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Introduction Multistakeholder engagement is crucial for conducting health services research. Delphi‐based methodologies combining iterative rounds of questions with feedback on and discussion of group results are a well‐documented approach to multistakeholder engagement. This study develops hypotheses about the impact of panel composition and topic on the propensity and meaningfulness of response changes in multistakeholder modified‐Delphi panels. Methods We conducted three online modified‐Delphi (OMD) multistakeholder panels using the same protocol. We assigned 60 maternal and child health professionals to a homogeneous (professionals only) panel, 60 pregnant or postpartum women (patients) to a homogeneous panel, and 30 professionals and 30 patients to a mixed panel. In Round 1, participants rated the seriousness of 11 maternal and child health outcomes using a 0–100 scale and explained their ratings. In Round 2, participants saw their own and their panel's Round 1 results and discussed them using asynchronous, anonymous discussion boards moderated by the study investigators. In Round 3, participants revised their original ratings. Our outcome measures included binary indicators of response changes to ratings of the low, medium and high severity maternal and child health outcomes and their meaningfulness, measured by a change of 10 or more points. Results Participants changed 818 of 1491 (55%) of responses; the majority of response changes were meaningful. Patterns of response changes were different for patients and professionals and for different levels of outcome seriousness. Using study results and the literature, we developed three hypotheses. First, OMD participants, regardless of their stakeholder group, are more likely to change their responses on preference‐sensitive topics where there is a range of viable alternatives or perspectives. Second, patients are more likely to change their responses and to do so meaningfully in mixed panels, whereas professionals are more likely to do so in homogeneous panels. Third, the association between panel composition and response change varies according to the topic (e.g., the level of outcome seriousness). Conclusions Results of our work not only helped generate empirically derived hypotheses to be tested in future research but also offer practical recommendations for designing multistakeholder OMD panels. Patient or Public Contribution Pregnant or postpartum women were involved in this study.

Abstract Background The IBD Qorus Collaborative aims to reduce variation and increase the value of care for the adult inflammatory bowel disease (IBD) community. To evaluate the success of the collaborative, we aimed to develop a balanced set of outcome measures that reflect a multistakeholder view of value in IBD care. To achieve this, we used the Clinical Value Compass framework and engaged a mixed-stakeholder group to conduct a modified Delphi process. The end result was a 10-measure set to assess the value of IBD care. Method The modified Delphi process included 3 iterative rounds of blinded voting and interactive webinar-style discussion. We recruited 18 participants for the Delphi panel, including clinicians, researchers, patients, Crohn’s & Colitis Foundation staff, and payers. Participants first identified constructs to measure, then identified the tools to measure those constructs. A literature review and environmental scan of current measures in 4 domains were performed, and relevant measures were proposed for discussion and voting in each domain. Throughout the process, participants were invited to contribute additional measures. Conclusion The modified Delphi process led to selection of 10 value measures across 4 domains: (1) patient experience; (2) functional status; (3) clinical status; and (4) health care costs and utilization. We have successfully completed a 3-stage modified Delphi process to develop a balanced set of value measures for adult IBD care. The value measure set expands upon prior efforts that have established quality measures for IBD care by adding cost and experience of care elements. This work positions IBD Qorus to better assess, study, improve, and demonstrate value at individual, system, and population levels and will inform and empower related research, improvement, and implementation efforts.

Background Evidence-based information on the resumption of daily activities following uncomplicated abdominal surgery is scarce and not yet standardized in medical guidelines. As a consequence, convalescence recommendations are generally not provided after surgery, leading to patients’ insecurity, needlessly delayed recovery and prolonged sick leave. The aim of this study was to generate consensus-based multidisciplinary convalescence recommendations, including advice on return to work, applicable for both patients and physicians. Method Using a modified Delphi method among a multidisciplinary panel of 13 experts consisting of surgeons, occupational physicians and general practitioners, detailed recommendations were developed for graded resumption of 34 activities after uncomplicated laparoscopic cholecystectomy, laparoscopic and open appendectomy, laparoscopic and open colectomy and laparoscopic and open inguinal hernia repair. A sample of occupational physicians, general practitioners and surgeons assessed the recommendations on feasibility in daily practice. The response of this group of care providers was discussed with the experts in the final Delphi questionnaire round. Results Out of initially 56 activities, the expert panel selected 34 relevant activities for which convalescence recommendations were developed. After four Delphi rounds, consensus was reached for all of the 34 activities for all the surgical procedures. A sample of occupational physicians, general practitioners and surgeons regarded the recommendations as feasible in daily practice. Conclusion Multidisciplinary convalescence recommendations regarding uncomplicated laparoscopic cholecystectomy, appendectomy (laparoscopic, open), colectomy (laparoscopic, open) and inguinal hernia repair (laparoscopic, open) were developed by a modified Delphi procedure. Further research is required to evaluate whether these recommendations are realistic and effective in daily practice.

