Adherence to guidance for prioritizing higher risk groups for breast cancer screening during the COVID-19 pandemic in the Ontario Breast Screening Program: a descriptive study.

BACKGROUND: Breast cancer screening in Ontario, Canada, was deferred during the first wave of the COVID-19 pandemic, and a prioritization framework to resume services according to breast cancer risk was developed. The purpose of this study was to assess the impact of the pandemic within the Ontario Breast Screening Program (OBSP) by comparing total volumes of screening mammographic examinations and volumes of screening mammographic examinations with abnormal results before and during the pandemic, and to assess backlogs on the basis of adherence to the prioritization framework. METHODS: A descriptive study was conducted among women aged 50 to 74 years at average risk and women aged 30 to 69 years at high risk, who participated in the OBSP. Percentage change was calculated by comparing observed monthly volumes of mammographic examinations from March 2020 to March 2021 with 2019 volumes and proportions by risk group. We plotted estimates of backlog volumes of mammographic examinations by risk group, comparing pandemic with prepandemic screening practices. Volumes of mammographic examinations with abnormal results were plotted by risk group. RESULTS: Volumes of mammographic examinations in the OBSP showed the largest declines in April and May 2020 (> 99% decrease) and returned to prepandemic levels as of March 2021, with an accumulated backlog of 340 876 examinations. As of March 2021, prioritization had reduced the backlog volumes of screens for participants at high risk for breast cancer by 96.5% (186 v. 5469 expected) and annual rescreens for participants at average risk for breast cancer by 13.5% (62 432 v. 72 202 expected); there was a minimal decline for initial screens. Conversely, the backlog increased by 7.6% for biennial rescreens (221 674 v. 206 079 expected). More than half (59.4%) of mammographic examinations with abnormal results were for participants in the higher risk groups. INTERPRETATION: Prioritizing screening for those at higher risk for breast cancer may increase diagnostic yield and redirect resources to minimize potential long-term harms caused by the pandemic. This further supports the clinical utility of risk-stratified cancer screening.

The UpPriority tool supported prioritization processes for updating clinical guideline questions.

OBJECTIVE: We aim to 1) use the UpPriority tool to identify which clinical questions (CQs) within the clinical guidelines (CGs) need to be prioritized for updating and 2) assess the implementation of the tool in a real-world set of CGs. STUDY DESIGN AND SETTING: We systematically assessed CQs from a sample of CGs developed in the Spanish National Health System CG program. We applied the UpPriority tool to each CG using a step-by-step process that included: 1) establishment of the UpPriority Implementation Working Group, 2) mapping of the original CG questions and recommendations, 3) development of a survey to prioritize CQs, 4) assessment of CQ's priority according to six items, 5) calculation and ranking of priority scores, 6) decision of prioritized CQs for updating, and 7) development of the priority report. We assessed the tool implementation process (appraisers' experience when using the tool) and the inter-observer reliability of the tool, and we provided suggestions for improvement. RESULTS: We included four CGs with a total of 107 CQs on the following topics: chronic heart failure (10 CQs), inherited retinal dystrophies (39 CQs), menopause (20 CQs), and open-angle glaucoma (38 CQs). We included a total of 30 participants, most of them clinicians that were members of the original CG development groups. CQs were classified in three groups: 1) high priority (CQs prioritized for updating [16/107; 15.0%]), 2) medium priority (CQs that could be prioritized for updating [47/107; 43.9%]), and low priority (CQs that were not prioritized for updating [44/107; 41.1%]). The mean time each appraiser needed to assess the CQs with the tool was 3.8 hours (range 0.5 to 10). Agreement among the appraisers varied among the CGs. Appraisers considered that the tool was useful. We suggest some areas for consideration when using the tool including: 1) identification of key appraisers, 2) customization of training materials, 3) establishment of priority thresholds, and 4) provision of methodological support. CONCLUSION: The UpPriority is a useful tool to identify which CQs within a CG need to be prioritized for update in a real-world scenario. Recruitment and training of topic experts are the main challenges when using the tool.

