Consensus Process Research Articles

An innovative linked Electronic Health Record derived data ecosystem for understanding the complexities of health and ageing.

ObjectiveWe describe the creation of an Electronic Health Record (EHR) derived linked data platform within the Australian National Centre for Healthy Ageing (NCHA). ApproachOur approach involved establishing a core set of EHR data suitable for research from the sole public health provider within a defined geographic region. Relevant items were selected based on published literature and consensus processes and curated within a specialised research data warehouse. Curation involved: data validation, quality assessment, internal linkage between episodes and data harmonisation/merging. An AI supported natural language processing pipeline was implemented to extract text-based data. Approvals were obtained from government agencies to link commonwealth claims data (primary care, medication, aged care, death) and state administrative hospital data, for all residents aged ≥60 years. Publicly available datasets were scoped for inclusion and collaborations established to incorporate local council data. ResultsA core of 113 curated items for >900,000 people over 10 years have been established across 4 hospitals and 10 community/outpatient services. Linked state and commonwealth data were obtained for 179,089 residents aged >60 years (Jan 2010-May 2021, linkage accuracy 98.4%). Environmental (greenery, air pollution, walkability) and Census data have been incorporated for each neighbourhood (Statistical Area 1). Data access, extraction and release has been tested through over 30 use-case projects in: dementia, residential aged care, medication use, homelessness, environmental impacts on health and ageing and health service redesign. ImplicationsThe NCHA Data Platform provides an international exemplar for the use of linked EHR data in advancing population health research.

Time to Consensus in International Negotiations

Contemporary international relations, anchored in the principles of multipolarity, frequently employ consensus-based decision-making, which prioritizes respect for all negotiating parties and ensures that the views of all participants are considered equally. While consensus remains a core mechanism for many international organizations, such as the World Trade Organization (WTO), it has increasingly come under criticism for its inefficiency and substantial time requirements. This highlights the importance of examining the factors that influence the time needed to reach consensus. Utilizing formal mathematical modeling based on a modified DeGroot model, this article explores how variables such as the size of the negotiating group, the level of authoritativeness, dominance dynamics within the group, and coalition formation affect the time required to achieve consensus. The findings indicate that an increase in group size, on its own, results in only a minor increase in the time needed to reach consensus, becoming a significant factor only when paired with high levels of authoritativeness among the participants. Conversely, the presence of a highly authoritative member within a negotiating group significantly prolongs decision-making time, even in smaller groups, and the formation of coalitions (e.g., due to multiple highly authoritative members) can make reaching consensus impossible. The "consensus minus k" rule, intended to break deadlocks, is found to be ineffective for international organizations with numerous participants and divergent interests. In hierarchical structures, consensus is typically achieved through preliminary negotiations within subgroups, which further prolongs the consensusbuilding process.

Developing a shared language: a proposed guide to frame early implementation science collaboration discussions.

Miscommunication between health care practitioners and implementation researchers can lead to a mismatch of expectations and understandings, resulting in wasted research and frustration. Conversely, combining the expertise and knowledge of those working in health care practice and implementation research can deliver context informed research questions and appropriate study designs. Achieving this ambition requires a shared language. We sought to develop a guide to identify a common language to constructively explore nascent implementation research concepts. We set up a working group, comprising of implementation researchers, health care practitioners and operational managers, to work through ideas generation, debate and a consensus process to generate and refine a discussion guide. The resultant guide steps health care practitioners and implementation researchers through a three-phase enquiry - Question 1: What is the implementation question? Question 2: What is the proposed implementation solution? And Question 3: How can the investigation of this idea be resourced? At each step, the health care practitioner and implementation researcher collaborate to include theory and practice and rigorously work through the question to build implementation on evidence and to promote diverse stakeholder engagement. The next steps for this study will be operationalising the discussion guide, as an interactive tool. Future evaluation, to test effectiveness, acceptability and feasibility will be designed with health care practitioners and implementation researchers.

Implementasi Karakter Keislaman Dalam Mengatasi Paham Radikalisme di Kalangan Mahasiswa

There are many religious activities at the university, both general and religious. Radicalism comes from the word radical which means massive or comprehensive, hard, sturdy, advanced and sharp (in thinking). Radical is usually defined as a political consensus of government that calls for radical change or reform as the way forward. This research uses a type of study or library research. This research aims to establish Islamic character in overcoming radicalism. The concept of radicalism itself is sometimes defined differently within interest groups. In this case, universities play an important role in efforts to instill the values ​​of moderation through education that includes the whole community, has a sense of tolerance, respects differences and spreads peace, and has the effect of reasonable understanding to benefit others, not to deny, doubt or even underestimating the stigma of takfiri, committing disgraceful acts and using religion as a basis to justify their actions.

