Multidisciplinary Steering Committee Research Articles

Use of the DMAIC Lean Six Sigma quality improvement framework to improve beta-lactam antibiotic adequacy in the critically ill.

Beta-lactam antibiotics are widely used in the intensive care unit due to their favorable effectiveness and safety profiles. Beta-lactams given to patients with sepsis must be delivered as soon as possible after infection recognition (early), treat the suspected organism (appropriate), and at a dose that eradicates the infection (adequate). Early and appropriate antibiotic delivery occurs in >90% of patients, but less than half of patients with sepsis achieve adequate antibiotic exposure. This project aimed to address this quality gap and improve beta-lactam adequacy using the DMAIC Lean Six Sigma quality improvement framework. A multidisciplinary steering committee was formed and completed a stakeholder analysis to define the gap in practice. An Ishikawa cause and effect (Fishbone) diagram was used to identify the root causes and an impact/effort grid facilitated prioritization of interventions. An intervention which included bundled education with the use of therapeutic drug monitoring (TDM; i.e., drug level testing) was projected to have the highest impact relative to the amount of effort and selected to address beta-lactam inadequacy in the critically ill. The education and TDM intervention were deployed through a Plan, Do, Study, Act (PDSA) cycle. In the three months after 'go-live,' 54 episodes of beta-lactam TDM occurred in 41 unique ICU patients. The primary quality metric of beta-lactam adequacy was achieved in 94% of individuals after the intervention. 94% of clinicians gauged the education provided as sufficient. The primary counterbalance of antimicrobial days of therapy, a core antimicrobial stewardship metric, was unchanged over time (favorable result; p=0.73). Application of the DMAIC Lean Six Sigma quality improvement framework effectively improved beta-lactam adequacy in critically ill patients. The approach taken in this quality improvement project is widely generalizable to other drugs, drug classes, or settings to increase the adequacy of drug exposure.

Developing an integrated clinical decision support system for the early identification and management of kidney disease—building cross-sectoral partnerships

BackgroundThe burden of chronic conditions is growing in Australia with people in remote areas experiencing high rates of disease, especially kidney disease. Health care in remote areas of the Northern Territory (NT) is complicated by a mobile population, high staff turnover, poor communication between health services and complex comorbid health conditions requiring multidisciplinary care.AimThis paper aims to describe the collaborative process between research, government and non-government health services to develop an integrated clinical decision support system to improve patient care.MethodsBuilding on established partnerships in the government and Aboriginal Community-Controlled Health Service (ACCHS) sectors, we developed a novel digital clinical decision support system for people at risk of developing kidney disease (due to hypertension, diabetes, cardiovascular disease) or with kidney disease. A cross-organisational and multidisciplinary Steering Committee has overseen the design, development and implementation stages. Further, the system’s design and functionality were strongly informed by experts (Clinical Reference Group and Technical Working Group), health service providers, and end-user feedback through a formative evaluation.ResultsWe established data sharing agreements with 11 ACCHS to link patient level data with 56 government primary health services and six hospitals. Electronic Health Record (EHR) data, based on agreed criteria, is automatically and securely transferred from 15 existing EHR platforms. Through clinician-determined algorithms, the system assists clinicians to diagnose, monitor and provide guideline-based care for individuals, as well as service-level risk stratification and alerts for clinically significant events.ConclusionDisconnected health services and separate EHRs result in information gaps and a health and safety risk, particularly for patients who access multiple health services. However, barriers to clinical data sharing between health services still exist. In this first phase, we report how robust partnerships and effective governance processes can overcome these barriers to support clinical decision making and contribute to holistic care.

Expert opinion on the use of contraception in people with multiple sclerosis.

Current guidance on the selection of appropriate contraception for people with multiple sclerosis (PwMS) is lacking. To address this gap, an expert-led consensus program developed recommendations to support clinicians in discussing family planning and contraception with women and men with multiple sclerosis (MS). A multidisciplinary steering committee (SC) of 13 international clinical experts led the program, supported by an extended faculty of 32 experts representing 18 countries. A modified Delphi methodology was used for decision-making and consensus-building. The SC drafted 15 clinical questions focused on patient-centered care, selection of contraception, and timing of stopping/starting contraception and disease-modifying therapies (DMTs). Statements addressing each question were drafted based on evaluation of published evidence and the experts' clinical experience. Consensus was reached if ⩾75% of respondents agreed (scoring 7-9 on a 9-point scale) with each recommendation. Consensus was reached on 24 of 25 proposed recommendations, including how and when to discuss contraception, types and safety of contraceptives, and how to evaluate the most appropriate contraceptive options for specific patient groups, including those with significant disability or being treated with DMTs. These expert recommendations provide the first practical, relevant, and comprehensive guidance for clinicians on the selection of contraception in PwMS.