Identifying Conditions With High Prevalence, Cost, and Variation in Cost in US Children's Hospitals.

Importance: Identifying high priority pediatric conditions is important for setting a research agenda in hospital pediatrics that will benefit families, clinicians, and the health care system. However, the last such prioritization study was conducted more than a decade ago and used International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Objectives: To identify conditions that should be prioritized for comparative effectiveness research based on prevalence, cost, and variation in cost of hospitalizations using contemporary data at US children's hospitals. Design, Setting, and Participants: This retrospective cohort study of children with hospital encounters used data from the Pediatric Health Information System database. Children younger than 18 years with inpatient hospital encounters at 45 tertiary care US children's hospitals between January 1, 2016, and December 31, 2019, were included. Data were analyzed from March 2020 to April 2021. Main Outcomes and Measures: The condition-specific prevalence and total standardized cost, the corresponding prevalence and cost ranks, and the variation in standardized cost per encounter across hospitals were analyzed. The variation in cost was assessed using the number of outlier hospitals and intraclass correlation coefficient. Results: There were 2 882 490 inpatient hospital encounters (median [interquartile range] age, 4 [1-12] years; 1 554 024 [53.9%] boys) included. Among the 50 most prevalent and 50 most costly conditions (total, 74 conditions), 49 (66.2%) were medical, 15 (20.3%) were surgical, and 10 (13.5%) were medical/surgical. The top 10 conditions by cost accounted for $12.4 billion of $33.4 billion total costs (37.4%) and 592 815 encounters (33.8% of all encounters). Of 74 conditions, 4 conditions had an intraclass correlation coefficient (ICC) of 0.30 or higher (ie, major depressive disorder: ICC, 0.49; type 1 diabetes with complications: ICC, 0.36; diabetic ketoacidosis: ICC, 0.33; acute appendicitis without peritonitis: ICC, 0.30), and 9 conditions had an ICC higher than 0.20 (scoliosis: ICC, 0.27; hypertrophy of tonsils and adenoids: ICC, 0.26; supracondylar fracture of humerus: ICC, 0.25; cleft lip and palate: ICC, 0.24; acute appendicitis with peritonitis: ICC, 0.21). Examples of conditions high in prevalence, cost, and variation in cost included major depressive disorder (cost rank, 19; prevalence rank, 10; ICC, 0.49), scoliosis (cost rank, 6; prevalence rank, 38; ICC, 0.27), acute appendicitis with peritonitis (cost rank, 13; prevalence rank, 11; ICC, 0.21), asthma (cost rank, 10; prevalence rank, 2; ICC, 0.17), and dehydration (cost rank, 24; prevalence rank, 8; ICC, 0.18). Conclusions and Relevance: This cohort study found that major depressive disorder, scoliosis, acute appendicitis with peritonitis, asthma, and dehydration were high in prevalence, costs, and variation in cost. These results could help identify where future comparative effectiveness research in hospital pediatrics should be targeted to improve the care and outcomes of hospitalized children.

Identifying what matters most for the health of older adults in Alberta: results from a James Lind Alliance Research Priority Setting Partnership.

BACKGROUND: As the number of older adults continues to increase, addressing their health becomes increasingly important for both the population and the health care system. The aim of this priority setting partnership was to use direct engagement with older adults, caregivers and health care providers to identify and prioritize the most important topics on the health of older adults that should be addressed by future research. METHODS: We followed the James Lind Alliance method. We conducted an initial online and paper survey from Jan. 22 to May 2, 2018, with older adults in Alberta aged 65 years and older to identify what respondents saw as being most important for the health of older adults. We formed responses into summary questions and checked them against existing evidence. We administered a second survey (July 3 to Aug. 2, 2018) to shortlist summary questions and held an in-person workshop (Aug. 30, 2018) to rank the list through discussion and shared decision-making. RESULTS: We recruited 670 participants (32.7% older adults, 19.7% caregivers, 46.9% health and social care workers) in the initial survey to tell us what topics on the health of older adults mattered most to them. Over 3000 responses generated 101 summary questions, of which only 4 were completely answered by existing evidence. The second prioritization survey was completed by 232 participants (28.4% older adults, 24.6% care partners, 47.0% health and social care workers) to produce a shortlist of 22 high priority questions. Twenty-two attendees participated in the summary workshop to create a prioritized list of 10 questions for future research that address aspects of the health system, provision of care and living well in older adulthood. INTERPRETATION: Older adults, caregivers and clinicians collectively produced a prioritized list of questions that matter most to older adults' health in Alberta. Provincial researchers and research funders should consider these unmet knowledge needs of end-users in future endeavours.

