What mobility factors are critical to include in a comprehensive mobility discharge assessment framework for older adults transitioning from hospital-to-home in the community? An international e-Delphi study.

PURPOSE: To prioritize and achieve consensus on mobility determinant factors [cognitive, financial, environmental, personal, physical, psychological, social] considered critical to include in the COmprehensive Mobility Discharge Assessment Framework (COMDAF) for older adults transitioning from hospital-to-home. MATERIALS AND METHODS: We conducted a three-round modified e-Delphi process with 60 international experts (seven older adults, nine family caregivers, 24 clinicians, and 20 researchers) from nine countries with universal or near-universal health coverage. Expert members rated 91 factors identified from scoping reviews using a 9-point scale: not important (1-3), important (4-6), and critical (7-9). RESULT: A total of 41 of 91 factors (45.1%) met the a-priori consensus criterion after three rounds: five cognitive, five environmental, two personal, 19 physical, six psychological, and six social factors. No financial factors reached a consensus. The older adult steering committee member recommended the addition of two environmental factors, resulting in 43 mobility factors included in the COMDAF. CONCLUSIONS: We advanced a comprehensive mobility framework by developing, through consensus, 43 mobility factors to be assessed as part of a COMDAF. However, its use in hospital-to-home may not be feasible. Therefore, future research will determine the core mobility factors for COMDAF and which measurement instruments best measure these factors. RELEVANCE: An interdisciplinary discharge rehabilitation team can utilize the COMDAF during hospital-to-home transition.Implications for rehabilitationMobility assessment following a hospital discharge is a complex process requiring an interdisciplinary discharge rehabilitation team.This study provided a comprehensive list of 91 factors across all seven mobility determinants (cognitive, environmental, financial, personal, physical, psychological, and social) for clinicians in other care settings to use as a starting point to determine which mobility factor should be assessed during older adults' hospital-to-home transition.This international e-Delphi study identified 43 factors within mobility determinants (cognitive, environmental, personal, physical, psychological, and social) to be included in a Comprehensive Mobility Discharge Assessment Framework to assess older adults' mobility during the hospital to home transition.Using these 43 factors, clinicians can identify which assessment tool is best suited to assess the factors while reflecting on the logistics and feasibility; this is the next phase of this project.

A national needs assessment to identify technical procedures in plastic surgery for simulation-based training.

Medical simulation is not developed and integrated into plastic surgery unlike other surgical specialties despite the procedures being complex and require practice. First step in enhancing simulation in plastic surgery is to clarify the need among peers. The objective of the study was to identify and prioritize the technical procedures that should be included in a simulation-based curriculum for residency training in plastic surgery. A panel of participants with key roles in the Danish plastic surgery specialist training program was appointed. Participation was voluntary. A national need assessment study was performed using a three-round Delphi process to collect information from the participants. In round 1, participants reported all the procedures that a newly qualified specialist in plastic surgery should be able to perform. In round 2, participants replied to a survey exploring the frequency of the procedures, the number of surgeons performing the procedure, the risk or discomfort for patients treated by an inexperienced surgeon and the feasibility of training the procedure in simulation, resulting in a preliminary ranking of procedures. In round 3, participants eliminated and reprioritized the identified procedures according to importance. Thirty-five of 37 agreed to enter the expert panel. The response rate was 97%, 86% and 86% for rounds 1, 2 and 3, respectively. Twenty-nine of 136 procedures identified in round 1 reached the final prioritized list of procedures relevant for simulation training in plastic surgery.

Enhancing Surgical Teaching Effectiveness: A Needs Assessment Study Using a Modified Delphi Process.

