"Going into the black box": a policy analysis of how the World Health Organization uses evidence to inform guideline recommendations.

Background: The World Health Organization (WHO) plays a crucial role in producing global guidelines. In response to previous criticism, WHO has made efforts to enhance the process of guideline development, aiming for greater systematicity and transparency. However, it remains unclear whether these changes have effectively addressed these earlier critiques. This paper examines the policy process employed by WHO to inform guideline recommendations, using the update of the WHO Consolidated HIV Testing Services (HTS) Guidelines as a case study. Methods: We observed guideline development meetings and conducted semi-structured interviews with key participants involved in the WHO guideline-making process. The interviews were recorded, transcribed, and analysed thematically. The data were deductively coded and analysed in line with the main themes from a published conceptual framework for context-based evidence-based decision making: introduction, interpretation, and application of evidence. Results: The HTS guideline update was characterized by an inclusive and transparent process, involving a wide range of stakeholders. However, it was noted that not all stakeholders could participate equally due to gaps in training and preparation, particularly regarding the complexity of the Grading Recommendations Assessment Development Evaluation (GRADE) framework. We also found that WHO does not set priorities for which or how many guidelines should be produced each year and does not systematically evaluate the implementation of their recommendations. Our interviews revealed disconnects in the evidence synthesis process, starting from the development of systematic review protocols. While GRADE prioritizes evidence from RCTs, the Guideline Development Group (GDG) heavily emphasized "other" GRADE domains for which little or no evidence was available from the systematic reviews. As a result, expert judgements and opinions played a role in making recommendations. Finally, the role of donors and their presence as observers during GDG meetings was not clearly defined. Conclusion: We found a need for a different approach to evidence synthesis due to the diverse range of global guidelines produced by WHO. Ideally, the evidence synthesis should be broad enough to capture evidence from different types of studies for all domains in the GRADE framework. Greater structure is required in formulating GDGs and clarifying the role of donors through the process.

New Insights on Expert Opinion About Eyewitness Memory Research.

Experimental psychologists investigating eyewitness memory have periodically gathered their thoughts on a variety of eyewitness memory phenomena. Courts and other stakeholders of eyewitness research rely on the expert opinions reflected in these surveys to make informed decisions. However, the last survey of this sort was published more than 20 years ago, and the science of eyewitness memory has developed since that time. Stakeholders need a current database of expert opinions to make informed decisions. In this article, we provide that update. We surveyed 76 scientists for their opinions on eyewitness memory phenomena. We compared these current expert opinions to expert opinions from the past several decades. We found that experts today share many of the same opinions as experts in the past and have more nuanced thoughts about two issues. Experts in the past endorsed the idea that confidence is weakly related to accuracy, but experts today acknowledge the potential diagnostic value of initial confidence collected from a properly administered lineup. In addition, experts in the past may have favored sequential over simultaneous lineup presentation, but experts today are divided on this issue. We believe this new survey will prove useful to the court and to other stakeholders of eyewitness research.

Use of an expert elicitation methodology to compare welfare impacts of two approaches for blood sampling European badgers (Meles meles) in the field.

In the UK and Republic of Ireland, the European badger (Meles meles) is considered the most significant wildlife reservoir of the bacterium Mycobacterium bovis, the cause of bovine tuberculosis (bTB). To expand options for bTB surveillance and disease control, the Animal and Plant Health Agency developed a bespoke physical restraint cage to facilitate collection of a small blood sample from a restrained, conscious badger in the field. A key step, prior to pursuing operational deployment of the novel restraint cage, was an assessment of the relative welfare impacts of the approach. We used an established welfare assessment model to elicit expert opinion during two workshops to compare the impacts of the restraint cage approach with the only current alternative for obtaining blood samples from badgers in the field, which involves administration of a general anaesthetic. Eleven panellists participated in the workshops, comprising experts in the fields of wildlife biology, animal welfare science, badger capture and sampling, and veterinary science. Both approaches were assessed to have negative welfare impacts, although in neither case were overall welfare scores higher than intermediate, never exceeding 5-6 out of a possible 8. Based on our assessments, the restraint cage approach is no worse for welfare compared to using general anaesthesia and possibly has a lower overall negative impact on badger welfare. Our results can be used to integrate consideration of badger welfare alongside other factors, including financial cost and efficiency, when selecting a field method for blood sampling free-living badgers.

