From this second round, 40 response options out of the remaining 61 achieved expert consensus. Two scenarios tapping the use of WAAP and quitting smoking did not reach sufficient consensus neither in the first nor in the selleck chemical second round; therefore, both were reformulated using information drawn from the focus group and interviews material. The remaining 21 response options that achieved only partial consensus in the second round were discussed with a second pulmonologist and amended for the third round. Third round Eleven doctors participated in an online survey designed to rate the remaining controversial response options. Only two of these responses did not achieve the established cut off point. The majority of experts who participated in the first and second round responded to this survey.

Stage III: questionnaire scoring A ranking of the response options was generated based on the results of the Delphi study. A few months after the Delphi study, doctors were invited to confirm the accuracy of the generated ranking, or to propose a different one in case of disagreement. Nine doctors responded to this survey and only three of the scenarios did not achieve a 100% agreement on the established ranking. Since, two of these scenarios reached a 78% agreement and the other a 67%, no modifications on the ranking were made. Each response option was scored from 1 (most inadequate) to 4 (most adequate). A sum scale of all 19 scenarios with 4 response options each resulted in a minimum score of 19 and a maximum score of 76.

Higher values represent higher judgment skills, indicating improved competency to use health knowledge on asthma self-management (Additional file 2: Appendix II). Results Intra-class correlation coefficients (ICC) were calculated to measure the similarity of doctors ratings in the three Delphi rounds. The overall ICC for the 76 response options corresponding to the 19 scenarios was 0.97 (Figure 2), and the ICC for the single scenarios ranged from 0.92 to 0.99. Figure 2 Improvement on doctors�� agreement on the response options rating, through the 3 Delphi rounds. In the final round, only two response options belonging to two different scenarios achieved less than the established cut-off of point of 60% expert agreement. However, they were not modified again, Dacomitinib since the ICC coefficients for both scenarios were high, 0.98 and 0.92 respectively, plus the most adequate and most inadequate response options for these scenarios were already identified in the prior rounds. One of the scenarios is about trigger avoidance (pets). The response option stating that the patient will ask the doctor for an alternative solution instead of giving away the pet created divided opinions among the doctors.