Background Rabies poses a significant threat to public health in India, with schoolchildren comprising approximately 40% of mortality due to this zoonotic disease. Despite ongoing interventions in schools to increase awareness about rabies and free-roaming dogs (FRD), the incidence of dog bites and rabies cases among schoolchildren continues to rise. This study addresses the limitations of existing awareness programs by exploring educators' perspectives and proposing innovative, feasible, and cost-effective interventions in schools. Methods A three-day workshop involving 19 teachers from seven schools representing diverse socio-economic backgrounds by adopting a modified Delphi method to achieve consensus on interventions identified during the process. Results The workshop recommends (a) promoting awareness in morning assemblies, (b) starting a wall magazine on One Health, (c) distributing and displaying information, education, and communication (IEC) materials, (d) encouraging infographics, paintings, sketches, and reels, (e) integrating rabies-related topics in co-curricular activities, (f) initiating interdisciplinary projects focusing on rabies awareness (g) displaying in rabies awareness stalls during exhibitions/school functions, and (h) discussing in parent-teachers meets. Conclusions This study identifies sustainable and pedagogically sound interventions to raise awareness about rabies and FRD in schools, contributing to the broader goal of reducing rabies-related mortality among school children.

Abstract STUDY QUESTION We aim to develop, disseminate and implement a minimum data set, known as a core outcome set, for future male infertility research. WHAT IS KNOWN ALREADY Research into male infertility can be challenging to design, conduct and report. Evidence from randomized trials can be difficult to interpret and of limited ability to inform clinical practice for numerous reasons. These may include complex issues, such as variation in outcome measures and outcome reporting bias, as well as failure to consider the perspectives of men and their partners with lived experience of fertility problems. Previously, the Core Outcome Measure for Infertility Trials (COMMIT) initiative, an international consortium of researchers, healthcare professionals and people with fertility problems, has developed a core outcome set for general infertility research. Now, a bespoke core outcome set for male infertility is required to address the unique challenges pertinent to male infertility research. STUDY DESIGN, SIZE, DURATION Stakeholders, including healthcare professionals, allied healthcare professionals, scientists, researchers and people with fertility problems, will be invited to participate. Formal consensus science methods will be used, including the modified Delphi method, modified Nominal Group Technique and the National Institutes of Health’s consensus development conference. PARTICIPANTS/MATERIALS, SETTING, METHODS An international steering group, including the relevant stakeholders outlined above, has been established to guide the development of this core outcome set. Possible core outcomes will be identified by undertaking a systematic review of randomized controlled trials evaluating potential treatments for male factor infertility. These outcomes will be entered into a modified Delphi method. Repeated reflection and re-scoring should promote convergence towards consensus outcomes, which will be prioritized during a consensus development meeting to identify a final core outcome set. We will establish standardized definitions and recommend high-quality measurement instruments for individual core outcomes. STUDY FUNDING/COMPETING INTEREST(S) This work has been supported by the Urology Foundation small project award, 2021. C.L.R.B. is the recipient of a BMGF grant and received consultancy fees from Exscentia and Exceed sperm testing, paid to the University of Dundee and speaking fees or honoraria paid personally by Ferring, Copper Surgical and RBMO. S.B. received royalties from Cambridge University Press, Speaker honoraria for Obstetrical and Gynaecological Society of Singapore, Merk SMART Masterclass and Merk FERRING Forum, paid to the University of Aberdeen. Payment for leadership roles within NHS Grampian, previously paid to self, now paid to University of Aberdeen. An Honorarium is received as Editor in Chief of Human Reproduction Open. M.L.E. is an advisor to the companies Hannah and Ro. B.W.M. received an investigator grant from the NHMRC, No: GNT1176437 is a paid consultant for ObsEva and has received research funding from Ferring and Merck. R.R.H. received royalties from Elsevier for a book, consultancy fees from Glyciome, and presentation fees from GryNumber Health and Aytu Bioscience. Aytu Bioscience also funded MiOXYS systems and sensors. Attendance at Fertility 2020 and Roadshow South Africa by Ralf Henkel was funded by LogixX Pharma Ltd. R.R.H. is also Editor in Chief of Andrologia and has been an employee of LogixX Pharma Ltd. since 2020. M.S.K. is an associate editor with Human Reproduction Open. K.Mc.E. received an honoraria for lectures from Bayer and Pharmasure in 2019 and payment for an ESHRE grant review in 2019. His attendance at ESHRE 2019 and AUA 2019 was sponsored by Pharmasure and Bayer, respectively. The remaining authors declare no competing interests. TRIAL REGISTRATION NUMBER Core Outcome Measures in Effectiveness Trials (COMET) initiative registration No: 1586. Available at www.comet-initiative.org/Studies/Details/1586. TRIAL REGISTRATION DATE N/A. DATE OF FIRST PATIENT’S ENROLMENT N/A.