Development of COVIDVax Model to Estimate the Risk of SARS-CoV-2-Related Death Among 7.6 Million US Veterans for Use in Vaccination Prioritization.

Importance: A strategy that prioritizes individuals for SARS-CoV-2 vaccination according to their risk of SARS-CoV-2-related mortality would help minimize deaths during vaccine rollout. Objective: To develop a model that estimates the risk of SARS-CoV-2-related mortality among all enrollees of the US Department of Veterans Affairs (VA) health care system. Design, Setting, and Participants: This prognostic study used data from 7 635 064 individuals enrolled in the VA health care system as of May 21, 2020, to develop and internally validate a logistic regression model (COVIDVax) that predicted SARS-CoV-2-related death (n = 2422) during the observation period (May 21 to November 2, 2020) using baseline characteristics known to be associated with SARS-CoV-2-related mortality, extracted from the VA electronic health records (EHRs). The cohort was split into a training period (May 21 to September 30) and testing period (October 1 to November 2). Main Outcomes and Measures: SARS-CoV-2-related death, defined as death within 30 days of testing positive for SARS-CoV-2. VA EHR data streams were imported on a data integration platform to demonstrate that the model could be executed in real-time to produce dashboards with risk scores for all current VA enrollees. Results: Of 7 635 064 individuals, the mean (SD) age was 66.2 (13.8) years, and most were men (7 051 912 [92.4%]) and White individuals (4 887 338 [64.0%]), with 1 116 435 (14.6%) Black individuals and 399 634 (5.2%) Hispanic individuals. From a starting pool of 16 potential predictors, 10 were included in the final COVIDVax model, as follows: sex, age, race, ethnicity, body mass index, Charlson Comorbidity Index, diabetes, chronic kidney disease, congestive heart failure, and Care Assessment Need score. The model exhibited excellent discrimination with area under the receiver operating characteristic curve (AUROC) of 85.3% (95% CI, 84.6%-86.1%), superior to the AUROC of using age alone to stratify risk (72.6%; 95% CI, 71.6%-73.6%). Assuming vaccination is 90% effective at preventing SARS-CoV-2-related death, using this model to prioritize vaccination was estimated to prevent 63.5% of deaths that would occur by the time 50% of VA enrollees are vaccinated, significantly higher than the estimate for prioritizing vaccination based on age (45.6%) or the US Centers for Disease Control and Prevention phases of vaccine allocation (41.1%). Conclusions and Relevance: In this prognostic study of all VA enrollees, prioritizing vaccination based on the COVIDVax model was estimated to prevent a large proportion of deaths expected to occur during vaccine rollout before sufficient herd immunity is achieved.

Top priorities for the next decade of nursing health services research.

BACKGROUND: The U.S. health care system faces increasing pressures for reform. The importance of nurses in addressing health care delivery challenges cannot be overstated. PURPOSE: To present a Nursing Health Services Research (NHSR) agenda for the 2020s. METHOD: A meeting of an interdisciplinary group of 38 health services researchers to discuss five key challenges facing health care delivery (behavioral health, primary care, maternal/neonatal outcomes, the aging population, health care spending) and identify the most pressing and feasible research questions for NHSR in the coming decade. FINDINGS: Guided by a list of inputs affecting health care delivery (health information technology, workforce, delivery systems, payment, social determinants of health), meeting participants identified 5 to 6 research questions for each challenge. Also, eight cross-cutting themes illuminating the opportunities and barriers facing NHSR emerged. DISCUSSION: The Agenda can act as a foundation for new NHSR - which is more important than ever - in the 2020s.

