rating on perceived importance by the panel in Round II and consensus-achieving questions were identified. Questions that did not reach consensus in Round II were posed again for expert re-rating in Round III. Twenty six of 47 questions reached consensus in Round II, with an additional 6 reaching consensus in Round III. Consensus-achieving questions rated highly on importance spanned a number of topics, including environmental effects on child development, intergenerational transmission of disadvantage, and designing BCS to inform intervention strategies. Investigating the effects of family/environmental factors and social disadvantage on a child's development should be prioritized in designing future BCS. The panel also recommended that future BCS are designed to inform intervention strategies.

The Applicability of the Clinical Features of English Childhood Apraxia of Speech to Cantonese: A Modified Delphi Survey.

Purpose Childhood apraxia of speech (CAS), a motor-based speech disorder, has been well studied in English contexts. However, there is a limited understanding of the applicability of its features to other languages. Thus, this study sought to determine the applicability of the features identified in the English CAS literature to Cantonese CAS. Method A two-round modified Delphi survey of experts was used to identify the clinical features of CAS in Cantonese speakers. Ten Cantonese-speaking qualified speech therapists were recruited as experts. In Round 1, the experts were asked an open-ended question about the clinical features of Cantonese CAS. In Round 2, the experts were asked to rate the importance of the proposed clinical features for making differential diagnoses of Cantonese CAS on a 5-point Likert scale ranging from 1 (very important) to 5 (not important at all). Results In Round 1, the expert panel identified 79 clinical features in nine domains. Sixty-two features (78.5%) were consistent with English CAS. Three English features were not identified in this study, while three features specifically related to Cantonese phonology were identified. In Round 2, 29 clinical features across six domains were found to meet the statistical criteria and were therefore regarded as important for making differential diagnoses of CAS among Cantonese speakers. Conclusions The results suggest that the clinical features identified in the English CAS literature are applicable to Cantonese CAS. The consistency of the findings implies that core and possible co-occurring features are shared between English and Cantonese CAS. The six features that were not common in both languages were discussed. Further investigation of CAS in and between different languages is recommended. This study is not the end point. Future studies can empirically examine the lexical tones or pitch variations to develop a possible objective measure for CAS.

Developing Impacts and Indicators for Sustainable Event Management Using a Triple Bottom Line Approach: A Study of Auto Expo

Marked by the pressing need to make events sustainable, this study aims to develop impacts and indicators for a special category event—The Auto Expo—one of the largest automobile events hosted in India. The study begins with literature review of event evaluation on key indicators of triple bottom line (TBL): economic, social, and environment. Historical roots of Auto Expo is also reviewed, which is then followed by a Delphi survey of experts from event organizers to auto professionals, and from academia to domain experts. A rigorous three-phase Delphi analysis is conducted following which resulted into 18 impacts and 25 indicators related to Auto Expo. The study also delves into potential methods that could be employed for holistic TBL evaluation of Auto Expo. Key challenges and issues in this regard are mentioned as well as discussing the implications of the research for stakeholders toward the end.

When experts disagree: Using the Policy Delphi method to analyse divergent expert expectations and preferences on UK energy futures

Recent literature has highlighted the need to critically examine the assumptions and values that influence scenario analysis and expert advice on contested topics. To this end, this paper presents the results of a large scale two-round Policy Delphi expert survey on UK energy futures. The survey constitutes one of the most detailed and wide-ranging analyses of UK-based energy researchers and stakeholders (policymakers, businesses and civil society groups). Through a quantitative and qualitative analysis of expert views on two particularly challenging and contested topics (the future of heating provision in buildings and the future of personal transport), we develop an understanding of the extent of expert disagreement and the reasons behind it. For both heating and transport cases, disagreements and uncertainties emerged in terms of a number of specific parameters (particularly related to technical performance and the feasible pace of technology diffusion) and structural uncertainties (related to system boundaries, sociotechnical dynamics and the endogenous role of policy), and also epistemic and normative differences amongst participants. By setting out the diversity of expert views and reasoning on contested issues, Policy Delphi can help decision-makers understand expert disagreement, and how it is associated with different epistemic and normative perspectives.