The screening and management of sleep disturbances in people living with HIV: Delphi consensus.

Sleep disturbances in people living with HIV (PLHIV) are frequent but their management remains insufficient. In the absence of specific recommendations, a DELPHI consensus research project was conducted in France to establish best practice. A multidisciplinary Steering Committee (STC) undertook a literature review and used it with clinical expertise to create statements that were voted on. Two profiles of healthcare professionals with significant experience in monitoring PLHIV were selected for the voting: physicians and nurses/psychologists. Votes were collected electronically, independently, and anonymously. The STC created 27 statements covering six areas: Screening of sleep disturbances, Investigation, First-line management, Referral to a specialist, Antiretroviral treatment (ARV), and Prevention. Two rounds of votes included 42 physicians and 32 nurses/psychologists. Consensus was reached for 24 out of 27 statements (89%) including: to assess quantity and quality of sleep among PLHIV at least annually, ideally using a common methodology within the medical department; to consider the temporary addition of a hypnotic treatment in cases of acute insomnia not improved by the rules of sleep hygiene, with full awareness of potential drug-drug interactions and risk of dependence; to correct ferritinaemia if <100 ng/mL before referral to a specialist when restless legs syndrome is suspected; to consider changing the time of ARV administration or an ARV switch within the same class when sleep disturbances are caused by an ARV. This DELPHI Consensus provides best practice for screening and managing sleep disturbances in PLHIV and optimising their quality of life.

An evidence-based quality assessment tool for ovarian cancer care delivery.

384 Background: Ovarian cancer is the fifth leading cause of cancer death among women in the United States (US). Optimizing care for patients with ovarian cancer using a systematic, guideline-concordant approach improves outcomes. However, notable gaps persist for most patients with ovarian cancer in the US. Beginning in 2018, the Association of Community Cancer Centers (ACCC) implemented a quality improvement (QI) initiative in community and academic cancer centers to address care gaps. From this work, our expert steering committee published a quality document to inform evidence based ovarian cancer care delivery. Methods: In Phase II of this project we used the quality document to inform a qualitative baseline self-assessment and development of four six-month QI initiatives at cancer centers in the US. Based on this work, we developed a quality assessment tool to aid cancer centers in performing QI needs-assessments using the ovarian cancer quality document. The assessment tool applies evidence-based care recommendations in key areas identified by our multidisciplinary steering committee comprised of experts in ovarian cancer care. Results: The assessment tool includes a series of program-level questions and addresses seven key domains: 1. Care coordination and patient education, 2. Prevention and screening, 3. Diagnosis and initial management, 4. Treatment planning, 5. Disease surveillance, 6. Equity in care, and 7. Quality of life. Each domain has between two and seven key recommendations identified. Sites rate themselves on a four-point scale (1-unsatisfactory, 2-needs improvement, 3-acceptable, 4-good) for each key recommendation. Each key recommendation is given equal weight, and a combined score from 0-100 is calculated for each of the seven domains. The tool includes a macro-enabled spreadsheet that makes necessary calculations and provides an overall score, domain-specific sub-scores, and a list of key recommendations that received low ratings. The tool is to be used by clinical sites to self-assess the quality of ovarian cancer care currently provided at their cancer program and serves as a needs assessment. It is recommended that the site team performs the self-assessment in the context of a facilitated half-day multidisciplinary team meeting. After the self-assessment, sites are encouraged to develop QI initiatives to address the gaps identified using the format and structure we have previously described. Conclusions: The QI Assessment tool provides an important resource for cancer centers to conduct needs assessments in key areas of ovarian cancer care. The needs assessment can be used to inform the implementation of program-specific QI initiatives to elevate quality care delivery.