Reimagining the ADR Alert Card: a novel approach to recurrence prevention in low-cost settings for adverse drug reactions

ObjectivesAdverse drug reactions (ADRs) are among the leading standalone causes of morbidity and hospitalisation and contribute substantially to an increase in healthcare expenditure. Repeat ADR events, although difficult to quantify,...

Appropriateness of Ketoanalogues of Amino Acids, Calcium Citrate, and Inulin Supplementation for CKD Management: A RAND/UCLA Consensus.

Current treatment for chronic kidney disease (CKD) focuses on improving manifestations and delaying progression. Nutritional approaches play a crucial role in CKD management, and various supplements have become available. Ketoanalogues of amino acids (KAs), calcium citrate, and inulin have been proposed as suitable supplements, yet their widespread use has been limited due to insufficient evidence. This study aimed to generate general guidance statements on the appropriateness of these supplements through a RAND/UCLA consensus process. A RAND/UCLA consensus panel was convened to evaluate the appropriateness of these supplements in different clinical scenarios. In this study, we present a subgroup analysis focusing on a panel of eleven clinical nephrologists from among the experts. Supplementation of low-protein diets (LPDs) and very low-protein diets (VLPDs) with KA was considered appropriate to reduce manifestations and delay CKD outcomes, supplementation with calcium citrate is considered appropriate to reduce CKD manifestations, and supplementation with inulin is considered appropriate to delay CKD outcomes and manage comorbidities. Based on a combination of clinical experience and scientific evidence, the panel reached a consensus that KA supplementation of LPD and VLPD, calcium citrate, and inulin are appropriate in patients with CKD across various scenarios.

Clinician-Prioritized Measures to Use in a Remote Concussion Assessment: Delphi Study.

There is little guidance available, and no uniform assessment battery is used in either in-person or remote evaluations of people who are experiencing persistent physical symptoms post concussion. Selecting the most appropriate measures for both in-person and remote physical assessments is challenging because of the lack of expert consensus and guidance. This study used expert consensus processes to identify clinical measures currently used to assess 5 physical domains affected by concussion (neurological examination, cervical spine, vestibular, oculomotor, or effort) and determine the feasibility of applying the identified measures virtually. The Delphi approach was used. In the first round, experienced clinicians were surveyed regarding using measures in concussion assessment. In the second round, clinicians reviewed information regarding the psychometric properties of all measures identified in the first round by at least 15% (9/58) of participants. In the second round, experts rank-ordered the measures from most relevant to least relevant based on their clinical experience and documented psychometric properties. A working group of 4 expert clinicians then determined the feasibility of virtually administering the final set of measures. In total, 59 clinicians completed survey round 1 listing all measures they used to assess the physical domains affected by a concussion. The frequency counts of the 146 different measures identified were determined. Further, 33 clinicians completed the second-round survey and rank-ordered 22 measures that met the 15% cutoff criterion retained from round 1. Measures ranked first were coordination, range of motion, vestibular ocular motor screening, and smooth pursuits. These measures were feasible to administer virtually by the working group members; however, modifications for remote administration were recommended, such as adjusting the measurement method. Clinicians ranked assessment of coordination (finger-to-nose test and rapid alternating movement test), cervical spine range of motion, vestibular ocular motor screening, and smooth pursuits as the most relevant measures under their respective domains. Based on expert opinion, these clinical measures are considered feasible to administer for concussion physical examinations in the remote context, with modifications; however, the psychometric properties have yet to be explored. RR2-10.2196/40446.