INTRODUCTION: As methods of measuring surgical resident competency become more defined, how can faculty know that they are effectively guiding residents toward increasing entrustment? The goal of this study was to use a systematic process to identify effective teaching behaviors, understand discrepancies between learner and teacher perception of behaviors, and provide an insight into areas for improvement in surgical teaching. MATERIALS AND METHODS: A modified Delphi process was used to create a list of critical teaching behaviors for surgical resident education in four domains: Operating Room, Clinic, Inpatient Rounds, and Didactics. Round One surveyed residents and faculty to identify critical teaching behaviors. In Rounds Two and Three, stakeholders narrowed the list to five behaviors in each domain. A needs assessment survey was created and used to identify (1) areas for improvement in residency education and (2) differences in perception of teaching behavior use between faculty and residents. RESULTS: Eighty one faculty and 56 residents in the Department of Surgery completed the survey. All teaching behaviors in the Operating Room, Clinic, and Rounds domains had a significant difference in response distribution between residents and faculty. Except in Didactics, residents perceived that teaching behaviors were performed less often by attending surgeons than was reported by the faculty members. CONCLUSIONS: A modified Delphi process is an effective way to create a needs assessment survey relating to how surgical education is delivered. Future steps will involve directed interventions aimed at improving the use of certain surgical teaching behaviors in our department.

Career Advancement for Surgeon-Educators:Findings from a Modified Delphi Process.

OBJECTIVES: Reward and recognition of surgical education as an academic activity remains a highly variable process between institutions. The goal of this study is to provide expert consensus definition of an academic surgical educator, with focus on criteria for academic promotion. STUDY DESIGN AND SETTING: Following IRB approval, a Web-based modified Delphi process was used to generate prioritized academic promotion criteria for surgical educators. PARTICIPANTS AND SETTING: Participants were recruited nationally from a pool of senior academic surgeons who are members of the Society of University Surgeons and the Society of Surgical Chairs. RESULTS: Following a three-round modified Delphi process, the top domains of educational activity for promotion to associate professor and professor were scholarship, teaching, and administration; mentorship was also a priority category for promotion to professor. The top three activities described for promotion to Associate Professor were active participation in conferences/ departmental educational activities for medical students and residents; educational portfolio demonstrating commitment to activities as an educator; and clinical teaching excellence at their home institution. The three activities most highly scored items for promotion to Professor were mentorship of junior surgical educators; active participation in conferences/ departmental educational activities for medical students and residents; and a record of teaching excellence at the medical student and resident levels. CONCLUSIONS: These findings demonstrate a progression from teacher to scholar to leader across a surgical educator's career, with each level incorporating and building upon the prior activities. Identification of categories and criteria may meaningfully inform best practices to be incorporated into the career development and promotion processes for surgeons on an educator academic pathway.

Assessment of Informed Consent and the Impact of Simulation on Anesthesia Trainees.

Introduction Over the years, the process of obtaining informed consent has evolved and now places an emphasis on the concept that patients should play a major role in medical decision making. Failure to adequately involve patients in making decisions regarding their health can lead to medicolegal consequences. Therefore, taking informed consent is a fundamental component of anaesthesia training. Simulation, for training, is an excellent tool that is being utilised widely in the training of medical professionals. The use of simulated training for teaching the process of informed consent is an innovative initiative that can provide improved results. Material and methods After approval from the institutional review board, a prospective clinical study was conducted at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, from August 2019 to September 2020. Sixteen anaesthesia trainees were randomly selected for the study. The study was divided into pre-interventional, interventional and post interventional phases. For data collection, a predesigned checklist was used. Data collected was analysed using SPSS version 23 (IBM Inc., Armonk, New York). The McNemar test was deployed to assess the difference between the baseline assessment and post-simulated training assessment; p-value < 0.05 was taken to be significant. Results Of the 16 participants, the majority were males (n= 13). A positive impact was observed in terms of improvement of the outcome of the following study components i.e., description of benefits of the procedure (p=0.01), disclosure of associated minor risks (p=0.005), disclosure of major risks (p=0.01), discussion of alternatives (p=0.001), teach back (p=0.001), documentation of patients' verbal agreement (p=0.01), and communication skills involving utilising the process of connecting, introduction, communication, permission, response, and exit (p = 0.01). Conclusion Simulated training had a positive impact in improving outcomes in the following study components: description of benefits of the procedure, disclosure of associated risks, discussion of alternatives, teach back, documentation of patients' verbal agreement, and utilisation of the process of connecting, introduction, communication, permission, responding, and exiting.

Development and Validation of an Instrument to Measure Health-Related Out-of-Pocket Costs: The Cost for Patients Questionnaire.

