Risk-based surveillance for meat-borne parasites.

There is a plethora of meat-borne hazards - including parasites - for which there may be a need for surveillance. However, veterinary services worldwide need to decide how to use their scarce resources and prioritise among the perceived hazards. Moreover, to remain competitive, food business operators - irrespective of whether they are farmers or abattoir operators - are preoccupied with maintaining a profit and minimizing costs. Still, customers and trade partners expect that meat products placed on the market are safe to consume and should not bear any risks of causing disease. Risk-based surveillance systems may offer a solution to this challenge by applying risk analysis principles; first to set priorities, and secondly to allocate resources effectively and efficiently. The latter is done through a focus on the cost-effectiveness ratio in sampling and prioritisation. Risk-based surveillance was originally introduced into veterinary public health in 2006. Since then, experience has been gathered, and the methodology has been further developed. Guidelines and tools have been developed, which can be used to set up appropriate surveillance programmes. In this paper, the basic principles are described, and by use of a surveillance design tool called SURVTOOLS (https://survtools.org/), examples are given covering three meat-borne parasites for which risk-based surveillance is 1) either in place in the European Union (EU) (Trichinella spp.), 2) to be officially implemented in December 2019 (Taenia saginata) or 3) only carried out by one abattoir company in the EU as there is no official EU requirement (Toxoplasma gondii). Moreover, advantages, requirements and limitations of risk-based surveillance for meat-borne parasites are discussed.

Prioritization of rehabilitation Domains for establishing spinal cord injury high performance indicators using a modification of the Hanlon method: SCI-High Project.

Objectives: To prioritize Domains of SCI Rehabilitation Care (SCI-Care) based on clinical importance and feasibility to inform the development of indicators of quality SCI-Care for adults with SCI/D in Canada. Methods: A 17-member external advisory committee, comprised of key stakeholders, ranked 15/37 Domains of rehabilitation previously flagged by the E-scan project team for gaps between knowledge generation and clinical implementation. Priority scores (D) were calculated using the Hanlon formula: D=[A+(2×B)]×C , where A is prevalence, B is seriousness, and C is the effectiveness of available interventions. A modified "EAARS" (Economic, Acceptability, Accessibility, Resources, and Simplicity) criterion was used to rank feasibility on a scale of 0-4 (4 is high). The product of these two scores determined the initial Domain ranking. Following the consensus process, further changes were made to the Domain rankings. Results: Despite a low feasibility score, Sexual Health was ranked as high priority; and, the Community Participation and Employment Domains were merged. The 11 final prioritized Domains in alphabetic order were: Cardiometabolic Health; Community Participation and Employment; Emotional Well-Being; Reaching, Grasping, and Manipulation; Self-Management; Sexual Health; Tissue Integrity; Urinary Tract Infection; Urohealth; Walking, and Wheeled Mobility. Conclusions: The modified Hanlon method was used to facilitate prioritization of 11 of 37 Domains to advance the quality of SCI-care by 2020. In future, the Spinal Cord Injury Rehabilitation Care High Performance Indicators (SCI-High) Project Team will develop structure, process and outcome indicators for each prioritized Domain.

Priorities, concerns, and regret among patients with head and neck cancer.

BACKGROUND: In the era of deintensification, little data are available regarding patients' treatment preferences. The current study evaluated treatment-related priorities, concerns, and regret among patients with head and neck squamous cell cancer (HNSCC). METHODS: A total of 150 patients with HNSCC ranked the importance of 10 nononcologic treatment goals relative to the oncologic goals of cure and survival. The level of concern regarding 11 issues and decision regret was recorded. Median rank was reported overall, and factors associated with odds of rank as a top 3 priority were modeled using logistic regression. RESULTS: Among the treatment effects analyzed, the odds of being a top 3 priority was especially high for cure (odds, 9.17; 95% confidence interval [95% CI], 5.05-16.63), followed by survival and swallow (odds, 1.26 [95% CI, 0.88-1.80] and odds, 0.85 [95% CI, 0.59-1.21], respectively). Prioritization of cure, survival, and swallow was similar based on human papillomavirus (HPV) tumor status. By increasing decade of age, older participants were found to be significantly less likely than younger individuals to prioritize survival (odds ratio, 0.72; 95% CI, 0.52-1.00). Concerns regarding mortality (P = .04) and transmission of HPV to the patient's spouse (P = .03) were more frequent among participants with HPV-associated HNSCC. Regret increased with additional treatment modalities (P = .02). CONCLUSIONS: Patients with HNSCC overwhelming prioritize cure, followed by survival and swallow. The decreased prioritization of survival by older age supports further examination of treatment preference by age. The precedence of oncologic over nononcologic priorities among patients regardless of HPV tumor status supports the conservative adoption of deintensification regimens until the interplay between competing oncologic and nononcologic treatment goals is better understood.