Stronger Together: A Successful Model of Health System-Community Collective Action During the COVID-19 Pandemic

Abstract: Background: Discontinuity between health care delivery systems and community-based organizations is a significant barrier to improving population health. Objective: To describe the facilitators and barriers experienced by a health system–community partnership 15 months after implementation. Methods: Coalition members who led committees within the coalition or had active, sustained participation in coalition activities were invited to participate. Qualitative interviews used a semi-structured interview guide that elicited information on coalition functioning. A content analysis used inductive and deductive codes which were reviewed using a consensus process. Final themes centered on factors that facilitated or impeded the coalition’s success in supporting community needs during the COVID-19 pandemic. Lessons Learned: Coalition stakeholder perspectives identified several critical factors: defined governance, a culture of trust that accelerates learning, reliable resources, and a health-care anchor organization committed to shared investment. Conclusions: Lessons from this endeavor contribute to a deeper understanding of successful practices for health system-community partnerships.

Dual strategies consensus reaching process for ranking consensus based probabilistic linguistic multi-criteria group decision-making method

Group consensus is critical in multi-criteria group decision-making (MCGDM). However, the extant consensus reaching process (CRP) methods focus on the consensus on the decision matrices rather than the rankings of alternatives. This paper proposes the dual strategies CRP for ranking consensus based probabilistic linguistic MCGDM. According to the decision matrices provided by decision makers, the rankings of alternatives are generated. Then, we define ranking similarity degree based on the individual alternative rankings and opinion similarity degree based on the decision matrices, respectively. Based on the ranking similarity degrees, the group consensus index (GCI) is defined and the dual strategies CRP are proposed. In the proposed CRP method, the first strategy pays attention to DMs with low ranking similarity degree but high opinion similarity degree, while the second strategy in CRP concentrates on DMs with low ranking similarity degree and low opinion similarity degree. The first strategy constructs minimum adjustment programming model while the second strategy directly provide adjustment advice according to the reference evaluation. These two strategies both aims to change the rankings of alternatives by adjusting the evaluations in the decision matrices. At length, an actual example is presented to demonstrate the effectiveness of the erected method and comparison analyses clarify its advantages and superiorities.

A consensus guideline on preferred items for reporting case series in homeopathy: The PITCH statement

BackgroundCase series is a valuable tool for sharing clinical experiences and generating research questions in the field of medicine. However, there is a lack of standardized reporting guideline for case series in homeopathy, which limits their utility and comparability. The aim of this study is to develop a reporting guideline for case series in homeopathy using a Delphi consensus process. MethodA group of 21 experts, with experience in reviewing, publishing, or editing case reports or series in homeopathy, were participated in the study. A modified Delphi consensus process was conducted with three rounds of electronic surveys to gather feedback and opinions on the items to be included in the reporting guideline. The GRADE group's nine-point Likert scale was used to rate each item's importance and criticality. ResultThe Delphi process resulted in a consensus-based reporting guideline for case series in homeopathy, which includes recommendations for reporting case series in eleven sections, including 'Title,' 'Abstract,' 'Keywords,' 'Introduction,' 'Methods,' 'Results,' 'Discussion,' 'Conclusion,' 'Patient Perspectives,' 'References,' and 'Additional Information.' PITCH comprises a total of 59 items that achieved consensus agreement. Of these, 13 are optional items and 14 items are exclusively applicable for prospective type of case series. ConclusionThe PITCH reporting guideline provides a structured and standardized approach for reporting case series in homeopathy. The authors, journal editors, reviewers, and educators are encouraged to adopt and implement the guideline to enhance the quality of case series in homeopathic publications.

Initiation of Increasing Tuberculosis Medication Supervisors Roles: An Action Research Approach

Indonesia is ranked second in the number of Tuberculosis (TB) cases worldwide. TB patients and their families experience a complex burden. Hence, support and strengthening TB medication supervisors (Pengawas Minum Obat/ PMO) role is needed. The aim of this study was to enhance the Community Health Center (CHC)-based PMOs’ role by improving their knowledge and strengthening peer group support. The method used was an action research cycle with four stages. The diagnosis stage was carried out by consensus decision making group with CHC to determine priority problems, namely the need to increase basic knowledge of TB and its treatment. Optimizing peer group was also necessary, as the Self Reporting Questionnaire-20 showed that more PMOs from patient families have psychological problems than cadres. The planning stage was conducted by preparing educational sessions and creating educational media. The action stage was a quasi-experimental (without control, non-randomization)—an educational talk show provided by the TB program manager, pulmonologist, and psychiatrist. Peer groups are also activated by triggering shared media education and discussion. At the evaluation stage, knowledge was measured by giving pre and post-tests (n= 21, total sampling). The results of the analysis using the Wilcoxon's Signed Ranks Test showed that participants' knowledge had increased significantly (p=0.000; r=0.59). In conclusion, education can increase PMO knowledge as an initial step to strengthen their role in supporting the success of TB treatment. Innovation, cross-sector assistance, and support are needed to enable the PMO to succeed in the TB program.