OBJECTIVE: The growth of healthcare spending is a major concern for insurers and governments but also for patients whose health problems may result in costs going beyond direct medical costs. To develop a comprehensive tool to measure direct and indirect costs of a health condition for patients and their families to various outpatient contexts. METHODS: We conducted a content and face validation including results of a systematic review to identify the items related to direct and indirect costs for patients or their families and an online Delphi to determine the cost items to retain. We conducted a pilot test-retest with 18 naive participants and analyzed data calculating intraclass correlation and kappa coefficients. RESULTS: An initial list of 34 items was established from the systematic review. Each round of the Delphi panel incorporated feedback from the previous round until a strong consensus was achieved. After 4 rounds of the Delphi to reach consensus on items to be included and wording, the questionnaire had a total of 32 cost items. For the test-retest, kappa coefficients ranged from -0.11 to 1.00 (median = 0.86), and intraclass correlation ranged from -0.02 to 0.99 (median = 0.62). CONCLUSIONS: A rigorous process of content and face development was implemented for the Cost for Patients Questionnaire, and this study allowed to set a list of cost elements to be considered from the patient's perspective. Additional research including a test-retest with a larger sample will be part of a subsequent validation strategy.

Primary health care financing interventions: a systematic review and stakeholder-driven research agenda for the Asia-Pacific region.

INTRODUCTION: Interventions targeting the financing of primary health care (PHC) systems could accelerate progress towards universal health coverage; however, there is limited evidence to guide best-practice implementation of these interventions. This study aimed to generate a stakeholder-led research agenda in the area of PHC financing interventions in the Asia-Pacific region. METHODS: We adopted a two-stage process: (1) a systematic review of financing interventions targeting PHC service delivery in the Asia-Pacific region was conducted to develop an evidence gap map and (2) an electronic-Delphi (e-Delphi) exercise with key national PHC stakeholders was undertaken to prioritise these evidence needs. RESULTS: Thirty-one peer-reviewed articles (including 10 systematic reviews) and 10 grey literature reports were included in the review. There was limited consistency in results across studies but there was evidence that some interventions (removal of user fees, ownership models of providers and contracting arrangements) could impact PHC service access, efficiency and out-of-pocket cost outcomes. The e-Delphi exercise highlighted the importance of contextual factors and prioritised research in the areas of: (1) interventions to limit out-of-pocket costs; (2) financing models to enhance health system performance and maintain PHC budgets; (3) the design of incentives to promote optimal care without unintended consequences and (4) the comparative effectiveness of different PHC service delivery strategies using local data. CONCLUSION: The research questions which were deemed most important by stakeholders are not addressed in the literature. There is a need for more research on how financing interventions can be implemented at scale across health systems. Such research needs to be pragmatic and balance academic rigour with practical considerations.

How to select patients for antireflux surgery? The ICARUS guidelines (international consensus regarding preoperative examinations and clinical characteristics assessment to select adult patients for antireflux surgery).

OBJECTIVE: Antireflux surgery can be proposed in patients with GORD, especially when proton pump inhibitor (PPI) use leads to incomplete symptom improvement. However, to date, international consensus guidelines on the clinical criteria and additional technical examinations used in patient selection for antireflux surgery are lacking. We aimed at generating key recommendations in the selection of patients for antireflux surgery. DESIGN: We included 35 international experts (gastroenterologists, surgeons and physiologists) in a Delphi process and developed 37 statements that were revised by the Consensus Group, to start the Delphi process. Three voting rounds followed where each statement was presented with the evidence summary. The panel indicated the degree of agreement for the statement. When 80% of the Consensus Group agreed (A+/A) with a statement, this was defined as consensus. All votes were mutually anonymous. RESULTS: Patients with heartburn with a satisfactory response to PPIs, patients with a hiatal hernia (HH), patients with oesophagitis Los Angeles (LA) grade B or higher and patients with Barrett's oesophagus are good candidates for antireflux surgery. An endoscopy prior to antireflux surgery is mandatory and a barium swallow should be performed in patients with suspicion of a HH or short oesophagus. Oesophageal manometry is mandatory to rule out major motility disorders. Finally, oesophageal pH (±impedance) monitoring of PPI is mandatory to select patients for antireflux surgery, if endoscopy is negative for unequivocal reflux oesophagitis. CONCLUSION: With the ICARUS guidelines, we generated key recommendations for selection of patients for antireflux surgery.

