Impact of information and deliberation on the consistency of preferences for prioritization in health care - evidence from discrete choice experiments undertaken alongside citizens' juries.

BACKGROUND: Public preferences are an important consideration for priority-setting. Critics suggest preferences of the public who are potentially naïve to the issue under consideration may lead to sub-optimal decisions. We assessed the impact of information and deliberation via a Citizens' Jury (CJ) or preference elicitation methods (Discrete Choice Experiment, DCE) on preferences for prioritizing access to bariatric surgery. METHODS: Preferences for seven prioritization criteria (e.g. obesity level, obesity-related comorbidities) were elicited from three groups who completed a DCE: (i) participants from two CJs (n = 28); (ii) controls who did not participate in the jury (n = 21); (iii) population sample (n = 1,994). Participants in the jury and control groups completed the DCE pre- and post-jury. DCE data were analyzed using multinomial logit models to derive "priority weights" for criteria for access to surgery. The rank order of criteria was compared across groups, time points and CJ recommendations. RESULTS: The extent to which the criteria were considered important were broadly consistent across groups and were similar to jury recommendations but with variation in the rank order. Preferences of jurors but not controls were more differentiated (that is, criteria were assigned a greater range of priority weights) after than before the jury. Juror preferences pre-jury were similar to that of the public but appeared to change during the course of the jury with greater priority given to a person with comorbidity. Conversely, controls appeared to give a lower priority to those with comorbidity and higher priority to treating very severe obesity after than before the jury. CONCLUSION: Being informed and undertaking deliberation had little impact on the criteria that were considered to be relevant for prioritizing access to bariatric surgery but may have a small impact on the relative importance of criteria. CJs may clarify underlying rationale but may not provide substantially different prioritization recommendations compared to a DCE.

Public preferences are an important consideration for priority-setting. However, some people worry that if the public doesn't know much about the issues, their opinions might not lead to the best decisions. To make these decisions, we used two different methods to get people's opinions: Deliberative methods and preference elicitation methods. Deliberative methods gather a small group of people and have them discuss an issue in detail, whereas preference elicitation methods seek opinions through surveying a large group of people.In this paper, we assessed the impact of information and deliberation via a deliberative method (Citizens' Jury, CJ) or a preference elicitation method (Discrete Choice Experiment, DCE) on preferences for prioritising access to bariatric surgery. We used data from two CJs and a DCE focussed on prioritising access to the surgery, to find out if the opinions of those in the CJs changed or stayed the same after they heard information from experts and discussed the topic.The results showed that the important criteria were rather similar across the groups, but the order of importance was a bit different. The people in CJs had more varied opinions after discussing it, while those who didn't discuss it had less varied opinions. The participants in CJs also prioritized those with other health problems more than they did at the beginning.This study helps us understand how different methods can be used to get the public's opinions on healthcare decisions.

Unveiling the dark side of glucose-regulated protein 78 (GRP78) in cancers and other human pathology: a systematic review.

Glucose-Regulated Protein 78 (GRP78) is a chaperone protein that is predominantly expressed in the lumen of the endoplasmic reticulum. GRP78 plays a crucial role in protein folding by assisting in the assembly of misfolded proteins. Under cellular stress conditions, GRP78 can translocate to the cell surface (csGRP78) were it interacts with different ligands to initiate various intracellular pathways. The expression of csGRP78 has been associated with tumor initiation and progression of multiple cancer types. This review provides a comprehensive analysis of the existing evidence on the roles of GRP78 in various types of cancer and other human pathology. Additionally, the review discusses the current understanding of the mechanisms underlying GRP78's involvement in tumorigenesis and cancer advancement. Furthermore, we highlight recent innovative approaches employed in downregulating GRP78 expression in cancers as a potential therapeutic target.

Self-assessed health status and neighborhood context.

In recent years, there has been growing interest in the relationship between the characteristics of neighborhoods and the health and well-being of residents. The focus on neighborhood as a health determinant is based on the hypothesis that residing in a disadvantaged neighborhood can negatively influence health outcomes beyond the effect of individual characteristics. In this article, we examine three possible ways of measuring neighborhood socio-economic status, and how they each impact on self-reported health status beyond the effect contributed by individual-level factors. Using individual-level data from the Household Income and Labor Dynamics Australia survey combined with neighborhood-level (suburb) data, we tested the proposition that how one measures neighborhood socio-economic characteristics may provide an important new insight into understanding the links between individual-level outcomes and neighborhood-level characteristics. The findings from the analysis illustrate that although individual-level factors may be important to understanding health outcomes, how one accounts for neighborhood-level socio-economic status may be equally important. The findings suggest that in developing place-based health programs, policy makers need to account for the complex interactions between individual drivers and the potential complexities of accounting for neighborhood socio-economic status.