Assuring fire safety in nuclear plants with international standards

This paper presents the evolution and benefits of international standards for fire safety engineering11Fire safety engineering and performance-based fire safety are both widely used, and both represent an engineering process to determine performance of a fire protection plan based on the results of fire calculations. developed at the International Organization of Standardization (ISO). The history of fire safety in nuclear power plants along with the need for fire safety regulation is discussed to lay the foundation for the standards development work. The evolution of fire safety regulation from prescriptive to performance-based is also presented as the background for the research.Extensive research of the issues that arise for performance-based fire safety regulation, specifically for computer models for fire safety calculations, which included international benchmark exercises formed the basis to identify the need for developing international standards for fire safety engineering. The research focused both on the verification and validation (V&V) of computer fire models and determining their predictive capability. The paper for the first time takes new scientific and engineering data from benchmark exercises to assess the suitability and applicability of computer fire models for application in nuclear power plants. The paper reports on the findings of the benchmark exercises and their use in formulating new requirements in ISO international standards on verification and validation of fire calculation methods and the fire safety engineering process through a consensus process of international experts.Discussion of the foundational research at the ISO fire safety engineering committee (ISO TC 92 SC 4) led to a consensus to revise two international standards. One specifying the principles and general requirements for fire safety engineering, and another on the verification and validation procedures for fire calculation methods. The development and content of these two international standards are discussed in this paper. An international technical report was subsequently developed at the ISO committee for conformity assessment (CASCO) to provide guidance for the certification of the fire safety engineering process, and specific parts of it, namely the V&V of fire calculation methods.It is concluded that the fire safety engineering international standards presented in this paper can support rigorous performance-based fire safety regulation for nuclear power plants. These ISO international standards will be particularly useful to nations that have not yet developed the regulatory infrastructure for nuclear power regulation. The international standards are also available to those that would like to transition to the use of international standards and an ISO standards-based certification scheme. Regulations based on these international standards will provide citizens with confidence in nuclear power as a viable option to address climate change.

Design as a learning opportunity in biology lessons—a cross-domain STEM approach and its impact on biological subject knowledge

There is a broad consensus in politics, economy and science about the importance of promoting STEM competences. To promote STEM skills in the classroom, we propose a cross-domain approach combining the STEM sub-domains of Biology and Technology/Engineering. Therefore, we have developed a model that illustrates how the STEM sub-domains of Biology and Technology/Engineering can complement each other in a cognitive process. Both sub-domains show similarities in working methods and consider structural and functional relationships. These synergies can be brought together in a design process. This approach leads to the question of the extent to which a cross-domain approach utilising a design process can be a learning opportunity for biological subject knowledge. Based on this model, we have created a learning arrangement on the topic of the ‘locomotor system’. Learners should use a design process to build a feeding machine inspired by structural-functional relationships in different locomotor systems. In a quasi-experimental study, we compared this Design approach with two alternative teaching approaches (a Reconstruction approach and a Biology approach). In the Reconstruction approach, students receive the same input on structural-functional relationships in locomotor systems but build their feeding machine according to a predetermined plan. In the Biology approach, no feeding machine is built; instead, structural-function relationships in locomotor systems are modelled using further examples from the animal world. 413 pupils (age: M = 12.53, SD = 0.818) took part in the study. Longitudinal and cross-sectional analyses emphasise the potential of the Design approach compared to the other methods and show significant differences in long-term learning outcomes. Path models illustrate that cognitive abilities (IQ) and participation in the ‘Design’-intervention group are decisive prerequisites for learning success. The results also show that students following the Design-approach develop a significantly improved understanding of concepts related to the musculoskeletal system. Using a design process combining biology and engineering presents a learning opportunity for students to develop long-term robust biological knowledge and understanding of biological concepts. Thus, using a design approach can be a cross-domain bridge for integrated STEM instruction in order to foster pupils’ knowledge acquisition and competences.