Unmet Medical Needs in Ulcerative Colitis: An Expert Group Consensus.

BACKGROUND: The authors aimed to conduct an extensive literature review and consensus meeting to identify unmet needs in ulcerative colitis (UC) and ways to overcome them. UC is a relapsing and remitting inflammatory bowel disease with varied, and changing, incidence rates worldwide. UC has an unpredictable disease course and is associated with a high health economic burden. During 2016 and 2017, a panel of experts was convened to identify, discuss and address areas of unmet need in UC. METHODS: PubMed and Cochrane Library databases were searched for relevant articles describing studies performed in patients with UC. These findings were used to generate a set of statements relating to unmet needs in UC. Consensus on these statements was then sought from a panel of 9 expert gastroenterologists using a modified Delphi review process that consisted of anonymous surveys followed by live meetings. RESULTS: In 2 literature reviews, over 5,000 unique records were identified and a total of 138 articles were fully reviewed. These were used to consider 26 areas of unmet need, which were explored in 2 face-to-face meetings, in which the statements were debated and amended, resulting in consensus on 30 final statements. The unmet needs identified were categorised into 7 areas: impact of UC on patients' daily life; importance of early diagnosis and treatment; drawbacks of existing treatments; urgent need for new treatments; and disease-, practice- or patient-focused unmet needs. CONCLUSIONS: These expert group meetings found a number of areas of unmet needs in UC, which is an important first step in tackling them in the future. Future research and development should be focused in these areas for the management of patients with UC.

The patient-centered dental home: A standardized definition for quality assessment, improvement, and integration.

OBJECTIVE: To develop the first standardized definition of the patient-centered dental home (PCDH). DATA SOURCES/STUDY SETTING: Primary data from a 55-member national expert panel and public comments. STUDY DESIGN: We used a modified Delphi process with three rounds of surveys to collect panelists' ratings of PCDH characteristics and open-ended comments. The process was supplemented with a 1-month public comment period. DATA COLLECTION/EXTRACTION METHODS: We calculated median ratings, analyzed consensus using the interpercentile range adjusted for symmetry, and qualitatively evaluated comments. PRINCIPAL FINDINGS: Forty-nine experts (89%) completed three rounds and identified eight essential PCDH characteristics, resulting in the following definition: "The patient-centered dental home is a model of care that is accessible, comprehensive, continuous, coordinated, patient- and family-centered, and focused on quality and safety as an integrated part of a health home for people throughout the life span." CONCLUSIONS: This PCDH definition provides the foundation for developing measures for research, care improvement, and accreditation and is aligned with the patient-centered medical home. Consensus among a broad national expert panel-including provider, payer, and accreditation stakeholder organizations and experts in medicine, dentistry, and quality measurement-supports the definition's usability and its potential to facilitate medical-dental primary care integration.

An Assessment Framework for e-Mental Health Apps in Canada: Results of a Modified Delphi Process.

BACKGROUND: The number of e-mental health apps is increasing rapidly. Studies have shown that the use of some apps is beneficial, whereas others are ineffective or do not meet users' privacy expectations. Individuals and organizations that curate, recommend, host, use, or pay for apps have an interest in categorizing apps according to the consensus criteria of usability and effectiveness. Others have previously published recommendations for assessing health-related apps; however, the extent to which these recommendations can be generalized across different population groups (eg, culture, gender, and language) remains unclear. This study describes an attempt by Canadian stakeholders to develop an e-mental health assessment framework that responds to the unique needs of people living in Canada in an evidence-based manner. OBJECTIVE: The objective of our study was to achieve consensus from a broad group of Canadian stakeholders on guiding principles and criteria for a framework to assess e-mental health apps in Canada. METHODS: We developed an initial set of guiding principles and criteria from a rapid review and environmental scan of pre-existing app assessment frameworks. The initial list was refined through a two-round modified Delphi process. Participants (N=25) included app developers and users, health care providers, mental health advocates, people with lived experience of a mental health problem or mental illness, policy makers, and researchers. Consensus on each guideline or criterion was defined a priori as at least 70% agreement. The first round of voting was conducted electronically. Prior to Round 2 voting, in-person presentations from experts and a persona empathy mapping process were used to explore the perspectives of diverse stakeholders. RESULTS: Of all respondents, 68% (17/25) in Round 1 and 100% (13/13) in Round 2 agreed that a framework for evaluating health apps is needed to help Canadian consumers identify high-quality apps. Consensus was reached on 9 guiding principles: evidence based, gender responsive, culturally appropriate, user centered, risk based, internationally aligned, enabling innovation, transparent and fair, and based on ethical norms. In addition, 15 informative and evaluative criteria were defined to assess the effectiveness, functionality, clinical applicability, interoperability, usability, transparency regarding security and privacy, security or privacy standards, supported platforms, targeted users, developers' transparency, funding transparency, price, user desirability, user inclusion, and meaningful inclusion of a diverse range of communities. CONCLUSIONS: Canadian mental health stakeholders reached the consensus on a framework of 9 guiding principles and 15 criteria important in assessing e-mental health apps. What differentiates the Canadian framework from other scales is explicit attention to user inclusion at all stages of the development, gender responsiveness, and cultural appropriateness. Furthermore, an empathy mapping process markedly influenced the development of the framework. This framework may be used to inform future mental health policies and programs.

