# Development of a Model Care Pathway for Myasthenia Gravis
## 3 Results
### CP Validation  
The newly defined model pathway was evaluated by the international experts [65]. The panel was composed of 85 physicians: 59 experts (69.4%) had more than 10 years of experience in treating MG patients; 20 (23.5%) had between 5 and 10 years of experience, and 6 (7.1%) had less than five years of experience. About the patients' volumes: 41 doctors (48.2%) treated between 5 and 20 patients monthly, 37 (43.5%) treated more than 20 patients and 7 (8.2%) treated less than five patients on a regular monthly basis. Most of the experts were working in a neuromuscular specialty center (\(n\) = 58, 68.2%), mainly in academic institutions (\(n\) = 50, 58.8%). Some experts described their working places more in detail, including as a private center (\(n\) = 25, 29.4%), a private not-for-profit (\(n\) = 3, 3.5%), a public institution (\(n\) = 10, 11.8%) or as another different typology of organization (\(n\) = 9, 10.6%). The patients were treated mainly in out-patient clinics (78.9%) and in hospitals (65.9% neurology wards and 21.2% day-care), followed by physiotherapy and rehabilitation centers (10.6%), and facilities for speech therapy and for occupational therapy (7.1% and 5.9% respectively). As shown in Table 1, we observed a high level of agreement among the experts both for completeness (from 85.9% to 95.3%) and for appropriateness (from 83.5% to 89.4%) of the proposed model care pathway. We did not observe any differences related to the provenience of the experts, except for the speech, swallowing, and dental management process that was considered incomplete by the Japanese experts (\(p\) = 0.02986; post-hoc \(p\) = 0.01642). We compared the experts' opinions with the LOE previously attributed from the literature and found no significant differences among the grades. In fact, approximately 3% of the experts considered the activities to be inappropriate regardless of the grade (2.7% of experts for class A and C activities, 3.2% for class B). In Table 2 we described and analysed the settings where the patients were treated along the process of care. Overall, patients' diagnosis and assessment and the administration of the pharmacological therapies were performed equally in ambulatory care (51.8% and 55.3%) and in hospital wards (45.9% and 42.1%) with significant regional differences. In fact, 22.9% of European experts diagnosed and administered treatment to their patients in ambulatory settings (\(p\) < 0.0001 and \(p\) < 0.0001 respectively). On the contrary, European patients mostly received their diagnosis in hospitals (\(p\) = 0.001543) whereas in the United States only 23.3% of the experts used the hospitals for the pharmacological treatment (\(p\) = 0.002065). Occupational therapy activities were carried out in nursing homes more frequently in the United States (25.6%) and Japan (28.6%) than the EU (5.7%) (\(p\) = 0.04046). Lastly, patient lifestyle support was mainly given in ambulatory care in the United States (83.7%) and in Japan (85.7%) when compared to EU (57.1%) (\(p\) = 0.0235). In overall, 25 potential bottlenecks emerged out of the 60 activities (41.6%). Of those, 8 were considered relevant because were reported by more than 5 experts.