Aligning ambulance dispatch priority to patient acuity: A methodology.

OBJECTIVE: In Victoria, Australia, Emergency Medical Service (EMS) demand has increased almost 5% per annum over the past 5 years. This may adversely affect response times to time-critical patients. Additionally, >55% of cases have received Code 1 (lights/sirens) responses. Primary telephone triage occurs using the Medical Priority Dispatch System (MPDS); however, MPDS is reported to be highly sensitive, with common over-triage. The present study describes the methodology applied to better align the response allocated to MPDS determinant codes with patient acuity. METHODS: Data between October 2013 and August 2014 were extracted from the Ambulance Victoria data warehouse. The decision to allocate MPDS determinant codes to a lower response priority and/or secondary triage was based on epidemiological profiling and, in some cases, expert panel review. RESULTS: The review identified 105 MPDS codes receiving a Code 1 response as suitable for a Code 2 (urgent) response, and 221 Code 1 or 2 codes as suitable for secondary triage. Data analysis estimated a reduction in Code 1 responses by 28%, and an increase in the secondary triage caseload by 120%. Modelling also predicted a 2.6 percentage point improvement in the proportion of Code 1 cases attended within 15 min. CONCLUSION: Analysis of a large EMS dataset supported changes to the EMS response priority for a number of MPDS determinant codes. Such changes should improve the alignment between EMS response and patient acuity, and improve response times to time-critical patients. Other EMS with electronic data could consider testing this methodology.

Involvement of community pharmacists in public health priorities: A multi-center descriptive survey in Ethiopia.

Located in the heart of the community and widely distributed geographically, community pharmacies provide a platform for a more proactive involvement in public health services. So far, little information has been gathered in Ethiopia on community pharmacists' level of involvement in public health services. The aim of the present study was, therefore, to document the level of involvement of community pharmacy professionals in the provision of public health services and the barriers to such involvement. This study employed a self-administered questionnaire based survey, which asked participants to indicate their frequency and level of involvement in providing public health services and their perceived barriers in providing such services. Surveys were undertaken from May to July, 2016 with 472 community pharmacy professionals working in community pharmacies in six cities of Amhara regional state of Ethiopia: Debre Markos, Gondar, Dessie, Bahir Dar, Woldya and Debre Birhan. Among 472 community pharmacy professionals approached, 412 (233 pharmacists and 179 pharmacy technicians) completed the survey with a response rate of 87.3%. Most respondents reported as being either "not at all involved" or "little involved" in counselling on smoking cessation (79.3%), and screening for hypertension (86.9%), diabetes (89.5%), and dyslipidemia (88.9%). On the other hand, they reported a higher level of involvement in the management and screening of infectious diseases (72.8%) and counseling with partners when initiating treatment for sexually transmitted diseases (68.9%). Lack of knowledge or clinical skills and lack of personnel or resources were the most commonly reported barrier for expanding such services. This survey revealed a low level of involvement of community pharmacists in public health services. In order to better integrate community pharmacies into future public health programs and optimize the contribution of community pharmacy professionals, interventions should focus on overcoming the identified barriers.

Comparison of a predictive algorithm with receptionist triage for priority public dental care.

OBJECTIVE: To determine the clinical validity and accuracy of an empirically derived triage model when compared with traditional priority assessment by receptionists. BACKGROUND: The use of predictive models to support evidence-based delivery of health care is increasing. Predictive models assist in predicting priority of need or treatment planning for patients and facilitate transparent and consistent decision-making. A predictive model for determining priority of need for dental care was evaluated against a reference standard dentist assessment and traditional receptionist assessment. METHODS: We sampled 310 patients seeking dental care. Participants were selected from people requesting care at two community dental clinics and who agreed to answer eight questions. Receptionists recorded their judgements of participant priority into three categories: care needed <48 h, 2-7 days or 8+ days. The 'reference standard' priority was determined by dental officers using the same categories. Model coefficients generated a predicted probability of requiring care. Sensitivity (Se), specificity (Sp), and predictive (PPV and NPV) and area under the curve (AUC) values were computed for two thresholds, <48 h versus 2+ days and <2-7 days versus 8+ days. RESULTS: At <48-h threshold, the model PPV was higher and NPV lower than receptionists in predicting patients not needing care. At the 2- to 7-day threshold, the model also performed better than receptionists in predicting those needing care for 2-7 days. AUC statistics show the model performed better than the traditional receptionist method. CONCLUSIONS: The predictive model outperformed traditional receptionist screening in predicting priority of care.