The approach to developing Ireland’s first national health protection strategy and lessons learnt

Abstract Health protection is recognised as an essential public health function by the World Health Organization. It includes the prevention and control of infectious disease, environmental and radiation risks, and the emergency response to major incidents. The COVID-19 pandemic has highlighted the importance of strengthening this function worldwide. To address this as a public health priority in Ireland, between January and October 2022 the first national first Health Protection Strategy (2022-2027) for the Health Service Executive (HSE) was developed. This was led by the then National Clinical Director for Health Protection supported by a Project Working Group (PWG), with governance and oversight from a multi-disciplinary Steering Committee (SC). Key steps in strategy formation included detailed stakeholder analysis, exploration of the policy context for the strategy, and development of a consultation plan with guidance of an external facilitator. Two SC consultation workshops were held (March and June 2022). Workshop 1 focused on defining strategic vision, aim, and objectives. Workshop 2 verified objectives and identified enablers. A subsequent e-consultation invited feedback from wider stakeholders (July 2022). The strategy, published 13th October 2022, outlines 10 strategic objectives and 11 associated enablers. Progression of strategy implementation will require further stakeholder engagement, development of implementation plans, and establishment of a monitoring and evaluation framework, including annual review of implementation. Strengths of the strategy development approach included multidisciplinary SC input and oversight, review of the national and international policy context, detailed stakeholder analysis and engagement, and the comprehensive consultation plan developed with external facilitator input. Lessons from our experience can support colleagues internationally to strategically set out their priorities for health protection beyond COVID-19. Key messages • The development of the first HSE Health Protection Strategy 2022-2027 is a critical step to ensure a clear framework for the delivery of national health protection functions going forward. • As the COVID-19 pandemic continues, public health bodies should strategically set out priorities for health protection beyond COVID-19 – lessons from our experience in doing so can inform this work.

Recommendations for assessing the risk of cardiovascular disease and venous thromboembolism before the initiation of targeted therapies for chronic inflammatory rheumatic diseases.

Patients with rheumatoid arthritis (RA) and other chronic inflammatory rheumatic disorders have increased risk of cardiovascular disease (CVD) and venous thromboembolism (VTE) compared with the general population. Moreover, recent data have raised concerns around a possible increased risk of major CV events (MACE) and VTE in patients treated with JAK inhibitors (JAKi). In October 2022, the PRAC has recommended measures to minimize the risk of serious side effects, including CV conditions and VTE, associated with all approved in chronic inflammatory diseases. To provide an adequate and feasible strategy to evaluate, at the individual level, the risk of CVD and VTE in patients with chronic inflammatory rheumatic diseases. A multidisciplinary steering committee comprised 11 members including rheumatologists, a cardiologist, a hematologist expert in thrombophilia and fellows. Systematic literature searches were performed and evidence was categorized according to standard guidelines. The evidence was discussed and summarized by the experts in the course of a consensus finding and voting process. Three overarching principles were defined. First, there is a higher risk of MACE and VTE in patients with chronic inflammatory rheumatic diseases compared with the general population. Second, the rheumatologist has a central role in the evaluation of the risk of CVD and VTE in patient with chronic inflammatory rheumatic diseases. Third, the risk of MACE and VTE should be regularly assessed in patients with chronic inflammatory rheumatic diseases, particularly before initiating targeted therapies. Eleven recommendations were defined to prevent potentially life-threatening complications of CVD and VTE in patients with chronic inflammatory rheumatic diseases, providing practical assessment of CVD and VTE before considering the prescription of targeted therapies, and especially JAKi. These practical recommendations based on expert opinion and scientific evidence provide consensus for the prevention and the assessment of CVD and VTE.

Managing the Risk of Lung Toxicity with Trastuzumab Deruxtecan (T-DXd): A Canadian Perspective.

Ongoing advances in precision cancer therapy have increased the number of molecularly targeted and immuno-oncology agents for a variety of cancers, many of which have been associated with a risk of pulmonary complications, among the most concerning being drug-induced interstitial lung disease/pneumonitis (DI-ILD). As the number of patients undergoing treatment with novel anticancer agents continues to grow, DI-ILD is expected to become an increasingly significant clinical challenge. Trastuzumab deruxtecan (T-DXd) is an antibody-drug conjugate targeting human epidermal growth factor receptor 2 that is gaining widespread use in the metastatic breast cancer setting and is undergoing exploration for other oncologic indications. ILD/pneumonitis is an adverse event of special interest associated with T-DXd, which has potentially fatal consequences if left untreated and allowed to progress. When identified in the asymptomatic stage (grade 1), T-DXd-related ILD can be monitored and treated effectively with the possibility of treatment continuation. Delayed diagnosis and/or treatment, however, results in progression to grade 2 or higher toxicity and necessitates immediate and permanent discontinuation of this active agent. Strategies are, therefore, needed to optimize careful monitoring during treatment to ensure patient safety and optimize outcomes. Several guidance documents have been developed regarding strategies for the early identification and management of T-DXd-related ILD, although none have been within the context of the Canadian health care environment. A Canadian multidisciplinary steering committee was, therefore, convened to evaluate existing recommendations and adapt them for application in Canada. A multidisciplinary approach involving collaboration among medical oncologists, radiologists, respirologists, and allied health care professionals is needed to ensure the proactive identification and management of T-DXd-related ILD and DI-ILD associated with other agents with a similar toxicity profile.