Chronic hypersensitivity pneumonitis in the southeastern United States: an assessment of how clinicians reached the diagnosis

BackgroundChronic hypersensitivity pneumonitis (cHP) is a disease caused by exposure to inhaled environmental antigens. Diagnosis of cHP is influenced by the awareness of the disease prevalence, which varies significantly in different regions, and how clinicians utilize relevant clinical information. We conducted a retrospective study to evaluate how clinicians in the Southeast United States, where the climate is humid favoring mold growth, diagnosed cHP using items identified in the international modified Delphi survey of experts, i.e., environmental exposure, CT imaging and lung pathology,MethodsWe searched Duke University Medical Center database for patients over the age of 18 with a diagnosis of cHP (ICD-9 code: 495) between Jan. 1, 2008 to Dec. 31, 2013 using a query tool, Duke Enterprise Data Unified Content Explorer (DEDUCE).ResultsFive hundred patients were identified and 261 patients had cHP confirmed in clinic notes by a pulmonologist or an allergist. About half of the patients lived in the Research Triangle area where our medical center is located, giving an estimated prevalence rate of 6.5 per 100,000 persons. An exposure source was mentioned in 69.3% of the patient. The most common exposure sources were environmental molds (43.1%) and birds (26.0%). We used Venn diagram to evaluate how the patients met the three most common cHP diagnostic criteria: evidence of environmental exposures (history or precipitin) (E), chest CT imaging (C) and pathology from lung biopsies (P). Eighteen patients (6.9%) met none of three criteria. Of the remaining 243 patients, 135 patients (55.6%) had one (E 35.0%, C 3.3%, P 17.3%), 81 patients (33.3%) had two (E + C 12.3%, E + P 17.3%, C + P 4.9%), and 27 patients (11.1%) had all three criteria (E + C + P). Overall, 49.4% of patients had pathology from lung biopsy compared to 31.6% with CT scan.ConclusionsEnvironmental mold was the most common exposure for cHP in the Southeast United States. Lung pathology was available in more than half of cHP cases in our tertiary care center, perhaps reflecting the complexity of referrals. Differences in exposure sources and referral patterns should be considered in devising future diagnostic pathways or guidelines for cHP.

Issue Highlights

Issue Highlights

Estudio Prospectivo de la Tecnología en la Educación Superior en Colombia al 2050

Esta investigación tiene como eje teórico y conceptual la tecnología y la educación superior en Colombia, plantea como pregunta de investigación ¿Cuáles serán los principales retos y desafíos que tendrá la educación superior en Colombia al año 2050 por los avances tecnológicos? El enfoque metodológico que se utiliza para el desarrollo de esta investigación es de corte mixto cualitativo y cuantitativo, el tipo de investigación es descriptiva y mediante el método del análisis de una encuesta a expertos Delphi, y un taller con expertos. Ellos plantean la necesidadde nuevos modelos de gestión de las universidades hacia una mayor profesionalización de las carreras universitarias, en donde se incluyan estas nuevas tecnologías. Se puede resaltar que las tecnologías de la información ycomunicación evidentemente pueden llegar a afectar en su conjunto la educación superior, pero también pueden potenciar y facilitar los procesos de enseñanza y aprendizaje para que sea más incluyente

대학생 진로개발역량을 위한 진로교과목 교육내용 개발: 전문가 델파이 조사를 중심으로

본 연구의 목적은 대학생 진로개발역량을 위한 진로교과목 교육내용을 도출하는 것이다. 이를 위해 대학생 진로개발역량 관련 문헌분석을 통해 교육내용 초안을 도출하고, 이에 대해 진로교과목 전문가를 대상으로 2차례의 델파이 조사를 2018년 8월 10일∼9월 14일 간 실시하였다. 수집한 자료를 활용하여 구성의 적절성, 표현의 명료성에 대한 내용타당도(CVR) 값을 분석하였다. 연구결과는 다음과 같다. 대학생 진로개발역량을 위한 진로교과목의 교육내용은 9개 영역 43개 하위내용으로 최종 도출되었다. 구체적으로는 ‘자기이해 및 긍정적 자아정체감 확립 영역(하위 6개 교육내용), 타인과의 긍정적 상호작용 이해 및 실천 영역(하위 4개 교육내용), 직업생활에 필요한 직업의식과 태도 고취 영역(하위 4개 교육내용), 직업 및 산업동향의 이해 영역(하위 4개 교육내용), 진로정보 탐색과 활용 영역(하위 6개 교육내용), 진로의사결정 영역(하위 4개 교육내용), 평생학습 중요성 인식 및 참여 영역(하위 4개 교육내용), 진로계획 수립·실천 및 관리영역(하위 5개 교육내용), 구직역량 함양 영역(하위 6개 교육내용)’이었다. 이러한 연구결과를 토대로 대학생 진로개발역량을 위한 진로교과목 교육내용의 시사점과 후속연구를 위한 제안을 논의하였다.