The increasing incidence of P. knowlesi malaria infection among humans is a public health threat. This zoonotic disease is challenging to eliminate owing to the presence of animal reservoirs. Understanding the factors such as the community’s belief, social context, drivers, and barriers can provide insights into malaria preventive behavior. It is crucial to improve the current preventive measures. This study aims to achieve consensus among malaria experts based on evidence from literature reviews and experts’ opinions on possible factors influencing malaria preventive behavior among communities exposed to P. knowlesi malaria infection. A modified Delphi study protocol was developed to gather experts’ consensus on the study framework to explore the factors influencing preventive behavior among communities exposed to P. knowlesi malaria infection. The framework is adapted from the ideation model, and it is integrated with other relevant theories and extensive literature reviews. We will use the modified Delphi protocol to reach a consensus. The experts will respond to each questionnaire item and a related open-ended questionnaire. Consensus is predetermined at more than 70% agreement on the items. We will use descriptive statistics and thematic analysis to analyze the data. All experts will remain anonymous to maintain the characteristics of a traditional Delphi study.

Background Cumulative evidence supports the importance of health literacy in determining the quality of healthcare delivery and outcomes. To enhance health literacy competencies among professionals and alleviate healthcare barriers owing to patients’ inadequate health literacy, evidence-based health literacy competency guidelines are needed for the development of health professionals’ training curricula. The aim of this study was to validate and refine a set of health literacy competencies, including knowledge, attitude, and skills of health professionals, and to prioritize the importance of health literacy practices among healthcare professionals. Methods We employed a consensus-building approach that utilized a modified three-round Delphi process conducted in 2017. An online Delphi panel was assembled, comprising 20 Taiwanese health literacy experts from diverse fields such as medicine, nursing, public health, language, and communication. A set of health literacy competencies previously identified and validated by an international panel of health literacy experts was cross-culturally translated. Results After three rounds of ratings and modifications, a consensus agreement was reached on 42 of 62 health literacy competencies, including 12 of 24 knowledge items, 9 of 11 attitude items, and 21 of 27 skill items. Of the 32 health literacy practices, “avoidance using medical jargon,” “speaking slowly and clearly with patients,” and “using analogies and examples” were deemed most important by the panelists. Conclusions The Delphi panel’s consensus helped to identify a set of core health literacy competencies that could serve as measurable learning objectives to guide the development of a health literacy curriculum for health professionals. The prioritized health literacy practices can be employed as indicators of health literacy competencies that health professionals should learn and routinely use in clinical settings.

Background Arthrogryposis multiplex congenita (AMC) is a group of rare disorders characterized by multiple joint contractures present at birth. Early rehabilitation is essential to minimize joint contractures and maximize autonomy and participation among individuals with AMC. However, there is little robust scientific evidence to inform best practice. This project aimed to develop consensus-based recommendations for the rehabilitation management of children with AMC in the following priority areas: early intervention and motor development, muscle and joint function, orthotics, mobility, participation in areas of life, pain, psychosocial wellbeing, and perioperative rehabilitation. Results This multi-phase project used an integrated knowledge translation approach. Based on the results from scoping reviews on the priority areas identified for the rehabilitation of children with AMC, and a clinician survey describing current practices in AMC rehabilitation, three panels of expert clinicians in occupational therapy, physical therapy, orthopedics, physiatry, and social work, as well as people with lived experience and researchers from 10 countries developed consensus-based recommendations for rehabilitation, in concordance with the Grading of Recommendations, Assessment, Development and Evaluations framework (GRADE) criteria. A modified Delphi process was completed with a wider group of international AMC experts to revise and validate the recommendations (Round 1 = 41 and Round 2 = 37 experts). A five-member external review panel appraised the recommendations using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. The final 16 recommendations reached a mean agreement rate of 96.6% after two Delphi rounds. The overall quality was rated at 96.6% on the AGREE II tool. Interviews with clinicians and managers identified facilitators and barriers to implementation of the recommendations in practice using the Theoretical Domain Framework. Conclusion Consensus-based, expert validated recommendations for the rehabilitation of children with AMC were developed by a wide range of stakeholders, healthcare users and providers. The proposed recommendations are expected to contribute to improving child- and family-centered practice and health outcomes. Future work includes a knowledge translation strategy to promote sharing and implementation of the recommendations in practice.