Compassion, collaboration, and community: Strategies for staff well-being.

Compassion, collaboration, and community: Strategies for staff well-being.

Abstract ED5-2: Support for patients with MBC

Abstract ED5-2: Support for patients with MBC

Quality standards for the care of people with giant cell arteritis in secondary care.

GCA is the commonest primary systemic vasculitis in adults, with significant health economic costs and societal burden. There is wide variation in access to secondary care GCA services, with 34% of hospitals in England not having any formal clinical pathway. Quality standards provide levers for change to improve services. The multidisciplinary steering committee were asked to anonymously put forward up to five aspects of service essential for best practice. Responses were qualitatively analysed to identify common themes, subsequently condensed into domain headings, and ranked in order of importance. Quality standards and metrics for each domain were drafted, requiring a minimum 75% agreement. 13 themes were identified from the initial suggestions. Nine quality standards with auditable metrics were developed from the top 10 themes. Patient Access, glucocorticoid use, pathways, ultrasonography, temporal artery biopsy, PET scan access, rheumatology/ophthalmology expertise, education, multidisciplinary working have all been covered in these quality standards. Access to care is a strand that has run through each of the developed standards. An audit tool was developed as part of this exercise. These are the first consensus auditable quality standards developed by clinicians from rheumatology and ophthalmology, nursing representatives and involvement of a patient charity. We hope that these standards will be adopted by commissioning bodies to provide levers for change from the improvement of patient care of individuals with GCA.

Consensus for Statements Regarding a Definition for Spinal Osteoarthritis for Use in Research and Clinical Practice: A Delphi Study.

To determine consensus among an international, multidisciplinary group of experts regarding definitions of spinal osteoarthritis for research and for clinical practice. A 15-member, multidisciplinary steering committee generated 117 statements for a 3-round Delphi study. Experts in back pain and/or osteoarthritis were identified and invited to participate. In round 1, participants could propose additional statements for voting. All statements were rated on a 1-9 Likert scale, and consensus was set at ≥70% of respondents agreeing or disagreeing with the statement and <15% of respondents providing the opposite response. In total, 255 experts from 11 different professional backgrounds were invited. From 173 available experts, 116 consented to participate. In round 1, 103 participants completed the survey, followed by 85 of 111 participants in round 2 (77%) and 87 of 101 participants in round 3 (86%). One-third of participants were from Europe (30%), most were male (58%), one-fifth were physical therapists (21%), and over one-third had been in their profession for 11-20 years (35%). Of 131 statements, consensus was achieved for 71 statements (54%): 53 in agreement (75%) and 18 in disagreement (25%). Although there was consensus for statements for definitions of spinal osteoarthritis that were analogous to definitions of osteoarthritis in appendicular joints, a future definition still needs refinement. Importantly, this Delphi highlighted that a future definition should be considered across a spectrum of structural changes and patient symptoms and expressed on a progressive scale.

Process, successes and challenges of building an inpatient preoperative evaluation team