Prioritising patients for bariatric surgery: building public preferences from a discrete choice experiment into public policy.

OBJECTIVES: To derive priority weights for access to bariatric surgery for obese adults, from the perspective of the public. SETTING: Australian public hospital system. PARTICIPANTS: Adults (N=1994), reflecting the age and gender distribution of Queensland and South Australia. PRIMARY AND SECONDARY OUTCOME MEASURES: A discrete choice experiment in which respondents indicated which of two individuals with different characteristics should be prioritised for surgery in repeated hypothetical choices. Potential surgery recipients were described by seven key characteristics or attributes: body mass index (BMI), presence of comorbid conditions, age, family history, commitment to lifestyle change, time on the surgical wait list and chance of maintaining weight loss following surgery. A multinomial logit model was used to evaluate preferences and derive priority weights (primary analysis), with a latent class model used to explore respondent characteristics that were associated with variation in preference across the sample (see online supplementary analysis). RESULTS: A preference was observed to prioritise individuals who demonstrated a strong commitment to maintaining a healthy lifestyle as well as individuals categorised with very severe (BMI≥50 kg/m2) or (to a lesser extent) severe (BMI≥40 kg/m2) obesity, those who already have obesity-related comorbidity, with a family history of obesity, with a greater chance of maintaining weight loss or who had spent a longer time on the wait list. Lifestyle commitment was considered to be more than twice as important as any other criterion. There was little tendency to prioritise according to the age of the recipient. Respondent preferences were dependent on their BMI, previous experience with weight management surgery, current health state and education level. CONCLUSIONS: This study extends our understanding of the publics' preferences for priority setting to the context of bariatric surgery, and derives priority weights that could be used to assist bodies responsible for commissioning bariatric services.

Engaging the public in healthcare decision-making: quantifying preferences for healthcare through citizens' juries.

INTRODUCTION: The optimal approach to engage the public in healthcare decision-making is unclear. Approaches range from deliberative citizens' juries to large population surveys using discrete choice experiments. This study promotes public engagement and quantifies preferences in two key areas of relevance to the industry partners to identify which approach is most informative for informing healthcare policy. METHODS AND ANALYSIS: The key areas identified are optimising appropriate use of emergency care and prioritising patients for bariatric surgery. Three citizens' juries will be undertaken-two in Queensland to address each key issue and one in Adelaide to repeat the bariatric surgery deliberations with a different sample. Jurors will be given a choice experiment before the jury, immediately following the jury and at approximately 1 month following the jury. Control groups for each jury will be given the choice experiment at the same time points to test for convergence. Samples of healthcare decision-makers will be given the choice experiment as will two large samples of the population. Jury and control group participants will be recruited from the Queensland electoral roll and newspaper advertisements in Adelaide. Population samples will be recruited from a large research panel. Jury processes will be analysed qualitatively and choice experiments will be analysed using multinomial logit models and its more generalised forms. Comparisons between preferences across jurors predeliberation and postdeliberation, control participants, healthcare decision-makers and the general public will be undertaken for each key issue. ETHICS AND DISSEMINATION: The study is approved by Griffith University Human Research Ethics Committee (MED/10/12/HREC). Findings of the juries and the choice experiments will be reported at a workshop of stakeholders to be held in 2015, in reports and in peer reviewed journals.

Treatment burden among people with chronic illness: what are consumer health organizations saying?

OBJECTIVES: To explore the perspectives of consumer health organizations about the burden of chronic illness and multiple treatment regimens experienced by the consumers they represent. METHODS: In-depth interviews (n = 15) were conducted with senior representatives from peak Australian consumer health organizations representing diabetes, asthma, cardiovascular disease, cancer, musculoskeletal illness and mental health. RESULTS: Medication burden, which included aspects such as multiple medications, side effects, stigma and adverse events resulting from medication use, emerged as the most significant and prevalent theme. Carer burden and the negative impact of financial burden was widely discussed, particularly for low-income earners with claims that these consumers were forced to prioritise medications according to how effective they perceived them to be. Time taken to learn about treatment, administer, and monitor or travel to obtain treatment also emerged as being burdensome, however, difficulty accessing treatment was considered to be particularly burdensome. The disjointed nature of care among healthcare services was thought to create a sense of confusion and distress. DISCUSSION: Many of the issues discussed by participants corroborated existing research, underscoring the complementary provider, and advocacy role of these organisations in mitigating treatment burden for people with chronic illness.

