The International Society for Clinical Densitometry (ISCD) convened the 9th adult Position Development Conference (PDC) at the request of the ISCD Board of Directors and Executive Committee. The PDC generates new and updated Official Positions which serve as widely cited scientific and clinical guidance in the field of musculoskeletal assessment. Additionally, Official Positions provide a foundation for ISCD educational and quality programs, in service of its mission to advance musculoskeletal health assessment and patient care. ISCD has convened 8 adult and 3 pediatric Position Development Conferences since 2002, and as of the most recent PDC in 2019 published a total of 218 adult positions1 Detailed presentation of each new Official Position and its substantiating literature appear in companion position papers in this volume of the Journal of Clinical Densitometry. Because the PDC process is extensive and numerous publications result, this Executive Summary presents an overview of PDC personnel and activities and introduces the new ISCD Official Positions for 2023 in context with existing Official Positions.  These Official Positions are intended to create guidance for researchers and clinicians in the present and emerging domains of musculoskeletal and body composition assessment.

The PDC formally begins with the request to commence from the ISCD Board and culminates in the Open and Closed Sessions at the ISCD Annual Meeting.  For this PDC, the ISCD Board's requested initiation was December 2021, with the PDC sessions held on March 28 and 29, 2023 in Northbrook, Illinois USA, about 25 miles north of Chicago. These sessions immediately preceded the ISCD Annual Meeting on March 29 – April 1, 2023

ISCD invites bone health professionals from all over the world to volunteer and participate in the 12-18 months long PDC process.  Those volunteers are grouped into three work categories: Steering Committee, Task Forces and Expert Panel. Various activities occur within and between groups over the 15–18-month PDC cycle.

The Steering Committee oversees all aspects of the conduct of PDC, including all the preliminary organization, all pre-PDC work, the conference itself, and the post-conference review and finalization of draft position papers for publication. Steering Committees consist of 3-5 ISCD members, with at least one member having extensive PDC experience. The Chair of the Steering Committee is typically invited to serve by the ISCD Executive Committee. The Chair then recommends and recruits additional participants; it is common (but not required) that the Chair is also an ISCD Executive Committee member. For 2023, three members comprised the Steering Committee (AC, RG, CS).

The Steering Committee meets regularly before and after the PDC sessions over approximately 18 months, via teleconference and in person at the PDC sessions. Designated Steering Committee members also meet regularly via teleconference with Task Force Chairs selected by the committee, guiding them through the many PDC task force activities and advising them on challenges and problems.

Early work of the Steering Committee is to solicit input from ISCD membership on potential topic areas for the PDC, with a membership-wide email call for topics. Additionally, the Steering Committee solicits input on possible topics from the ISCD Executive Committee and other ISCD leaders like board members. All requests are gathered in a standard format through the ISCD website over 4-6 weeks, and substantiating references may be submitted. For 2023, 29 formal topic area requests were submitted. The Steering Committee then collates these and with the assistance of ISCD Executive Committee preliminarily ranks them in importance to ISCD and its constituents and refers these to the Scientific Advisory Council (SAC). SAC evaluates topic areas for consideration at the PDC based on five criteria: 1) their relation to and support of ISCD's Mission, 2) the existence of a sufficient body of literature that the creation of a task force is warranted and there is a significant likelihood of Official Positions resulting, 3) there exists  significant controversy in a topic area that development of positions would advance the field, 4) resulting Official Positions are applicable to  ISCD's constituencies, emphasizing relevance and utility, and 5) Official Positions developed would support, assist and direct ISCD educational activities (14). The Steering Committee referred the top five SAC-ranked topics to the ISCD Executive Council, and after healthy debate, three topic areas were forwarded to the ISCD Board of Directors and approved for the 2023 PDC: 1) Dual-energy X-ray Absorptiometry (DXA) Reporting, 2) Serial Bone Mineral Density (BMD) Monitoring, and 3) Trabecular Bone Score (TBS) Application and Reporting.

Subsequent work is focused on choosing Task Force (TF) Chairs, refining Key Questions for task force inquiry, overseeing task force activity, forming and coordinating the Expert Panel, supervising of draft Official Positions and supporting position manuscripts, and conducting the initial round of expert voting. Moderators for PDC Open Session are chosen by the committee as well.  This period of ongoing activity lasts for approximately 9 months, until just before the conference.

At the conference, committee members oversee all aspects of the open and closed sessions, in collaboration with ISCD staff. Major milestones are execution of the full-day Open Session with TF Chair presentations, expert voting and audience input and participation, as well as supervision of the voting and recording of scoring. Day 2 of the conference sees the committee supervising the all-day Expert Panel closed session discussion, voting and wordsmithing of agreed Official Positions.

After the PDC sessions, work of the committee continues with preparation of the slate of Official Positions for ISCD Board of Directors voting and ongoing communication with TF Chairs to refine and finalize position paper manuscripts for publication. The Steering Committee serves as the editorial group for the draft position papers.