Equine pituitary pars intermedia dysfunction: Identifying research priorities for diagnosis, treatment and prognosis through a priority setting partnership.

Pituitary pars intermedia dysfunction (PPID) is the most prevalent endocrine disorder of older equids. To date, key research areas likely to have the greatest impact on equine health have not been identified. In human medicine, public and patient involvement is widely used to inform research agendas. This study aimed to engage with veterinary surgeons and horse owners to identify evidence gaps ('uncertainties') and prioritise these into a list of the 10 most important PPID research questions. The James Lind Alliance (JLA) Priority Setting Partnership (PSP) Framework was adapted. Questions about the diagnosis, treatment and prognosis of PPID were gathered via an online survey targeting veterinary surgeons and horse owners with experience of PPID. Thematic analysis was used to form a longlist of collated indicative research questions (CIRQs), defined by the JLA as true 'evidence uncertainties' when not answered by a published, clinically relevant, up-to-date systematic review. In an interim prioritisation survey, questions were ranked by weighted scores creating a shortlist of 25 that were taken forward to the PSP workshop, where participants reached a consensus on the top 10. Useable responses containing ≥1 question were received from 524 respondents (92.6% owners, n = 485; 7.4% veterinary surgeons, n = 39). After screening for relevance, 1,260 individual questions were included in thematic analysis, resulting in 47 CIRQs. Interim prioritisation votes for the CIRQs were received from 360 respondents. The top 10 questions prioritised at the PSP workshop focused on long-term prognosis, diagnostic accuracy, efficacy of pergolide treatment, alternative treatment/management strategies and potential treatment options for poor responders to pergolide. The quantity of questions generated indicates an extensive number of uncertainties regarding the diagnosis, treatment and prognosis of PPID. The top 10 research questions will help to inform key areas for evidence synthesis and knowledge translation, and to direct future research into areas most important to end users involved in caring for and treating animals with PPID.

Thyroid fine-needle aspiration trends before, during, and after the lockdown: what we have learned so far from the COVID-19 pandemic.

PURPOSE: Nowadays, the clinical management of thyroid nodules needs to be multi-disciplinary. In particular, the crosstalk between endocrinologists and cytopathologists is key. When FNAs are properly requested by endocrinologists for nodules characterised by relevant clinical and ultrasound features, cytopathologists play a pivotal role in the diagnostic work-up. Conversely, improper FNA requests can lead to questionable diagnostic efficiency. Recently, recommendations to delay all non-urgent diagnostic procedures, such as thyroid FNAs, to contain the spread of COVID-19 infection, have made the interplay between endocrinologists and cytopathologists even more essential. The objective of this study was to assess the impact of COVID-19 pandemic on our practice by evaluating the total number of FNAs performed and the distribution of the Bethesda Categories before, during, and after the lockdown. METHODS: We analysed the FNA trends before (1st January 2019 to March 13th 2020), during (March 14th to May 15th), and after (May 16th to July 7th) the lockdown. RESULTS: Although the total number of weekly FNAs dropped from 62.1 to 23.1, our referring endocrinologists managed to prioritise patients with high-risk nodules. In fact, in the post-lockdown, the weekly proportion of benign diagnoses dropped on average by 12% and that of high-risk diagnoses increased by 6%. CONCLUSIONS: The lesson we have learned so far from this pandemic is that by applying safety protocols to avoid contagion and by increasing the threshold for FNA requests for thyroid nodules, we can continue to guarantee our services to high-risk patients even in times of a health crisis.

Prioritising recommendations following analyses of adverse events in healthcare: a systematic review.