BackgroundUrgent surgical cases have worse outcomes and are responsible for most case cancellations and delays. Improving preoperative care of urgent cases is cost saving and can potentially improve patient outcomes. We describe the design and implementation of a Rapid OR Decision Evaluation and Optimization (RODEO) service to assess patients requiring urgent surgery during their admission (“inpatients"). We hypothesized that the RODEO service will reduce Operating Room (OR) delays and cancellations. MethodsA multidisciplinary steering committee designed RODEO to be staffed by Advanced Practice Providers (APPs) with attending physician support. The attendings were available on the phone with the level of support changing as the APPs became more experienced. Initially the service focused on orthopedic trauma patients but expanded to other surgical specialties. RODEO assessment included evaluating chronic medical conditions, ordering testing and consults, medication management and communication with the patient care teams. Monthly meetings of the steering committee using standard data reports were used to identify areas for improvement. The primary outcome was the ratio of OR delays and cancellations due to incomplete workup to all OR delays and cancellations. ResultsBetween April 2020 and March 2021, 730 patients were assessed by the RODEO service. When RODEO needed to prioritize within the trauma patient population, the service focused on medically complex patients, (54% of patients had at least one chronic medical diagnosis), 20% of patients had respiratory disease, 19% cardiovascular disease, 18% diabetes, 16% renal disease, and 10% chronic pain. Optimization included ordering guidelines directed testing (48% of patients), managing chronic medications (46% of patients), requesting consults from other services (28% of patients), and placing orders (17% of patients). A significant portion of RODEO work involved multidisciplinary communication. We found that OR delays due to incomplete workup were reduced from 19% of total OR delays to 0%. Surgery cancellations due to incomplete workup were reduced from 50% of all cancellations to 0%. Expansion of RODEO services to other surgical specialties is achievable. DiscussionA service providing preoperative evaluation and optimization to surgical inpatients is feasible and may reduce delays and cancellation due to incomplete workup. Potential limitations to our findings are that RODEO was designed for a specific setting; and that the implementation coincided with the COVID-19 pandemic. Future research will need to assess the effect of RODEO on postoperative outcomes. ConclusionA specialized preoperative team optimizing surgical inpatients can reduce OR delays and cancellations

Gestion pratique des inhibiteurs de PARP : Un consensus national DELPHI

Despite an increasing number of therapeutic indications, there are no specific recommendations regarding the management of PARP inhibitors other than what is specified in the SmPC of each substance. A Delphi French consensus was conducted to establish practical guidelines to meet the needs identified by healthcare professionals and patients. Following the Delphi method, statements to optimize PARP inhibitor management were drafted by a multidisciplinary Steering Committee made up of 17 experts. These statements were submitted to the independent and anonymous vote of clinicians involved in treating patients on PARP inhibitors. This article presents 52 statements on the following topics: initiation and treatment; management of adverse events (hematological effects, gastrointestinal effects, renal effects, pulmonary effects, cutaneous effects, hypertension, insomnia, fatigue, dizziness); special populations and situations; communication with the patient; adherence. Forty-nine statements obtained voter consensus after 3 voting rounds. A hematologist and a nephrologist supplemented this task by drafting an expert opinion on the risk of occurrence of secondary leukemia and nephrological toxicity. This paper is the first Delphi consensus on the practical management of PARP inhibitors. The pragmatic recommendations resulting from this paper should make it possible to manage the side effects of PARP inhibitors better and thus prevent early treatment discontinuation and improve patient adherence by preserving quality of life.

Development and Pilot-Testing of a Patient Decision-Making Aid for Nutrition in Age-Related Macular Degeneration.

ObjectiveWe described the development and pilot-testing of an application based patient decision-making aid (PDA) for nutrition in age-related macular degeneration (AMD). Alpha-testing and beta-testing were performed to explore the PDA’s usability, acceptability, and comprehensibility in the design stage and in “real-life” conditions.MethodsA nutrition PDA was developed in this study by a multidisciplinary steering committee that consisted of ophthalmologists, nurses, nutritionists, and methodologists using a systematic development process. The PDA was based on a smartphone native installation and a free-to-use app. First, based on information from literature reviews and focus group interviews for needs assessment, we developed a decision aid prototype. Second, we conducted the alpha testing to explore the acceptability, usability, and comprehensibility of the PDA prototype among 18 AMD patients. Third, a before/after study was conducted to assess changes in the attitudes, risk perceptions, intentions, knowledge, decisional conflicts, and decision self-efficacy of 33 AMD patients.ResultsThe alpha test proved that the nutrition PDA is acceptable and usable. In the beta test, after the AMD participants used the PDA, their scores for knowledge [mean = 13.3, standard deviation (SD) = 2.92], attitude (mean = 18.97, SD = 2.19), decision self-efficacy (mean = 23.94, SD = 6.04), and preparation significantly increased (mean = 26.30, SD = 4.90), and their score for decisional conflict significantly decreased (mean = 10.15, SD = 3.66). There was no significant difference in anxiety (mean = 2.64, SD = 1.08) before and after the use of the PDA. The mean score in the system usability scale was above 70 (mean = 72.61; SD = 5.38), which indicates the good usability of the PDA. With regard to the PDA acceptability, the scores for satisfaction with its comprehensibility, satisfaction with its attractiveness, and satisfaction with its emotional support were 5.49 (SD = 1.03), 5.30 (SD = 1.40), and 4.91(SD = 1.07), respectively, which show its adequate acceptability.ConclusionOur study showed that the nutrition PDA was an acceptable and suitable instrument for AMD patients and fit the values of all its stakeholders. This study is an important step in supporting shared decision-making, which has the potential to provide a more patient-centered and value-based nutrition health system for individuals with different types of AMD.