Stakeholder perceptions of the Commission for the Conservation of Antarctic Marine Living Resources Marine Protected Area planning process

Establishing Marine Protected Areas (MPAs) in international waters is critical for the conservation of marine biodiversity. The Commission for the Conservation of Antarctic Marine Living Resources (CCAMLR) is a global leader in high seas conservation, having established two international MPAs in Antarctica’s Southern Ocean, as part of a commitment to establish a representative system of MPAs for the CAMLR Convention Area. CCAMLR MPAs are adopted by consensus. However, consensus decision-making has slowed the MPA adoption process, and since 2016 the Commission has been unable to agree and implement further MPAs, which has stalled the development of the circumpolar representative system. The key aim of this study was to identify how features of the planning process contribute to outcomes, problems and solutions. We conducted semi-structured interviews with 18 scientists, policymakers, and expert observers from fisheries and environmental non-government organisations involved in CCAMLR MPA planning, to explore their perceptions (experiences, opinions, impressions) of the planning process. Our results identify four key features that are influential across multiple areas of the CCAMLR MPA planning and decision-making process: i) a lack of common understanding; ii) the influence of historical relationships and legacy in subsequent planning processes; iii) inconsistencies between expectations of and requirements for MPA planning; and iv) the degree to which CCAMLR principles and practices, norms, and values are shared. We demonstrate how these four features may help or hinder the effectiveness of the current planning process. We then make suggestions regarding how the planning process could be adapted to capitalise on these features.

Kearifan Lokal dan Ketaatan Adat: Studi Kualitatif tentang Kebudayaan dan Sistem Pemerintahan di Kampung Naga

Kampung Naga, a traditional village in Tasikmalaya renowned for its cultural authenticity and unique governance system, is the focus of this study. The research aims to delve deeper into the local wisdom and adherence to traditions among the Kampung Naga community. Using a qualitative approach, the study analyzes how traditional values and customary governance systems impact the daily lives of the Kampung Naga residents. The findings indicate that the Kampung Naga community continues to uphold inherited local wisdom, such as mutual cooperation, consensus-based decision-making, and respect for nature. Adherence to customs also serves as a strong foundation in preserving the cultural and social integrity of the community. The study concludes that local wisdom and adherence to customs play a crucial role in shaping the identity and sustainability of the Kampung Naga community.

Pendidikan Kewarganegaraan Berbasis Adat: Studi Kasus Masyarakat Kampung Naga

In the era of globalization, indigenous communities are increasingly at risk of losing their identity and traditional values. Kampung Naga, one of the oldest traditional villages in Indonesia, has a complex social and cultural system. This study aims to deeply examine the role of traditional institutions in shaping and instilling civic values in the indigenous community of Kampung Naga. Through a qualitative case study method, this research analyzes the structure of traditional institutions, decision-making mechanisms, and customary practices related to citizenship. The results of the study show that traditional institutions have a central role in preserving the values of mutual cooperation, consensus-based decision-making, and respect for nature. Customary practices such as traditional ceremonies, village meetings, and social sanctions serve as effective social control mechanisms in shaping the character of good citizens. This study concludes that the traditional institutions of Kampung Naga can serve as a model for the development of character education and citizenship rooted in local values.

PRACTICE: Development of a Core Outcome Set for Trials of Physical Rehabilitation in Critical Illness.

Rationale Findings from individual trials of physical rehabilitation interventions in critically ill adults have limited potential for meta-analysis and informing clinical decision-making due to heterogeneity in selection and reporting of outcomes used for evaluation. Objective The objective of this study was to determine a core outcome set (COS) for use in all future trials evaluating physical rehabilitation interventions delivered across the critical illness continuum of recovery. Methods An international, two-round, online, modified Delphi consensus process, following recommended standards, was conducted. Participants (N=329) comprised three stakeholder groups (Researchers, n=58 (18%); Clinicians, n=247 (75%); Patients and Caregivers, n=24 (7%)), and represented 26 countries and 9 healthcare professions. Participants rated the importance of a range of relevant outcomes. Outcomes included in the COS were those prioritised of "critical importance" by all three stakeholder groups. Results Survey response rates were 88% (Round 1) and 91% (Round 2). From a total of 32 initial outcomes, the following outcomes reached consensus for inclusion in the COS: Physical Function, Activities of Daily Living, Survival, Health-related Quality of Life, Exercise Capacity, Cognitive Function, Emotional and Mental Wellbeing, and Frailty. Conclusion This study developed a consensus-generated COS for future clinical research evaluating physical rehabilitation interventions in critically ill adults across the continuum of recovery. Ascertaining recommended measurement instruments for these core outcomes is now required to facilitate implementation of the COS. This article is open access and distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/).