PURPOSE: The purpose of this systematic review was to identify an appropriate method-a user-friendly and validated method-that prioritises recommendations following analyses of adverse events (AEs) based on objective features. DATA SOURCES: The electronic databases PubMed/MEDLINE, Embase (Ovid), Cochrane Library, PsycINFO (Ovid) and ERIC (Ovid) were searched. STUDY SELECTION: Studies were considered eligible when reporting on methods to prioritise recommendations. DATA EXTRACTION: Two teams of reviewers performed the data extraction which was defined prior to this phase. RESULTS OF DATA SYNTHESIS: Eleven methods were identified that are designed to prioritise recommendations. After completing the data extraction, none of the methods met all the predefined criteria. Nine methods were considered user-friendly. One study validated the developed method. Five methods prioritised recommendations based on objective features, not affected by personal opinion or knowledge and expected to be reproducible by different users. CONCLUSION: There are several methods available to prioritise recommendations following analyses of AEs. All these methods can be used to discuss and select recommendations for implementation. None of the methods is a user-friendly and validated method that prioritises recommendations based on objective features. Although there are possibilities to further improve their features, the 'Typology of safety functions' by de Dianous and Fiévez, and the 'Hierarchy of hazard controls' by McCaughan have the most potential to select high-quality recommendations as they have only a few clearly defined categories in a well-arranged ordinal sequence.

Value judgment of new medical treatments: Societal and patient perspectives to inform priority setting in The Netherlands.

BACKGROUND: In many countries, medical interventions are reimbursed on the basis of recommendations made by advisory boards and committees that apply multiple criteria in their assessment procedures. Given the diversity of these criteria, it is difficult to find common ground to determine what information is required for setting priorities. OBJECTIVE: To investigate whether society and patients share the same interests and views concerning healthcare priorities. METHODS: We applied a framework of discrete choice models in which respondents were presented with judgmental tasks to elicit their preferences. They were asked to choose between two hypothetical scenarios of patients receiving a new treatment. The scenarios graphically presented treatment outcomes and patient characteristics. Responses were collected through an online survey administered among respondents from the general population (N = 1,253) and patients (N = 1,389) and were analyzed using conditional logit and mixed logit models. RESULTS: The respondents' preferences regarding new medical treatments revealed that they attached the most relative importance to additional survival years, age at treatment, initial health condition, and the cause of disease. Minor differences in the relative importance assigned to three criteria: age at treatment, initial health, and cause of disease were found between the general population and patient samples. Health scenarios in which patients had higher initial health-related quality of life (i.e., a lower burden of disease) were favored over those in which patients' initial health-related quality of life was lower. CONCLUSIONS: Overall, respondents within the general population expressed preferences that were similar to those of the patients. Therefore, priority-setting studies that are based on the perspectives of the general population may be useful for informing decisions on reimbursement and other types of priority-setting processes in health care. Incorporating the preferences of the general population may simultaneously increase public acceptance of these decisions.

Prioritization of Medicine Importation by the Private Sector in Sudan: Evidence from a Data Analysis, 2012-2015.

OBJECTIVES: The objective of this study is to analyze the annual medicines imported by private sector for the period between 2012 and 2015 with the help of priority system based on ABC-VEN matrix analysis and therapeutic category analysis. METHODS: A retrospective cross-sectional study was conducted. The Always, Better, and Control (ABC) analysis based on drug expenditure and Vital, Essential, and Nonessential (VEN) analysis based on the criticality of the drugs was performed for annual importation in 2015. RESULTS: Using ABC analysis, we found that 47 items (9.2%) accounted for 70% of the budget (class A), whereas a larger numbers of items (344; 67.2%) accounted for only 10% of the importation costs (class C). A moderate number of items (120; 23.5%) comprised 20% of the annual medicine importation value (class B). VEN analysis revealed that 89 items (17.4%) in the vital category constituted 41.6% of the importation value, whereas 349 (68.3%) grouped as essential constituted 45.1% of the value, and 73 (14.2%) of the items considered as nonessential medicines consumed only 13.3% of the total medicines imported in 2015. From the resultant ABC-VEN coupled matrix, three categories were created I, II and III. CONCLUSION: In view of limited resources, it is important that the existing resources should be utilized appropriately. This study identified a range of suggestions for better medication importation. The ABC and VEN analyses along with the therapeutic category analysis technique are convenient, systematic, and replicable methods and should be adopted for optimization and prioritization of resources.