Consensus statement on the management of late-onset rheumatoid arthritis.

OBJECTIVES: Late-onset rheumatoid arthritis (LORA), which has been increasing in recent years, lacks evidence for initial treatment. Japanese rheumatology experts recognized this gap and addressed it by developing consensus statements on the first clinical application of LORA. METHODS: These statements were created following an introductory discussion about treatment fundamentals, which included a review of existing literature and cohort data. The steering committee created a draft, which was refined using a modified Delphi method that involved panel members reaching a consensus. The panel made decisions based on input from geriatric experts, clinical epidemiologists, guideline developers, patient groups, and the LORA Research Subcommittee of the Japan College of Rheumatology. RESULTS: The consensus identified four established facts, three basic approaches, and six expert opinions for managing LORA. Methotrexate was recommended as the primary treatment, with molecular-targeted agents being considered if treatment goals cannot be achieved. An emphasis was placed on assessing the lives of older patients due to challenges in risk management and methotrexate accessibility caused by comorbidities or cognitive decline. CONCLUSIONS: The experts substantiated and refined 13 statements for the initial treatment of LORA. To validate these claims, the next is to conduct a registry study focusing on new LORA cases.

Development of an interdisciplinary training program about chronic pain management with a cognitive behavioural approach for healthcare professionals: part of a hybrid effectiveness-implementation study.

BACKGROUND: Many applied postgraduate pain training programs are monodisciplinary, whereas interdisciplinary training programs potentially improve interdisciplinary collaboration, which is favourable for managing patients with chronic pain. However, limited research exists on the development and impact of interdisciplinary training programs, particularly in the context of chronic pain. METHODS: This study aimed to describe the development and implementation of an interdisciplinary training program regarding the management of patients with chronic pain, which is part of a type 1 hybrid effectiveness-implementation study. The targeted groups included medical doctors, nurses, psychologists, physiotherapists, occupational therapists, dentists and pharmacists. An interdisciplinary expert panel was organised to provide its perception of the importance of formulated competencies for integrating biopsychosocial pain management with a cognitive behavioural approach into clinical practice. They were also asked to provide their perception of the extent to which healthcare professionals already possess the competencies in their clinical practice. Additionally, the expert panel was asked to formulate the barriers and needs relating to training content and the implementation of biopsychosocial chronic pain management with a cognitive behavioural approach in clinical practice, which was complemented with a literature search. This was used to develop and adapt the training program to the barriers and needs of stakeholders. RESULTS: The interdisciplinary expert panel considered the competencies as very important. Additionally, they perceived a relatively low level of healthcare professionals' possession of the competencies in their clinical practice. A wide variety of barriers and needs for stakeholders were formulated and organized within the Theoretical Domain Framework linked to the COM-B domains; 'capability', 'opportunity', and 'motivation'. The developed interdisciplinary training program, including two workshops of seven hours each and two e-learning modules, aimed to improve HCP's competencies for integrating biopsychosocial chronic pain management with a cognitive behavioural approach into clinical practice. CONCLUSION: We designed an interdisciplinary training program, based on formulated barriers regarding the management of patients with chronic pain that can be used as a foundation for developing and enhancing the quality of future training programs.

Common pitfalls, and how to avoid them, in child and adolescent psychopharmacology: Part I.

As Faculty of the British Association for Psychopharmacology course on child and adolescent psychopharmacology, we present here what we deem are the most common pitfalls, and how to avoid them, in child and adolescent psychopharmacology. In this paper, we specifically addressed common pitfalls in the pharmacological treatment of attention-deficit/hyperactivity disorder, anxiety, bipolar disorder, depression, obsessive-compulsive disorder and related disorders, and tic disorder. Pitfalls in the treatment of other disorders are addressed in a separate paper (part II).

Common pitfalls, and how to avoid them, in child and adolescent psychopharmacology: Part II.

As Faculty of the British Association for Psychopharmacology course on child and adolescent psychopharmacology, we present here what we deem are the most common pitfalls, and how to avoid them, in child and adolescent psychopharmacology. In this paper, we specifically addressed common pitfalls in the pharmacological treatment of autism and intellectual disability, eating disorders, neuropsychiatric correlates of epilepsy, and psychosis. Pitfalls in relation to the treatment of other disorders are addressed in a separate paper (Part I).