1577P Optimizing the management of PARP inhibitors in clinical practice: Results of a DELPHI French consensus

PARP inhibitors (PARPi) have brought considerable progress in the management of ovarian cancer and are now one of the therapeutic options for patients with breast, prostate, and pancreatic cancers. Despite the increasing number of therapeutic indications, the practical use of PARPi remains suboptimal in terms of adequate management of adverse events and adherence - both of which would maximize patient benefit. Therefore, specific recommendations are needed. A Delphi consensus was conducted to suggest statements for improved use of PARPi. A multidisciplinary steering committee of 17 experts (oncologists, nurses, pharmacist, and patient association representative) drafted statements which were submitted to the independent and anonymous vote of clinicians and health care professionals with clinical experience of PARPi (panelists). Statements were divided into the following topics: Initiation and Treatment; Management of adverse events (including hematological, gastrointestinal, insomnia, fatigue, dizziness); Specific populations and situations; Communication with the patient; Adherence. After three voting rounds of the 61 panelists, 49/52 (94%) assertions obtained a consensus. We report here 21 statements specifically related to supportive care (19/21 obtained a consensus). It includes recommendations not to use erythropoiesis-stimulating agents (ESAs) or hematopoietic granulocyte-colony stimulating factors (G-CSFs) to treat PARPi related anemia and neutropenia, given the lack of efficacy data in this setting. Symptomatic antiemetic/anti-nausea treatments can be used to relieve grade 1 gastrointestinal adverse events, while grade ≥2 gastrointestinal adverse events should be managed with treatment interruption/dose reduction. The consensus also recommends to systematically prescribe antidopaminergics when resuming PARPi treatment after interruption due to emesis. The 21 statements will be fully presented and discussed in the communication. This work is the first Delphi consensus on the practical use of PARPi. The pragmatic guidance resulting from this work should help in the management of PARPi adverse events thus improving adherence by preserving patient quality of life.

Governance of Clinical AI applications to facilitate safe and equitable deployment in a large health system: Key elements and early successes.

One of the key challenges in successful deployment and meaningful adoption of AI in healthcare is health system-level governance of AI applications. Such governance is critical not only for patient safety and accountability by a health system, but to foster clinician trust to improve adoption and facilitate meaningful health outcomes. In this case study, we describe the development of such a governance structure at University of Wisconsin Health (UWH) that provides oversight of AI applications from assessment of validity and user acceptability through safe deployment with continuous monitoring for effectiveness. Our structure leverages a multi-disciplinary steering committee along with project specific sub-committees. Members of the committee formulate a multi-stakeholder perspective spanning informatics, data science, clinical operations, ethics, and equity. Our structure includes guiding principles that provide tangible parameters for endorsement of both initial deployment and ongoing usage of AI applications. The committee is tasked with ensuring principles of interpretability, accuracy, and fairness across all applications. To operationalize these principles, we provide a value stream to apply the principles of AI governance at different stages of clinical implementation. This structure has enabled effective clinical adoption of AI applications. Effective governance has provided several outcomes: (1) a clear and institutional structure for oversight and endorsement; (2) a path towards successful deployment that encompasses technologic, clinical, and operational, considerations; (3) a process for ongoing monitoring to ensure the solution remains acceptable as clinical practice and disease prevalence evolve; (4) incorporation of guidelines for the ethical and equitable use of AI applications.