The corneal transplant score: a simple corneal graft candidate calculator.

BACKGROUND: Shortage of corneas for transplantation has created long waiting lists in most countries. Transplant calculators are available for many organs. The purpose of this study is to describe a simple automatic scoring system for keratoplasty recipient candidates, based on several parameters that we consider most relevant for tissue allocation, and to compare the system's accuracy in predicting decisions made by a cornea specialist. METHODS: Twenty pairs of candidate data were randomly created on an electronic spreadsheet. A single priority score was computed from the data of each candidate. A cornea surgeon and the automated system then decided independently which candidate in each pair should have surgery if only a single cornea was available. RESULTS: The scoring system can calculate values between 0 (lowest priority) and 18 (highest priority) for each candidate. Average score value in our randomly created cohort was 6.35 ± 2.38 (mean ± SD), range 1.28 to 10.76. Average score difference between the candidates in each pair was 3.12 ± 2.10, range 0.08 to 8.45. The manual scoring process, although theoretical, was mentally and emotionally demanding for the surgeon. Agreement was achieved between the human decision and the calculated value in 19 of 20 pairs. Disagreement was reached in the pair with the lowest score difference (0.08). CONCLUSIONS: With worldwide donor cornea shortage, waiting for transplantation can be long. Manual sorting of priority for transplantation in a long waiting list is difficult, time-consuming and prone to error. The suggested system may help achieve a justified distribution of available tissue.

Priority setting in guideline development: article 2 in Integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report.

INTRODUCTION: Professional societies, like many other organizations around the world, have recognized the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. Priority setting is an essential component of developing clinical practice guidelines informed by the best available research evidence. It ensures that resources and attention are devoted to those areas in which clinical recommendations will provide the greatest benefit to patients, clinicians, and policy makers. This is the second of a series of 14 articles that methodologists and researchers from around the world prepared to advise guideline developers in respiratory and other diseases. This review focuses on priority setting, addressing five key questions. METHODS: In this review, we addressed the following questions. (1) At which steps of guideline development should priorities be considered? (2) How do we create an initial list of potential topics within the guideline? (3) What criteria should be used to establish priorities? (4) What parties should be involved and what processes should be used to set priorities? (5)What are the potential challenges of setting priorities? We updated an existing review on priority setting, and searched PubMed and other databases of methodological studies for existing systematic reviews and relevant methodological research. We did not conduct systematic reviews ourselves. Our conclusions are based on available evidence, our own experience working with guideline developers, and workshop discussions. RESULTS AND DISCUSSION: Existing literature on priority setting largely applies to identifying priorities for which guidelines to develop rather than setting priorities for recommendations within a guideline. Nonetheless, there is substantial consensus about the general factors that should be considered in setting priorities. These include the burdens and costs of illness, potential impact of a recommendation, identified deficits or weak points in practice, variation or uncertainty in practice, and availability of evidence. The input of a variety of stakeholders is useful in setting priorities, although informal consultation is used more often than formal methods. Processes for setting priorities remains poorly described in most guidelines.

Multi-criteria decision analysis for setting priorities on HIV/AIDS interventions in Thailand.

BACKGROUND: A wide range of preventive, treatment, and care programs for HIV/AIDS are currently available and some of them have been implemented in Thailand. Policy makers are now facing challenges on how the scarce resources for HIV/AIDS control can be spent more wisely. Although effectiveness and cost-effectiveness information is useful for guiding policy decisions, empirical evidence indicates the importance of other criteria, such as equity and the characteristics of the target population, also play important roles in priority setting. This study aims to experiment with the use of multi-criteria decision analysis (MCDA) to prioritise interventions in HIV/AIDS control in Thailand. METHODS: We used MCDA to rank 40 HIV/AIDS interventions on the basis of the priority setting criteria put forward by three groups of stakeholders including policy makers, people living with HIV/AIDs (PLWHA), and village health volunteers (VHVs). MCDA incorporated an explicit component of deliberation to let stakeholders reflect on the rank ordering, and adapt where necessary. RESULTS: Upon deliberation, policy makers expressed a preference for programs that target high risk groups such as men who have sex with men, injecting drug users, and female sex workers. The VHVs preferred interventions that target the youth or the general population, and gave lower priority to programs that target high risk groups. PLWHA gave all interventions the same priority. The rank order correlation between the priorities as expressed before and after deliberation was 37% among the policy makers and 46% among the VHVs. CONCLUSION: This study documented the feasibility of MCDA to prioritize HIV/AIDS interventions in Thailand, and has shown the usefulness of a deliberative process as an integrated component of MCDA. MCDA holds potential to contribute to a more transparent and accountable priority setting process, and further application of this approach in the prioritisation of health interventions is warranted.