Task forces are the engines that move the PDC forward. Task forces are led by the Task Force (TF) Chair, and as noted above chairs are chosen by the Steering Committee not only for their solid knowledge of the topic area(s) under consideration, but just as importantly for their willingness and ability to lead the task force effectively by respecting deadlines, resolving differences, communicating efficiently and effectively and by adapting to changing circumstances. TF Chairs are thoroughly briefed in the mechanics and expectations of the PDC. For this PDC, the Steering Committee also designated Senior Mentors with extensive experience at ISCD to assist and guide TF Chairs, which broadened the potential pool of TF Chairs by encouraging candidates to lead under experienced supervision.

Task force members are selected by the chair, based on subject matter experience and ability to work within the PDC framework: the time commitment is substantial, and the deadline requirements are critical. Task force size is typically 6-10 members, and members ideally represent the broad diversity of bone health professionals around the globe. Task forces work for approximately six months before the actual conference, performing systematic-review-level literature searches to answer to Key Questions. These literature searches become the evidence base for the proposed Official Positions. The task forces may be divided into subgroups based on sub-topic areas and specific Key Questions. Although no formal systematic review methods are required, both past and present task forces have leveraged well-known systematic frameworks and literature quality assessment tools like PICO2, the Newcastle Ottawa Scale3, and the PRISMA rubric for citation selection4. Search strategies are carefully documented.

The Steering Committee enlists a group of worldwide experts to review draft positions and substantiating literature. The typical number of expert panelists is 9 to 13, with odd numbers of panelists preferred to avoid ties in voting. For 2023, nine experts participated in the PDC. Expert panelists must possess strong knowledge of the chosen topics, as well as the ability to critically review and assess scientific literature supporting proposed positions.  Experts review draft position papers and vote on draft positions at three points in the PDC timeline, utilizing the ISCD-adapted version of the UCLA/RAND Appropriateness Method (UCLA/RAM, see description below) and are thoroughly briefed in the method. Experts may also be required to participate in wordsmithing of accepted Official Positions after the PDC sessions conclude if this work is not completed at the meeting. The typical duration of service for expert panelists is 4-6 months.

There is an increasing drive to provide evidence-based care to patients, but most clinical medicine lacks high-quality substantiation for treatment decisions, osteoporosis and bone health practice included.  A few recent clinical guidelines on osteoporosis evaluation and treatment offer recommendations with extensive evidence assessment,5, 6, 7, 8, but highest-level evidence may not be uniformly available. Other authors have pointed out the important role of clinical judgment even when osteoporosis evidence-based guidelines are available9 and the fact that clinical guidelines can be inappropriately applied in circumstances where they may not be valid.10  Therefore, to bridge known gaps between best available science and the demands of clinical practice, and to honor the role of clinical judgment in everyday practice, ISCD utilizes a modification of the UCLA/RAND Appropriateness Method (UCLA/RAM) with rounds of expert voting and discussion, and a focus on an agreement-based method.

The UCLA/RAM evolved from a 1950’s RAND Corporation effort called DELPHI. The RAND Corporation originated after World War II as a military planning spin-off of the Douglas Aircraft Company.11 In the DELPHI system questionnaires and rounds of voting with controlled access to scoring yielded consensus on military decision-making.12  In the 1980’s UCLA partnered with RAND to modify DELPHI principles to assess appropriateness of medical treatments and surgical procedures in specific circumstances. Appropriateness in the original context of UCLA/RAM is defined as follows: “An appropriate procedure is one in which "the expected health benefit (e.g., increased life expectancy, relief of pain, reduction in anxiety, improved functional capacity) exceeds the expected negative consequences (e.g., mortality, morbidity, anxiety, pain, time lost from work) by a sufficiently wide margin that the procedure is worth doing, exclusive of cost”.13] ISCD has modified the UCLA/RAM definition of appropriateness to address musculoskeletal measurement and reporting instead of medical and surgical procedures, and more specifically has modified the workflows to involve PDC attendees in open discussions while maintaining critical foundations of the UCLA/RAM process.14 Details of the  mechanics and scoring of UCLA/RAM framework and ISCD's modifications have been published previously15, and will not be extensively reviewed here, but voting on draft positions occurs in three rounds: 1) a remote blinded closed round of voting (hereinafter referred to as “First Round”) on draft Official Positions (beginning 2-3 months before the PDC meeting, accomplished electronically), with voting categories of  “Appropriate”, “Uncertain” or “Not Appropriate” according to the modified UCLA/RAM rubric and with data and comments returned to the task forces for revisions and modifications, 2)  a round of open voting (hereinafter referred to as “Second Round”) at the PDC following TF Chair presentations, expert discussion and comments, and the open forum for PDC audience attendees to comment, and 3) an additional “closed” round (hereinafter referred to as “Third Round”) at the Closed Session the next day which includes experts, TF Chairs and Steering Committee, to further discuss and resolve contentious or unresolved draft  “Uncertain” positions.

Along with an Appropriateness score, draft positions are also rated on Quality of Evidence (Good/Fair/Poor), Strength of Recommendation (A/B/C, where “A” = strong and supported by the evidence, “B” = supported by evidence, and “C” = supported by expert opinion) and “Worldwide” versus “Local” applicability (W vs L). Details of the additional rating categories have been previously published.15 As a general example, the reader would see an overall grade appearing in the position paper text after the approved Official Positions, with a format like: “Grade: Fair – B – W (Worldwide)”.