The UpPriority tool was developed to guide the prioritization of clinical guideline questions for updating.

OBJECTIVE: The objective of the study is to develop a pragmatic tool to prioritize clinical guideline (CG) questions for updating, the UpPriority tool. STUDY DESIGN AND SETTING: The development of this tool consisted of the following: (1) establishment of the working group, (2) generation of the initial version, (3) optimization of the tool (including an initial feasibility test, semistructured interviews, Delphi consensus survey, second feasibility test, external review, and pilot test), and (4) approval of the final version. RESULTS: A total of 87 participants including methodologists, clinicians, and other relevant stakeholders contributed to the development of the UpPriority tool. The tool consists of six items: (1) impact of outdated recommendations on safety, (2) availability of new relevant evidence, (3) context relevance of the clinical question, (4) methodological applicability of the clinical question, (5) user's interest, and (6) impact on access to health care. The UpPriority tool includes detailed guidance for using the tool and rating each item (using a 7-point Likert scale), for calculating and ranking the questions, and for summarizing results. CONCLUSION: The UpPriority tool could be useful for standardizing prioritization processes when updating CGs and for fostering more efficient use of resources in the CG field.

Chronic patients' satisfaction and priorities regarding medical care, information and services and quality of life: a French online patient community survey.

BACKGROUND: The French healthcare system is evolving to meet the challenges of an aging population, the growing prevalence of chronic diseases, the development of new technologies and the increasing involvement of patients in the management of their disease. The aim of this study is to assess the satisfaction and priorities of chronic patients regarding medical care, information and services and their quality of life. METHODS: A cross-sectional study was conducted from February to March 2018 via the French Carenity platform. Adult patients enrolled in type 1 diabetes, heart failure or obesity communities were invited to answer an online questionnaire. A numeric scale from 0 (meaning not satisfied) to 5 was used to evaluate patients' satisfaction. Patients' priorities were assessed using a ranking question. Patients' satisfaction and priorities have been combined in a matrix to identify patients' expectations. RESULTS: Sixty-seven respondents of each condition answered a questionnaire. The most important and least satisfactory items about medical care are availability and active listening from healthcare providers, as well as access to coordinated and multidisciplinary care. Regarding information and services, respondents mostly expect connected medical devices, in addition to lifestyle and dietary measures. As for the quality of life, respondents fear that their chronic condition will keep impacting their daily mood and ability to do physical activities. CONCLUSIONS: This study shows that chronic patients want to be more actively involved in their care pathway. Patient training and therapeutic patient education programs could help them manage their chronic conditions within a patient-centred healthcare system.

Life's hard and then you die: the end-of-life priorities of people experiencing homelessness in the UK.

BACKGROUND: People experiencing homelessness often die young and without adequate support. In the UK, they fail to access palliative care services and their end-of-life priorities remain poorly understood. AIMS: To explore the end-of-life concerns, fears, preferences and priorities of a sample of people experiencing homelessness in the UK. METHODS: This is an interpretive phenomenology. Data collected through semi-structured, audio-recorded, face-to-face interviews with 21 homeless participants in the UK were analysed iteratively using thematic analysis. Findings have been interpreted through the lens of Merleau-Ponty's philosophy. RESULTS: Eight themes are reported: spiritual concerns; practical concerns; fear of needing care; fear of being forgotten; preference for dying suddenly; preference for being somewhere comfortable where people know me; prioritising autonomy and self-determination; and prioritising authenticity. CONCLUSION: A strengths-based, trauma-informed, person-centred, collaborative 'compassionate community' approach to care is recommended for people experiencing homelessness at end of life.

Personalized Cancer Follow-Up Care Pathways: A Delphi Consensus of Research Priorities.