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

BACKGROUND: Current guidance on the selection of appropriate contraception for people with multiple sclerosis (PwMS) is lacking. OBJECTIVE: 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). METHODS: 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. RESULTS: 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. CONCLUSION: These expert recommendations provide the first practical, relevant, and comprehensive guidance for clinicians on the selection of contraception in PwMS.

Current Expectations and Opinions on Single-port Robotic Surgery: A Survey Among European Experts by the SPARC Collaborative Group.

Single-port (SP) robotic surgery is a relatively new technology that is expected to become available on the European market within a year. We investigated the current expectations of robotic surgery experts and opinion leaders practicing in Europe. A 17-item online questionnaire was sent to 120 participants identified as "experts" on the basis of their general contributions to the field of robotic surgery. Overall, 90 responses were registered, with a response rate of 75%. Italy (30%), France (15%), and the UK (12%) provided the most participants, who worked mainly in academic-either public (60%) or private (20%)-hospitals. Most respondents (79%) had no previous experience with "single site" surgery, and attendance at scientific meetings (79%) and perusal of the literature (65%) were the sources of SP knowledge most frequently reported. The perceived advantages of SP robotic surgery included lower invasiveness (61%), easier access to the retroperitoneal or extraperitoneal space (53%), better cosmetic results (44%), and lower postoperative pain (44%). The most "appealing" SP procedures were retroperitoneal partial nephrectomy via an anterior approach (43%) and transvesical simple prostatectomy (43%). Within the limitations of this type of analysis, our findings suggest high interest and a positive attitude towards SP technology overall. Patient summary: Technology for single-port (SP) robotic surgery, in which just one skin incision is made in the abdomen to perform the operation, will soon be available in Europe. We conducted a survey on SP surgery among European experts in urological robotic surgery. The results show that there is high interest in and a positive attitude to SP surgery. The SP approach could result in better cosmetic results and lower postoperative pain for patients.

A Review of the Diagnostic and Therapeutic Gaps in Rosacea Management: Consensus Opinion.

Rosacea is a common, chronic inflammatory disease characterized by both fluctuating and fixed heterogeneous signs such as facial erythema, papules/pustules, telangiectasia, acute vasodilation (flushing), and phymatous changes, and symptoms such as cutaneous stinging and burning. The shift to a phenotype-based approach to rosacea management has improved the consistency of recommendations across recent published guidelines. Consistent and thorough guidance for the classification, diagnosis, and management of the disease is difficult, as the mechanisms underlying the development of rosacea are still not completely understood nor universally accepted. Here, we provide a critical review of current published guidance, and gaps in the knowledge and management of rosacea. We present the recently approved microencapsulated benzoyl peroxide as an effective topical treatment option for papulopustular rosacea. Benzoyl peroxide (BPO) has been used in acne management for many years; however, many clinicians perceive treatment of rosacea with any BPO formulation to be counterintuitive because of concerns of potential skin irritation, while the lack of an accepted mechanism of action on rosacea pathophysiology means that others may be hesitant to use BPO as a treatment. Minocycline foam 1.5% is also an option for the treatment of inflammatory lesions in rosacea, with a decreased risk of systemic adverse events compared with oral minocycline.

Expert opinion survey on Israel's food system: implications for food and health policies.

BACKGROUND: While there has been increasing global recognition and impetus for action to transform food systems towards greater food security, sustainability and better health outcomes, Israel has only recently begun to focus on the diverse challenges of its food system and its potential for transformation. METHODS: An expert opinion survey (n = 50) on Israel's food system was conducted as part of a larger study on the systemic features of Israel's food system transition to understand its policy gaps and find strategies towards a healthy and sustainable food system. The survey ranks the relevance and importance of food system challenges and policy preferences. Policy implications are then examined by identifying potential priorities, gaps and dissensus. RESULTS: The survey finds that there is a majority agreement (76%) that Israel's food policies are lacking or severely lacking. Respondents relate strongly to both concepts of nutritional security (90% think that access to nutritious food is relevant or highly relevant) and national food security (more than 80% perceive food security as part of national security). Respondents overwhelmingly recognize the benefits of Israeli agriculture with 60-90% agreeing or strongly agreeing that it benefits food security, economic value and national identity. Top-ranked problems include overall systemic problems such as the lack of national goals, strategic planning, and integrated policymaking across ministries, and specific ones such as food waste, costly farming inputs, and food affordability. The most preferred policy actions include establishing a national strategy for food and agriculture, making food affordable for vulnerable households, and incentivising sustainable farming methods. The key policy gaps include the lack of resilience in agriculture and the food system, insufficient data and knowledge for policy action, inadequate attention to the regulation of the food industry for better health and inadequate food policy attention for minority groups. CONCLUSIONS: Building on this study's findings, further policy research and implementation areas to be covered include government responsibility for universal food security, strategic systemic policies for food systems, prevention and preparedness for future crises, and promoting resilience. The way forward may best be through an inter-ministerial committee with the responsibility, budgets, mandate and executive authority to plan data-driven policies for a sustainable food system for Israel's future.