Background There is a growing need for Entrustable Professional Activities (EPAs) specifically tailored to health professions educators including dental educators, whose responsibilities extend well beyond clinical expertise. Despite the breadth and complexity of these responsibilities, the current literature lacks EPA frameworks that are explicitly designed to reflect the unique and multifaceted scope of practice of dental educators. Objective The objective of this Modified Delphi study was to develop a validated and consensus-based set of EPAs for dental educators. Methods A three-stage consensus-building approach was employed in this study: (1) identification of existing EPAs in the literature through a systematic scoping review; (2) two rounds of a Modified Delphi exercise conducted via online questionnaires; and (3) a final in-person consensus focus group discussion to refine and finalise the list of EPAs. A total of 40 EPAs were systematically identified through a scoping review of the literature. These EPAs were subsequently evaluated by a panel of 10 experts using a three-stage modified Delphi technique. Consensus was quantitatively define as median rating of ≥3 on a 4-point Likert scale, with an item-level Content Validity Index (i-CVI) of ≥0.8. Open ended responses were thematically analysed. Results In the first round, consensus was reached to eliminate 6 EPAs, 7 EPAs further consolidated to 2 EPAs, 12 EPAs were revised and 15 EPAs were accepted without revision. In the second round, a total of 81 EPAs, comprising 29 retained from the first round and 52 newly suggested EPAs, were reviewed. Consensus was reached to exclude 1 EPA. By the end of Round 2, 80 EPAs were brought forward to the third round, which was conducted as in-person focus group meeting. The final round resulted in the elimination of 6 EPAs and the consolidation of 9 EPAs into 3, culminating in the endorsement of 68 EPAs, which were systematically organized into 12 distinct domains. Conclusions This study successfully developed a validated and consensus-based set of 68 EPAs tailored for dental educators, addressing a critical gap in the current literature. This set provides a foundational tool to guide professional development, performance assessment, and role definition of dental educator.

Background Achondroplasia is the most common form of skeletal disorder with disproportionate short stature. Vosoritide is the first disease-specific, precision pharmacotherapy to increase growth velocity in children with achondroplasia. Limb surgery is a standard approach to increase height and arm span, improve proportionality and functionality, as well as correcting deformities. The aim of this study was to gain expert opinion on the combined use of vosoritide and limb surgery in children and adolescents with achondroplasia. Methods An international expert panel of 17 clinicians and orthopaedic surgeons was convened, and a modified Delphi process undertaken. The panel reviewed 120 statements for wording, removed any unnecessary statements, and added any that they felt were missing. There were 26 statements identified as facts that were not included in subsequent rounds of voting. A total of 97 statements were rated on a ten-point scale where 1 was ‘Completely disagree’ and 10 ‘Completely agree’. A score of ≥ 7 was identified as agreement, and ≤ 4 as disagreement. All experts who scored a statement ≤ 4 were invited to provide comments. Results There was 100% agreement with several statements including, “Achieve a target height, arm span or upper limb length to improve daily activities” (mean level of agreement [LoA] 9.47, range 8–10), the “ Involvement of a multidisciplinary team in a specialist centre to follow up the patient” (mean LoA 9.67, range 7–10), “ Planning a treatment strategy based on age and pubertal stage” (mean LoA 9.60, range 8–10), and “ Identification of short- and long-term goals, based on individualised treatment planning” (mean LoA 9.27, range 7–10), among others. The sequence of a combined approach and potential impact on the physes caused disagreement, largely due to a lack of available data. Conclusions It is clear from the range of responses that this modified Delphi process is only the beginning of new considerations, now that a medical therapy for achondroplasia is available. Until data on a combined treatment approach are available, sharing expert opinion is a vital way of providing support and guidance to the clinical community.