Development of personalized, stratified follow-up care pathways where care intensity and setting vary with needs could improve cancer survivor outcomes and efficiency of health-care delivery. Advancing such an approach in the United States requires identification and prioritization of the most pressing research and data needed to create and implement personalized care pathway models. Cancer survivorship research and care experts (n = 39) participated in an in-person workshop on this topic in 2018. Using a modified Delphi technique-a structured, validated system for identifying consensus-an expert panel identified critical research questions related to operationalizing personalized, stratified follow-up care pathways for individuals diagnosed with cancer. Consensus for the top priority research questions was achieved iteratively through 3 rounds: item generation, item consolidation, and selection of the final list of priority research questions. From the 28 research questions that were generated, 11 research priority questions were identified. The questions were categorized into 4 priority themes: determining outcome measures for new care pathways, developing and evaluating new care pathways, incentivizing new care pathway delivery, and providing technology and infrastructure to support self-management. Existing data sources to begin answering questions were also identified. Although existing data sources, including cancer registry, electronic medical record, and health insurance claims data, can be enhanced to begin addressing some questions, additional research resources are needed to address these priority questions.

Value of Information Analytical Methods: Report 2 of the ISPOR Value of Information Analysis Emerging Good Practices Task Force.

The allocation of healthcare resources among competing priorities requires an assessment of the expected costs and health effects of investing resources in the activities and of the opportunity cost of the expenditure. To date, much effort has been devoted to assessing the expected costs and health effects, but there remains an important need to also reflect the consequences of uncertainty in resource allocation decisions and the value of further research to reduce uncertainty. Decision making with uncertainty may turn out to be suboptimal, resulting in health loss. Consequently, there may be value in reducing uncertainty, through the collection of new evidence, to better inform resource decisions. This value can be quantified using value of information (VOI) analysis. This report from the ISPOR VOI Task Force describes methods for computing 4 VOI measures: the expected value of perfect information, expected value of partial perfect information (EVPPI), expected value of sample information (EVSI), and expected net benefit of sampling (ENBS). Several methods exist for computing EVPPI and EVSI, and this report provides guidance on selecting the most appropriate method based on the features of the decision problem. The report provides a number of recommendations for good practice when planning, undertaking, or reviewing VOI analyses. The software needed to compute VOI is discussed, and areas for future research are highlighted.

Human leptospirosis as a doubly neglected disease in Brazil. / A leptospirose humana como doença duplamente negligenciada no Brasil.

The aim of this article is to analyze discrepancies and informational gaps which produce a doubly neglected version of human leptospirosis in the Brazilian public health policy. To achieve this goal, we compared data on morbidity, mortality, hospital and social costs, population profiles, vector habits, social health determinants and diagnostic practices related to leptospirosis with another disease of higher recognition in Brazil: dengue fever. Our analysis shows that the arbitrariness of criteria for assigning health priorities, the invisibility of the population profile of human leptospirosis in official data and its mimetic character in clinic corroborate the production of a version of human leptospirosis that is invisible and, because of that, doubly neglected by the Brazilian public health policy. We conclude that these discrepancies and informational gaps are related to the fact that human leptospirosis affects a population which the State has no interest in keeping alive.

O objetivo do presente artigo é analisar as discrepâncias e lacunas informacionais que produzem uma versão duplamente negligenciada da leptospirose humana na política pública de saúde brasileira. Para alcançar esse objetivo, comparamos dados de morbidade, mortalidade, custos hospitalares e sociais, perfis populacionais, hábitos dos vetores, determinantes sociais de saúde e práticas diagnósticas relacionadas à leptospirose com outra doença de maior reconhecimento no país: a dengue. Nossa análise mostra que a arbitrariedade dos critérios para atribuições de prioridades de intervenção em saúde, a invisibilidade do perfil populacional da leptospirose humana nos dados oficiais da política de saúde e seu caráter clínico mimético corroboram para a produção de uma versão da leptospirose humana que é invisível e, portanto, duplamente negligenciada pela política pública de saúde brasileira. Concluímos que essas discrepâncias e lacunas informacionais relacionam-se ao fato de que a leptospirose humana acomete uma população que o Estado não tem interesse em manter viva.

