Consensus Process

A face-to-face consensus meeting was held in Toronto, Canada, in February 2018. The international consensus group comprised five voting gastroenterologists (including the chair: D.C.S.), from Canada, the United States and the United Kingdom. Other participants included a nonvoting moderator (J.K.M.), the two GRADE experts (F.T., G.I.L.) and a nonvoting observer.

The consensus process was facilitated by the CAG via a web-based consensus platform (ECD Solutions, Atlanta, GA). The platform allowed consensus participants to review results of the initial literature searches and select and link the references to specific statements. Copies of the selected references were available to all members of the consensus group. The full consensus group voted anonymously on their level of agreement with the individual statements using a modified Delphi process (20,21). Participants suggested revisions and commented on the statements, after which, the specific statements were revised through two iterations.

At the 1-day consensus meeting, evidence for each of the PICO questions was presented, after which an Evidence-to-Decision framework was completed (22). Each PICO question was discussed and revised, and voting members anonymously indicated their level of agreement on a scale of 1 to 5. In favour of a specific strategy was defined as 75% or more of votes being 5 (strongly yes) or 4 (yes). A vote against the strategy was defined as 75% or more of votes being 1 (strongly no) or 2 (no). A vote of 3 indicated neutrality. Once reaching agreement on the PICO question, the strength of the recommendation (strong versus conditional) was determined based on the following four components: (i) CoE, (ii) benefit/harm balance, (iii) patients’ values/preferences and (iv) resource requirements (23). When the CoE was low or very low, unless at least one of the other three factors was overwhelmingly strong, the strength of the recommendation typically would default (without a vote) to conditional, using the phrasing ‘we suggest’. If the statement warranted a vote, and 75% or more of participants voted as strong, then the recommendation would be designated as strong and the phrasing contained ‘we recommend’.

During the meeting, consensus was not reached on four of the PICO questions; therefore, no statement was developed and no recommendations were made. Evidence and subsequent discussion pertaining to these four questions is summarized briefly in the text.

The manuscript was drafted initially by the meeting chair (D.C.S.), and then reviewed and revised by the remaining members of the consensus group. The manuscript then was made available to all CAG members for comment over a 2-week period before submission for publication.

In accordance with CAG policy, written disclosures of any potential conflicts of interest for the 24 months before the consensus meeting were provided by all participants, reviewed by the CAG ethics committee and made available to all group members.