Health status after traumatic injury.

BACKGROUND: This study explored the relationships between health-related quality of life and postacute factors such as patients' perceived access to information and support, perceptions of illness and ability to provide self-care after traumatic injury. METHODS: Adults (18 years or older) admitted to hospital for ≥ 24 hours for the acute treatment of trauma in two hospitals in Queensland, Australia, were enrolled in a prospective cohort study. Questionnaires completed at hospital discharge and 3 months and 6 months incorporated the following: demographic data; psychological factors (Revised Illness Perception Questionnaire, Information, Autonomy and Support Scale, and Therapeutic Self-Care Scale); and outcome data (medical short form-36). Data on injury and hospital stay were obtained from health care records and the Queensland Trauma Registry. RESULTS: One hundred ninety-four patients with a median Injury Severity Score 9 (interquartile range, 5-14) were enrolled, with 125 (64%) completing questionnaires at 6 months. More than half the cohort reported symptoms of pain, fatigue, stiff joints, sleep difficulties, and loss of strength. All subscale scores on the short form-36 were below Australian norms 6 months after injury. Predictors of poor physical health included older age, lower extremity injury, and increased perceived consequences of their injuries, whereas predictors of poor mental health included younger age, female gender, and lower perceived control over their environment. CONCLUSIONS: Patients with minor to moderate injury based on anatomic injury scoring systems have ongoing challenges with recovery including problematic symptoms and low quality of life. Interventions aimed toward assisting recovery should not be limited to trauma patients with major injury. LEVEL OF EVIDENCE: Prognostic study, level III.

Probing the mechanism of FET3 repression by Izh2p overexpression.

We previously reported a role for the IZH2 gene product in metal ion metabolism. Subsequently, Izh2p was also identified as a member of the PAQR family of receptors and, more specifically, as the receptor for the plant protein osmotin. In this report, we investigate the effect of Izh2p on iron homeostasis. We show that overproduction of Izh2p prevents the iron-dependent induction of the Fet3p component of the high-affinity iron-uptake system and is deleterious for growth in iron-limited medium. We demonstrate that the effect of Izh2p requires cAMP-dependent kinase and AMP-dependent kinase and is not mediated by general inhibition of the Aft1p iron-responsive transcriptional activator. We also show that Izh2p-overproduction negatively regulates Nrg1p/Nrg2p- and Msn2p/Msn4p-dependent reporters. Furthermore, we show that the Nrg1p/Nrg2p and Msn2p/Msn4p pairs are epistatic to each other with respect to their effects on FET3 expression. Finally, we show that the mechanism by which PAQR receptors activate signal transduction pathways is likely to be conserved from yeast to humans.

The role of practice nurses in coordinated care of people with chronic and complex conditions.

General practice in Australia must cope with growing numbers of individuals with chronic and complex needs. The Australian Government has recognised the need to reform the primary health care sector to address this issue, with recent initiatives, such as coordinated care. The overall goal of coordinated care at a national level is to facilitate integrated care for people with chronic and complex conditions, by enhancing collaborative partnerships among general practitioners, primary health care providers, community service providers and clients. Interestingly, practice nurses (PNs) have not been identified as key stakeholders in the coordinated care service delivery model in Australia. In contrast, an expanded role for PNs has been in place in the United Kingdom and New Zealand for some time. This paper is based on focus group discussions with Australian PNs who have had a range of experiences in coordinated care models. The study identifies an important role for PNs, suggesting trial of a variety of models of coordinated care that include PNs in chronic disease management process.

Use of the 'BRASS' to identify ICU patients who may have complex hospital discharge planning needs.

Intensive care unit (ICU) transition programmes and discharge liaison nurse roles have emerged because the move from the ICU to the general wards has been found to be problematic for patients, their families and even health care professionals As these programmes are costly, it is essential that they are delivered to those for whom positive outcomes are most likely to be achieved. This paper reports on the use of the Blaylock Risk Assessment Screening Score (BRASS) to identify ICU patients who are at risk of complex hospital discharge needs Use of BRASS at admission was not particularly specific: that is, it was not able to identify consistently those at risk of prolonged ICU and hospital stay and ICU readmission. BRASS was fairly sensitive, correctly identifying over 95% of individuals who did not have a prolonged hospital stay BRASS is easy to use, but may be no better than severity of illness scoring systems in identifying ICU patients who potentially have complex hospital discharge planning needs; if used, it should not be completed on ICU admission alone.