Assembling a population health management maturity index using a Delphi method.

BACKGROUND: Although local initiatives commonly express a wish to improve population health and wellbeing using a population health management (PHM) approach, implementation is challenging and existing tools have either a narrow focus or lack transparency. This has created demand for practice-oriented guidance concerning the introduction and requirements of PHM. METHODS: Existing knowledge from scientific literature was combined with expert opinion obtained using an adjusted RAND UCLA appropriateness method, which consisted of six Dutch panels in three Delphi rounds, followed by two rounds of validation by an international panel. RESULTS: The Dutch panels identified 36 items relevant to PHM, in addition to the 97 items across six elements of PHM derived from scientific literature. Of these 133 items, 101 were considered important and 32 ambiguous. The international panel awarded similar scores for 128 of 133 items, with only 5 items remaining unvalidated. Combining literature and expert opinion gave extra weight and validity to the items. DISCUSSION: In developing a maturity index to help assess the use and progress of PHM in health regions, input from experts counterbalanced a previous skewedness of item distribution across the PHM elements and the Rainbow Model of Integrated Care (RMIC). Participant expertise also improved our understanding of successful PHM implementation, as well as how the six PHM elements are best constituted in a first iteration of a maturity index. Limitations included the number of participants in some panels and ambiguity of language. Further development should focus on item clarity, adoption in practice and item interconnectedness. CONCLUSION: By employing scientific literature enriched with expert opinion, this study provides new insight for both science and practice concerning the composition of PHM elements that influence PHM implementation. This will help guide practices in their quest to implement PHM.

Review and expert opinion on MAFLD, oxidative stress and multifunctional management.

Metabolic-associated fatty-liver disease (MAFLD), previously known as non-alcoholic fatty liver disease, is the most widespread and emerging chronic liver disease worldwide, with increasing prevalence rates also in the Asia-Pacific region. The disease has a high socio-economic burden as it negatively impacts the finances and quality of life of individuals affected and has a major burden on healthcare systems. The most important pathological event in MAFLD aetiopathogenesis is oxidative stress, which leads to functional and structural abnormalities in the liver as well as being involved in the development of other concomitant cardiometabolic diseases. MAFLD is a rather complex multisystemic clinical condition involving liver damage and a wide spectrum of extrahepatic manifestations such as obesity, type 2 diabetes, metabolic syndrome and cardiovascular diseases. This complexity requires the cooperation of multiple experts to identify MAFLD at an early stage, treat associated comorbidities, and promptly refer the patient to the hepatologist when needed. This review summarizes the current knowledge about MAFLD and reports the opinion of a group of experts on the increasing prevalence and burden of the disease in the southeast Asia region, the current journey of patients with MAFLD in developing countries, the role of oxidative stress and antioxidant treatment, and the importance of a multidisciplinary approach for early diagnosis and disease management. This article is part of the Current clinical use of silymarin in the treatment of toxic liver diseases: a case series Special Issue: https://www.drugsincontext.com/special_issues/current-clinical-use-of-silymarin-in-the-treatment-of-toxic-liver-diseases-a-case-series.

Step 3: Critical Appraisal of Evidence-Expert Opinion.

Critically appraising the literature is the third step in the evidence-based practice process. The lowest level of evidence includes expert opinion and related types of literature. This column describes the appraisal of this type of literature using a specific set of questions.