Dynamic Byzantine Fault-Tolerant Consensus Algorithm with Supervised Feedback Mechanisms

Among the existing consensus algorithms, there are very few low-latency consensus algorithms that can simultaneously take into account node dynamics, fault tolerance, and scalability, and which are applicable to large-scale open scenarios where low latency is required. Therefore, this paper proposes a low-latency scalable dynamic consensus algorithm with high fault tolerance utilizing a combination of layered and threshold signature technologies, known briefly as LTSBFT. Firstly, LTSBFT achieves linear communication complexity through the utilization of threshold signature technology and a two-layer structure. Secondly, the mutual supervision feedback mechanism among nodes enables the attainment of linear complexity for reaching consensus on the faulty upper-layer nodes during the view-change. Lastly, a node dynamic protocol was proposed for the first time to support dynamic changes in the number of nodes during the consensus process. That is to say, consensus can still be reached when the number of nodes dynamically changes without interrupting the client’s request for consensus in the network. The experimental results indicate that LTSBFT exhibits lower communication latency and higher throughput compared to the classic HotStuff and PBFT algorithms. Furthermore, in comparison to double-layer PBFT, the LTSBFT has been demonstrated to have improved fault tolerance.

Key stages of adapting the acquis communautaire to Ukraine's legal system: a historical overview

The article is aimed at clarifying the status of regulatory and legal support for the process of adaptation of the national legislation to the acquis communautaire. It is stated that the Ukrainian state has already completed most of the steps to join the EU. Attention is focused on the relevance of the study, which is due to Ukraine's officially obtaining the EU candidate status and the transition to the negotiation process between the EU and Ukraine on the latter's accession to the EU. The author analyses the provisions of Ukrainian legislation and scientific research on the understanding of the concept of ‘acquis communautaire’. The author's definition of this legal phenomenon is formulated, which should be understood as the sources of EU law, standards, principles of external and internal activities and other achievements of the European Communities. The author's own approach to distinguishing four stages of adaptation of the national legislation to the acquis communautaire in chronological order is proposed. The first stage was when Ukrainian legislation implemented the EU norms and standards to establish economic cooperation between Ukraine and the EU in various areas for the development of various relations between the partners. The second stage was a testament to the irresistible desire of Ukraine and Ukrainians to be part of the EU community and contributed to the signing and entry into force of the EU-Ukraine Association Agreement. The third stage demonstrates Ukraine's path from the signing of the EU-Ukraine Association Agreement to the EU candidate status. The fourth stage is connected with the European Council's announcement of the start of negotiations with Ukraine on the country's accession to the EU and the need for comprehensive harmonisation and adaptation of Ukrainian legislation to the EU acquis in connection with the prospect of EU membership. It is emphasised that the implementation of the acquis communautaire into the national legal system should pursue national interests and be a political, economic, legal and social consensus on key issues of European integration transformations

How to Tackle Discordance in Adjuvant Chemotherapy Recommendations by Using Oncotype DX Results, in Early-Stage Breast Cancer.

The use of the Oncotype DX test reduces the rate of adjuvant chemotherapy recommendations. Few in-depth analyses have been performed on this decision-making process. We retrospectively analyzed patient data based on available Oncotype DX test results (RS) irrespective of nodal status at a single center. We collected recommendations from six oncologists, first without RS (pre-RS) and then with RS results (post-RS). We investigated changes in recommendations, agreement between oncologist decisions, and the effect of different National Comprehensive Cancer Network (NCCN) recommendation categories (for, against, and considering chemotherapy). Data from 201 patients were included in the analysis. Recommendation of chemotherapy decreased by an average of 39.5%. Agreement improved substantially with RS, with a kappa value pre-RS of 0.37 (fair agreement) and post-RS of 0.75 (substantial agreement). Discordance remained substantial in cases where the NCCN recommendations considered chemotherapy only (32%). Pre-RS consensus against chemotherapy predicted low RS results (50 out of 51 patients). Post-RS consensus was highest in the NCCN chemotherapy recommendation group. The Oncotype DX test substantially improves decision accuracy in recommending adjuvant chemotherapy. It may be further improved with a consensus decision. In the case of pre-RS consensus against chemotherapy, the test can be spared.