미래형 신산업단지의 입지적합성 평가지표체계 개발 연구

This study suggested the necessity of introducing the future-oriented new industrial complex as a way to enhance the competitiveness of the industrial complex in response to the industrial ecosystem change caused by the 4th industrial revolution. To evaluate the location suitability for the new industrial complex, location indices were developed in this study. The flexibility of location and connectivity to neighboring areas of the future-oriented new industrial complexes were the focused subjects of this study. In-depth expert consultation and Delphi survey were conducted to construct an index system and to measure the indices. Afterwards, the AHP analysis was conducted to elucidate the weighting by indicators. As a result, the indicators of industrial innovation environment were the most important in the major category. In addition, the convenience of workers, especially urban environment, was analyzed as an important factor for success of the future-oriented new industrial complex. The indicators which are closely related to the concept and purpose of the future-oriented new industrial complex turned out to have the higher weight compared to other indicators. From the point of view of the developers of the industrial complexes or tenant companies, the implications for deriving suitable locations for development of industrial complexes among urban under-utilized sites are suggested. Furthermore, It is expected that the government will be able to apply the development system to stimulate the development of these new industrial complexes and to prepare guidelines for selecting locations.

The 2019 Revised Version of Association Research Circulation Osseous Staging System of Osteonecrosis of the Femoral Head

BackgroundThe Association Research Circulation Osseous (ARCO) presents the 2019 revised staging system of osteonecrosis of the femoral head (ONFH) based on the 1994 ARCO classification. MethodsIn October 2018, ARCO established a task force to revise the staging system of ONFH. The task force involved 29 experts who used a web-based survey for international collaboration. Content validity ratios for each answer were calculated to identify the levels of agreement. For the rating queries, a consensus was defined when more than 70% of the panel members scored a 4 or 5 rating on a 5-point scale. ResultsResponse rates were 93.1%-100%, and through the 4-round Delphi study, the 1994 ARCO classification for ONFH was successfully revised. The final consensus resulted in the following 4-staged system: stage I—X-ray is normal, but either magnetic resonance imaging or bone scan is positive; stage II—X-ray is abnormal (subtle signs of osteosclerosis, focal osteoporosis, or cystic change in the femoral head) but without any evidence of subchondral fracture, fracture in the necrotic portion, or flattening of the femoral head; stage III—fracture in the subchondral or necrotic zone as seen on X-ray or computed tomography scans. This stage is further divided into stage IIIA (early, femoral head depression ≤2 mm) and stage IIIB (late, femoral head depression >2 mm); and stage IV—X-ray evidence of osteoarthritis with accompanying joint space narrowing, acetabular changes, and/or joint destruction. This revised staging system does not incorporate the previous subclassification or quantitation parameters, but the panels agreed on the future development of a separate grading system for predicting disease progression. ConclusionA staging system has been developed to revise the 1994 ARCO classification for ONFH by an expert panel-based Delphi survey. ARCO approved and recommends this revised system as a universal staging of ONFH.

Usefulness of new diagnostic criteria for chronic hypersensitivity pneumonitis established on the basis of a Delphi survey: A Japanese cohort study.

Chronic hypersensitivity pneumonitis (CHP) is a fibrotic interstitial lung disease (ILD) caused by repeated exposure to a variety of organic particles. In November 2017, new criteria for CHP diagnosis were proposed by Morisset etal. based on a modified Delphi survey of ILD experts. However, it remains unclear whether these criteria are useful to accurately diagnose CHP. We aimed to evaluate the newly proposed CHP diagnostic criteria. We retrospectively applied Morisset's CHP diagnostic criteria to consecutive Japanese patients who underwent surgical lung biopsy for diagnosis of ILD from 2008 to 2015. All patients underwent bronchoalveolar lavage and pulmonary function testing. Patients who had connective tissue disease complications or showed an acute or subacute disease onset were excluded. A total of 251 patients were included. The diagnoses based on multidisciplinary discussion (MDD) were CHP (n=27), idiopathic pulmonary fibrosis (n=117), unclassifiable interstitial pneumonia (IP) (n=65), and other diagnoses (n=42). Of the 27 MDD-CHP patients, 14 were classified as a CHP group with diagnostic confidence >50% and 13 were not categorized (sensitivity, 51.9%; specificity, 77.7%). Morisset's CHP diagnostic criteria could help avoid SLB for the diagnosis of CHP in seven patients. Of the 13 MDD-CHP patients who were not categorized in the CHP group with diagnostic confidence >50%, the reason for the exclusion was an inconsistent with UIP pattern without CHP features. Half of the MDD-CHP patients were diagnosed with CHP using Morisset's CHP diagnostic criteria. Further investigation will be important for developing improved diagnostic criteria for CHP.