A stakeholder-informed approach to the identification of criteria for the prioritization of zoonoses in Canada.

BACKGROUND: Zoonotic diseases account for over 60% of all communicable diseases causing illness in humans and 75% of recently emerging infectious diseases. As limited resources are available for the control and prevention of zoonotic diseases, it is necessary to prioritize diseases in order to direct resources into those with the greatest needs. The selection of criteria for prioritization has traditionally been on the basis of expert opinion; however, details of the methods used to identify criteria from expert opinion often are not published and a full range of criteria may not be captured by expert opinion. METHODOLOGY/PRINCIPAL FINDINGS: This study used six focus groups to identify criteria for the prioritization of zoonotic diseases in Canada. Focus groups included people from the public, animal health professionals and human health professionals. A total of 59 criteria were identified for prioritizing zoonotic diseases. Human-related criteria accounted for the highest proportion of criteria identified (55%), followed by animal-related criteria (26%) then pathogen/disease-related criteria (19%). Similarities and differences were observed in the identification and scoring of criteria for disease prioritization between groups; the public groups were strongly influenced by the individual-level of disease burden, the responsibility of the scientific community in disease prioritization and the experiences of recent events while the professional groups were influenced by the societal- and population-level of disease burden and political and public pressure. CONCLUSIONS/SIGNIFICANCE: This was the first study to describe a mixed semi-quantitative and qualitative approach to deriving criteria for disease prioritization. This was also the first study to involve the opinion of the general public regarding disease prioritization. The number of criteria identified highlights the difficulty in prioritizing zoonotic diseases. The method presented in this paper has formulated a comprehensive list of criteria that can be used to inform future disease prioritization studies.

[Appropriateness in echocardiography and clinical priority classification criteria: a proposal from the Italian Society of Cardiovascular Echography]. / Appropriatezza dell'esame ecocardiografico e definizione delle classi di priorità: una proposta della Società Italiana di Ecografia Cardiovascolare.

One of the main tasks of a scientific society is to define the theoretical bases and appropriate management strategies with the aim to maintain a high-quality diagnostic and therapeutic standard. As far as echocardiography is concerned, the task of the Italian Society of Cardiovascular Echography is to provide appropriate, complete, and useful echocardiographic tests for clinical application, as well as procedural, technological, organizational and economic indications to be adopted in clinical practice. In addition, there is an increasing need for regulating access to echocardiographic assessment according to clinical priority, because of the huge proportion of patients who should undergo a first or follow-up echocardiographic evaluation. The aim of this document is to implement appropriateness in echocardiography for the study and follow-up of cardiovascular diseases, and to optimize demand on the basis of clinical priority classification criteria outlined by the scientific societies and used by the National Health Service. Besides cardiovascular diseases, this document also addresses other diseases that often require echocardiographic investigation, such as liver diseases, connective tissue diseases, endocrine diseases, peripheral vascular and oncological diseases. Although not included in the previous guidelines, clinical priority and followup criteria are defined also for these groups of diseases according to the available literature. In conclusion, this document aims at guaranteeing access to the diagnostic echocardiographic procedures provided by the National Health Service to the general population, with practical indications on how to solve the problem of waiting lists.

Identifying research priorities for health care priority setting: a collaborative effort between managers and researchers.

BACKGROUND: To date there has been relatively little published about how research priorities are set, and even less about methods by which decision-makers can be engaged in defining a relevant and appropriate research agenda. We report on a recent effort in British Columbia to have researchers and decision-makers jointly establish an agenda for future research into questions of resource allocation. METHODS: The researchers enlisted decision-maker partners from each of British Columbia's six health authorities. Three forums were held, at which researchers and decision-makers from various levels in the health authorities considered possible research areas related to three key focus areas: (1) generation and use of decision criteria and measurement of 'benefit' against such criteria; (2) identification of so-called 'disinvestment' opportunities; and (3) evaluation of the effectiveness of priority setting procedures. Detailed notes were taken from each forum and synthesized into a set of qualitative themes. RESULTS: Forum participants suggested that future research into healthcare priority setting would benefit from studies that were longitudinal, comparative, and/or interdisciplinary. As well, participants identified two broad theme areas in which specific research projects were deemed desirable. First, future research might usefully consider how formal priority setting and resource allocation projects are situated within a larger organizational and political context. Second, additional research efforts should be devoted to better understanding and improving the actual implementation of priority setting frameworks, particularly with respect to issues of change management and the resolution of impediments to action on recommendations for resource allocation. CONCLUSION: We were able to validate the importance of initial areas posed to the group and observed emergence of additional concerns and directions of critical importance to these decision-makers at this time. It is likely that the results are broadly applicable to other healthcare contexts. The implementation of this research agenda in British Columbia will depend upon the ability of the researchers and decision-makers to develop particular projects that fit within the constraints of existing funding opportunities. The process of engagement itself had benefits in terms of connecting decision-makers with their peers and sparking increased interest in the use and refinement of priority setting frameworks.