Intravascular Ultrasound Use in Peripheral Arterial and Deep Venous Interventions: Multidisciplinary Expert Opinion From SCAI/AVF/AVLS/SIR/SVM/SVS.

Percutaneous revascularization is the primary strategy for treating lower extremity venous and arterial disease. Angiography is limited by its ability to accurately size vessels, precisely determine the degree of stenosis and length of lesions, characterize lesion morphology, or correctly diagnose postintervention complications. These limitations are overcome with use of intravascular ultrasound (IVUS). IVUS has demonstrated the ability to improve outcomes following percutaneous coronary intervention, and there is increasing evidence to support its benefits in the setting of peripheral vascular intervention. At this stage in its evolution, there remains a need to standardize the use and approach to peripheral vascular IVUS imaging. This manuscript represents considerations and consensus perspectives that emerged from a roundtable discussion including 15 physicians with expertise in interventional cardiology, interventional radiology, and vascular surgery, representing 6 cardiovascular specialty societies, held on February 3, 2023. The roundtable's aims were to assess the current state of lower extremity revascularization, identify knowledge gaps and need for evidence, and determine how IVUS can improve care and outcomes for patients with peripheral arterial and deep venous pathology.

Expert Opinion on the Utility of Telemedicine in Obesity Care: Recommendations on a Hybrid Multidisciplinary Integrated Care Follow-Up Algorithm.

PURPOSE OF REVIEW: The proposed expert opinion was prepared by a panel of obesity and law specialists from Turkey to review the utility of telemedicine in obesity care and to provide a guidance document with recommendations on a hybrid multidisciplinary integrated care follow-up algorithm and the legislation governing telemedicine practice to assist obesity specialists in practicing the telemedicine. RECENT FINDINGS: The efficacy and feasibility of telemedicine interventions in supporting obesity management programs even during pandemics confirm that obesity is a particularly well-suited field for telemedicine, emphasizing the strong likelihood of continued utilization of telemedicine in obesity management, beyond the pandemic period. Telemedicine has great potential to address several barriers to ongoing weight-management care, such as challenges of access to specialized care, cost, and time limitations as well as patient adherence to treatment. However, telemedicine practice should complement rather than replace the in-person visits which are unique in building rapport and offering social support. Accordingly, the participating experts recommend the use of a hybrid integrated care model in the management of obesity, with the use of telemedicine, as an adjunct to in-person visits, to enable the provision of suggested intensive obesity management via frequent visits by a multidisciplinary team of obesity specialists. Further research addressing the utility of telemedicine in terms of optimal modality and duration for successful long-term obesity management outcomes is necessary to develop specific guidelines on telemedicine practice. In addition, the legislation governing the norms and protocols on confidentiality, privacy, access, and liability needs to be improved.

Optimising Radioligand Therapy for Patients with Gastro-Entero-Pancreatic Neuroendocrine Tumours: Expert Opinion from an Italian Multidisciplinary Group.

Radioligand therapy (RLT) with lutetium (177Lu) oxodotreotide is an approved therapy in combination with somatostatin analogues (SSAs) for patients with advanced, well-differentiated G1-G2, gastro-entero-pancreatic neuroendocrine tumours (GEP-NETs) that progress on SSAs. We conducted a series of round table meetings throughout Italy to identify issues related to RLT delivery to patients with GEP-NETs. Four key issues were identified: (1) the proper definition of tumour progression prior to RLT initiation; (2) the impact of RLT in patients with bone metastases and/or high hepatic tumour burden; (3) the optimal follow-up protocol after RLT; and (4) organisational issues related to RLT use and managerial implications. This article reviews the literature relating to the aforementioned issues and makes recommendations based on available evidence and Italian NET experts' opinions. In particular, the group recommends the development of a diagnostic-therapeutic care pathway (DTCP) for patients undergoing RLT which provides systematic guidance but can still be individualised for each patient's clinical and psychosocial needs. A DTCP may clarify the diagnostic, therapeutic and post-treatment monitoring process, and improve communication and the coordination of care between hub and spoke centres. The DTCP may also contribute to changes in the care process related to the 2013/59/EURATOM Directive and to the definition of costs when planning for future or updated reimbursement of RLT in Italy.

Fluoroscopic image-based behavior analysis can objectively explain subjective expert assessment of wire navigation skill.