A leptospirose humana como doença duplamente negligenciada no Brasil / Human leptospirosis as a doubly neglected disease in Brazil

Resumo O objetivo do presente artigo é analisar as discrepâncias e lacunas informacionais que produzem uma versão duplamente negligenciada da leptospirose humana na política pública de saúde brasileira. Para alcançar esse objetivo, comparamos dados de morbidade, mortalidade, custos hospitalares e sociais, perfis populacionais, hábitos dos vetores, determinantes sociais de saúde e práticas diagnósticas relacionadas à leptospirose com outra doença de maior reconhecimento no país: a dengue. Nossa análise mostra que a arbitrariedade dos critérios para atribuições de prioridades de intervenção em saúde, a invisibilidade do perfil populacional da leptospirose humana nos dados oficiais da política de saúde e seu caráter clínico mimético corroboram para a produção de uma versão da leptospirose humana que é invisível e, portanto, duplamente negligenciada pela política pública de saúde brasileira. Concluímos que essas discrepâncias e lacunas informacionais relacionam-se ao fato de que a leptospirose humana acomete uma população que o Estado não tem interesse em manter viva.

Abstract The aim of this article is to analyze discrepancies and informational gaps which produce a doubly neglected version of human leptospirosis in the Brazilian public health policy. To achieve this goal, we compared data on morbidity, mortality, hospital and social costs, population profiles, vector habits, social health determinants and diagnostic practices related to leptospirosis with another disease of higher recognition in Brazil: dengue fever. Our analysis shows that the arbitrariness of criteria for assigning health priorities, the invisibility of the population profile of human leptospirosis in official data and its mimetic character in clinic corroborate the production of a version of human leptospirosis that is invisible and, because of that, doubly neglected by the Brazilian public health policy. We conclude that these discrepancies and informational gaps are related to the fact that human leptospirosis affects a population which the State has no interest in keeping alive.

Which Priorities for Health and Well-Being Stand Out After Accounting for Tangled Threats and Costs? Simulating Potential Intervention Portfolios in Large Urban Counties.

Policy Points Interventions in a regional system with intertwined threats and costs should address those threats that have the strongest, quickest, and most pervasive cross-impacts. Instead of focusing on an individual county's apparent shortcomings, a regional intervention portfolio can yield greater results when it is designed to counter those systemic threats, especially poverty and inadequate social support, that most undermine health and well-being virtually everywhere. Likewise, efforts to reduce smoking, addiction, and violent crime and to improve routine care, health insurance, and youth education are important for most counties to unlock both short- and long-term potential. CONTEXT: Counties across the United States must contend with multiple, intertwined threats and costs that defy simple solutions. Decision makers face the necessary but difficult task of prioritizing those interventions with the greatest potential to produce equitable health and well-being. METHODS: Using County Health Rankings data for a predefined peer group of 39 urban US counties, we performed statistical regressions to identify 37 cross-impacts among 15 threats to health and well-being. Adding appropriate time delays, we then developed a dynamic model of these cross-impacts and simulated each of the counties over 20 years to assess the likely impact of 12 potential interventions-individually and in a combined portfolio-for three outcomes: (1) years of potential life lost, (2) fraction of adults in fair or poor health, and (3) total spending on urgent services. FINDINGS: The combined portfolio yielded improvements by year 20 that are considerably greater than those at year 5, indicating that the time delays have a major effect. Despite the wide variation in threat levels across counties, the list of top-ranked interventions is strikingly similar. Poverty reduction and social support were the most highly ranked interventions, even in the shorter term, for all outcomes in all counties. Interventions affecting smoking, addiction, routine care, health insurance, violent crime, and youth education also were important contributors to some outcomes. CONCLUSIONS: To safeguard health and well-being in a system dominated by tangled threats and costs, the most important priorities for a county cannot be simply inferred from a profile of its relative strengths and weaknesses. Two interventions stood out as the top priorities for almost all the counties in this study, and six others also were important contributors. Interventions directed toward these priority areas are likely to yield the greatest impact, irrespective of the county's specifics. A significant concentration of resources in a regional portfolio therefore ought to go to these strongest contributors for equitable health and well-being.