Back pain: a National Health Priority Area in Australia?

The aim of the National Health Priority Area (NHPA) initiative is to promote cooperation between government and non-government organisations to monitor, report on and develop strategies to improve health outcomes for Australians. The seven existing NHPAs (cancer control, injury prevention and control, cardiovascular health, mental health, diabetes mellitus, asthma and musculoskeletal conditions) were selected on the basis of their profound burden on the health of Australians. Up to eighty per cent of Australians will experience back pain at some point in their lives and 10% will experience significant disability as a result. Back pain disrupts individuals' quality of life and accounts for an enormous cost to the community. Integrating back pain into the NHPA framework has many potential benefits, including more systematic development and implementation of programs aimed at minimising back pain-related disability by providing a focus for policy, legislation and public awareness; and promotion of best-practice management of the condition. A disadvantage of making back pain an NHPA is the risk that back pain management could become further medicalised and ineffective interventions could become more accepted. Coordinated action on back pain is needed, and integrating back pain into the NHPA framework is one solution. Informed decision making through consultation with key stakeholders is a necessary first step towards ensuring that favourable outcomes are achieved.

Do different stakeholder groups share mental health research priorities? A four-arm Delphi study.

BACKGROUND: Despite considerable investment in research priority setting within diverse fields of healthcare, little is known about the extent to which different stakeholder groups share research priorities. Conflicting priorities may jeopardize stakeholder engagement in research. OBJECTIVE: To identify the research priorities of different stakeholder groups within mental health care and examine the extent and nature of agreement between them. DESIGN: Using a Delphi technique, we conducted parallel consultation processes within four different stakeholder groups. Each group process consisted of three rounds. SETTING AND PARTICIPANTS: The study was carried out within a mental health and learning disabilities trust in southern England. Participants were recruited from the following groups: mental health service users (34), informal carers (26), mental health practitioners (35) and service managers (23). FINDINGS: There were striking differences between the four groups in respect of their ability and willingness to make priority decisions. These differences notwithstanding, there was considerable overlap in respect of their research interests. All groups identified and attached high importance to issues relating to the promotion of independence, self-esteem and recovery. The quality of in-patient care, the place of psychological therapies and the relationship between physical and mental health also emerged across the board. CONCLUSIONS: The confluence of four different stakeholder groups around a number of clear themes is highly encouraging, providing a framework within which to construct a research agenda and suggesting that mental health research can be built on solid partnerships.

Citizens' juries in planning research priorities: process, engagement and outcome.

BACKGROUND: Involving members of the public in setting priorities for health research in becoming increasingly common practice. One method used in public involvement exercises is the citizens' jury. OBJECTIVE: This article examines some challenges and benefits of citizens' juries, including issues relating to process, public engagement and outcome. DESIGN: In Bristol, UK, a citizens' jury was held with the aim of identifying local priorities for research into health and social care. This jury is used as an example through which key issues in public involvement and jury processes are explored. SETTING AND PARTICIPANTS: The Bristol Citizens' Jury comprised 20 members of the public ('jurors'), an oversight panel and a steering group. The jurors met at 11 consecutive sessions during 2006 over a period of 16 weeks, which culminated in a written report. All the sessions were audio-recorded, five sessions were observed and video-recorded, and 16 jurors completed written feedback forms at the end of the jury process. FINDINGS AND CONCLUSION: In this article we discuss degree and timing of public involvement in the process of health research; the role of context; representation of communities; processes of deliberation and knowledge production; and how constraints of time and cost may affect public involvement. It was clear that jurors who took part in the Bristol Citizens' Jury were engaged and committed. This engagement may be related to jurors' belief in their ability to shape future research alongside concern about the relevance of the issues under discussion. Opposing emotions of tension and harmony are a crucial part of the deliberation process.