Psychomotor skill and decision-making efficiency in surgical wire navigation can be objectively evaluated by analysis of intraoperative fluoroscopic image sequences. Prior work suggests that such image-based behavior analysis of operating room (OR) performance can predict performer experience level (R2 = 0.62) and agree with expert opinion (the current standard) on the quality of a final implant construct (R2 = 0.59). However, it is unclear how objective image-based evaluation compares with expert assessments for entire technical OR performances. This study examines the relationships between three key variables: (1) objective image-based criteria, (2) expert opinions, and (3) performing surgeon experience level. A paired-comparison survey of seven experts, based upon eight OR fluoroscopic wire navigation image sequences, shows that the experts' preferences are best explained by objective metrics that reflect psychomotor and decision-making behaviors which are counter-productive to successful implant placement, like image count (R2 = 0.83) and behavior tally (R2 = 0.74). One such behavior, adjustments away from goal, uniquely correlated well with all three key variables: a fluoroscopic image-based analysis composite score (R2 = 0.40), expert consensus (R2 = 0.76), and performer experience (R2 = 0.41). These results confirm that experts view less efficient technical behavior as indicative of lesser technical proficiency. While expert assessments of technical skill were reliable and consistent, neither individual nor consensus expert opinion appears to correlate with performer experience (R2 = 0.11).

Perspective: Peer Evaluation of Recommendations for CONSORT Guidelines for Randomized Controlled Trials in Nutrition.

Creating effective dietary guidance requires a rigorous evidence base that is predominantly developed from robust clinical trials or large-scale cohort studies, with the quality of the data available depending on the completeness and accuracy of their reporting. An international group of academics from 14 institutions in 12 different countries and on 5 continents, working on behalf of the Federation of European Nutrition Societies within its "Improving Standards in the Science of Nutrition" initiative, reviewed the Consolidated Standards of Reporting Trials (CONSORT) statement checklist as it pertains to nutrition trials. This perspective piece documents the procedure followed to gain input and consensus on the checklist previously published by this group, including its presentation and interrogation at the International Union of Nutritional Sciences International Congress of Nutrition 2022 (IUNS-ICN 22), inputs from a survey of journal editors, and its piloting on 8 nutrition trials of diverse designs. Overall, the initiative has been met with considerable enthusiasm. At IUNS-ICN 22, refinements to our proposal were elicited through a World Café method discussion with participating nutrition scientists. The contributing journal editors provided valuable insights, and the discussion led to the development of a potential tool specific to assess adherence to the proposed nutrition extension checklist. The piloting of the proposed checklist provided evidence from real-life studies that reporting of nutrition trials can be improved. This initiative aims to stimulate further discussion and development of a CONSORT-nutrition-specific extension.

Expert Opinion on Addressing the Gap in Injection Technique and Needle Reuse for People with Diabetes in Indonesia.

The use of insulin for patients with diabetes mellitus in Indonesia appears to be under expectation; moreover, there are gaps in knowledge regarding the proper injection technique and pen needle reuse by both healthcare professionals (HCPs) and patients. To address these issues, a scientific expert meeting was held with the participation of endocrinologists and public health specialist from many different organizations in Indonesia to identify the challenges and problem related to injection technique, high pen needle reuse rate, and the need of all stakeholders. The experts agreed that it is necessary to ensure physicians to start the initiation phase as early as indicated, continue optimizing its dosage to reach targeted blood sugar based on guideline, and involve all relevant stakeholders to improve insulin distribution and patient access in every primary care facility in order to optimize the use of insulin or other injectable diabetes medications in Indonesia. Additionally, the experts believed that education on proper injection technique and improved reuse rate of pen needle is necessary. To date, Indonesian Diabetes Educators Association (IDEA/PEDI) has established guideline on injection technique. There are also recommendations on injection technique and needle reuse from Indonesian Society of Endocrinology (PERKENI) and Forum for Injection Technique & Therapy: Expert Recommendations (FITTER); however, this guideline/recommendation should be disseminated more widely among HCPs. In addition, cost-effectiveness studies based on local data are needed to propose and convince the Payors and other stakeholders. This article can be used as a guidance for HCPs and policymakers to improve current practice on injection technique, pen needle reuse, needle prescription and reimbursement policy in Indonesia and elsewhere.