Building Consensus: Development of Best Practice Guidelines on Wrong Level Surgery in Spinal Deformity.

STUDY DESIGN: Consensus-building using the Delphi and nominal group technique. OBJECTIVE: To establish best practice guidelines using formal techniques of consensus building among a group of experienced spinal deformity surgeons to avert wrong-level spinal deformity surgery. SUMMARY OF BACKGROUND DATA: Numerous previous studies have demonstrated that wrong-level spinal deformity occurs at a substantial rate, with more than half of all spine surgeons reporting direct or indirect experience operating on the wrong levels. Nevertheless, currently, guidelines to avert wrong-level spinal deformity surgery have not been developed. METHODS: The Delphi process and nominal group technique were used to formally derive consensus among 16 fellowship-trained spine surgeons. Surgeons were surveyed for current practices, presented with the results of a systematic review, and asked to vote anonymously for or against item inclusion during three iterative rounds. Agreement of 80% or higher was considered consensus. Items near consensus (70% to 80% agreement) were probed in detail using the nominal group technique in a facilitated group meeting. RESULTS: Participants had a mean of 13.4 years of practice (range: 2-32 years) and 103.1 (range: 50-250) annual spinal deformity surgeries, with a combined total of 24,200 procedures. Consensus was reached for the creation of best practice guidelines (BPGs) consisting of 17 interventions to avert wrong-level surgery. A final checklist consisting of preoperative and intraoperative methods, including standardized vertebral-level counting and optimal imaging criteria, was supported by 100% of participants. CONCLUSION: We developed consensus-based best practice guidelines for the prevention of wrong-vertebral-level surgery. This can serve as a tool to reduce the variability in preoperative and intraoperative practices and guide research regarding the effectiveness of such interventions on the incidence of wrong-level surgery. LEVEL OF EVIDENCE: Level V.

A modified Delphi process to identify clinical and research priorities in patient and family centred critical care.

PURPOSE: To identify elements which enable patient and family centred care (PFCC) in the intensive care unit (ICU) and priorities for PFCC research. MATERIALS AND METHODS: We engaged a panel of multidisciplinary stakeholders in a modified Delphi process. Items generated from a literature review and panelist suggestions were rated in 3 successive rounds on a scale from 1 to 7. Median score was used to rate each item's priority, with 5 or more indicating "essential priority," 4 or 5 "moderate priority" and 3 or less "low priority." Interquartile range (IQR) was used to measure consensus, with IQR of 1 indicating "high" consensus, 2 "moderate" consensus, and 3 or greater "low" consensus. RESULTS: Six items were rated essential elements for facilitating PFCC with high consensus (flexible visiting hours, family participation in bedside care, trained family support person, interventions to facilitate continuity of care, staff education to support families, continuity of staff assignments). Three items were rated essential research topics: interventions to facilitate continuity of care following ICU discharge (moderate consensus), family participation in bedside care (low consensus), and decision aids for end of life decision-making (low consensus). CONCLUSIONS: Stakeholders identified clear and distinct priorities for PFCC in clinical care and research, though there was greater consensus for clinical care.