ACCORD guideline for reporting consensus-based methods in biomedical research and clinical practice: a study protocol

BackgroundStructured, systematic methods to formulate consensus recommendations, such as the Delphi process or nominal group technique, among others, provide the opportunity to harness the knowledge of experts to support clinical decision making in areas of uncertainty. They are widely used in biomedical research, in particular where disease characteristics or resource limitations mean that high-quality evidence generation is difficult. However, poor reporting of methods used to reach a consensus – for example, not clearly explaining the definition of consensus, or not stating how consensus group panellists were selected – can potentially undermine confidence in this type of research and hinder reproducibility. Our objective is therefore to systematically develop a reporting guideline to help the biomedical research and clinical practice community describe the methods or techniques used to reach consensus in a complete, transparent, and consistent manner.MethodsThe ACCORD (ACcurate COnsensus Reporting Document) project will take place in five stages and follow the EQUATOR Network guidance for the development of reporting guidelines. In Stage 1, a multidisciplinary Steering Committee has been established to lead and coordinate the guideline development process. In Stage 2, a systematic literature review will identify evidence on the quality of the reporting of consensus methodology, to obtain potential items for a reporting checklist. In Stage 3, Delphi methodology will be used to reach consensus regarding the checklist items, first among the Steering Committee, and then among a broader Delphi panel comprising participants with a range of expertise, including patient representatives. In Stage 4, the reporting guideline will be finalised in a consensus meeting, along with the production of an Explanation and Elaboration (E&E) document. In Stage 5, we plan to publish the reporting guideline and E&E document in open-access journals, supported by presentations at appropriate events. Dissemination of the reporting guideline, including a website linked to social media channels, is crucial for the document to be implemented in practice.DiscussionThe ACCORD reporting guideline will provide a set of minimum items that should be reported about methods used to achieve consensus, including approaches ranging from simple unstructured opinion gatherings to highly structured processes.

Recommendations for the implementation of genetic testing for metastatic prostate cancer patients in Canada.

Genetic testing in advanced prostate cancer is rapidly moving to become standard of care. Testing for genetic alterations in genes involved in DNA repair pathways, particularly those implicated in the homologous recombination repair (HRR) pathway, in patients with metastatic prostate cancer (mPCa) can inform selection of optimal therapies, as well as provide information about familial cancer risks; however, there are currently no consistent Canadian guidelines in place for genetic testing in mPCa. A multidisciplinary steering committee guided the process of an environmental scan to define the current landscape, as well as the perceived challenges, through interviews with specialists from 14 sites across Canada. The challenges most commonly identified include limited testing guidelines and protocols, inadequate education and awareness, and insufficient resources. Following the environmental scan, an expert multidisciplinary working group with pan-Canadian representation from medical oncologists, urologists, medical geneticists, genetic counsellors, pathologists, and clinical laboratory scientists convened in virtual meetings to discuss the challenges in implementation of genetic testing in mPCa across Canada. Key recommendations from the working group include implementation of germline and tumor HRR testing for all patients with mPCa, with a mainstreaming model in which non-geneticist clinicians can initiate germline testing. The working group defined the roles and responsibilities of the various healthcare providers (HCPs) involved in the genetic testing pathway for mPCa patients. In addition, the educational needs for all HCPs involved in the genetic testing pathway for mPCa were defined. As genetic testing for mPCa becomes standard of care, additional resources and investments will be required to implement the changes that will be needed to support the necessary volume of genetic testing, to ensure equitable access, and to provide education to all stakeholders.

Best-Practice Recommendations for Chiropractic Care for Pregnant and Postpartum Patients: Results of a Consensus Process

ObjectiveThe purpose of this project was to develop a best-practices document on chiropractic care for pregnant and postpartum patients with low back pain (LBP), pelvic girdle pain (PGP), or a combination. MethodsA modified Delphi consensus process was conducted. A multidisciplinary steering committee of 11 health care professionals developed 71 seed statements based on their clinical experience and relevant literature. A total of 78 panelists from 7 countries were asked to rate the recommendations (70 chiropractors and representatives from 4 other health professions). Consensus was reached when at least 80% of the panelists deemed the statement to be appropriate along with a median response of at least 7 on a 9-point scale. ResultsConsensus was reached on 71 statements after 3 rounds of distribution. Statements included informed consent and risks, multidisciplinary care, key components regarding LBP during pregnancy, PGP during pregnancy and combined pain during pregnancy, as well as key components regarding postpartum LBP, PGP, and combined pain. Examination, diagnostic imaging, interventions, and lifestyle factors statements are included. ConclusionAn expert panel convened to develop the first best-practice consensus document on chiropractic care for pregnant and postpartum patients with LBP or PGP. The document consists of 71 statements on chiropractic care for pregnant and postpartum patients with LBP and PGP.