Neuronal Activity in the Gustatory Cortex during Economic Choice.

An economic choice entails computing and comparing the values of individual offers. Offer values are represented in the orbitofrontal cortex (OFC)-an area that participates in value comparison-but it is unknown where offer values are computed in the first place. One possibility is that this computation takes place in OFC. Alternatively, offer values might be computed upstream of OFC. For choices between edible goods, a primary candidate is the gustatory region of the anterior insula (gustatory cortex, GC). Here we recorded from the GC of male rhesus monkeys choosing between different juice types. As a population, neurons in GC represented the flavor, the quantity, and the subjective value of the juice chosen by the animal. These variables were represented by distinct groups of cells and with different time courses. Specifically, chosen value signals emerged shortly after offer presentation, while neurons encoding the chosen juice and the chosen quantity peaked after juice delivery. Surprisingly, neurons in GC did not represent individual offer values in a systematic way. In a computational sense, the variables encoded in GC follow the process of value comparison. Thus our results argue against the hypothesis that offer values are computed in GC. At the same time, signals representing the subjective value of the expected reward indicate that responses in GC are not purely sensory. Thus neuronal responses in GC appear consummatory in nature.

Low-Value Practices for Pelvic Floor Dysfunction-Choosing Wisely Recommendations from the Brazilian Association of Physiotherapy in Women's Health: Observational Study.

INTRODUCTION AND HYPOTHESIS: The Choosing Wisely campaign is an international initiative that is aimed at promoting a dialog between professionals, helping the population to choose an evidence-based, truly necessary and risk-free care. The aim of the study was to develop the Choosing Wisely Brazil list on Women's Health Physiotherapy in the area of the pelvic floor. METHODS: A observational study was carried out between January 2022 and July 2023, proposed by the Brazilian Association of Physiotherapy in Women's Health, and developed by researchers working in the area of the pelvic floor. The development of the list consisted of six stages: a panel of experts, consensus building, national research, a review by the Choosing Wisely Brazil team, preparation of the list, and publication of the recommendations. Descriptive and content analyses were carried out in order to include evidence-based recommendations with over 80% agreement by physiotherapists in Brazil. RESULTS: The expert panel was made up of 25 physiotherapists who submitted 63 recommendations. Seven physiotherapists/researchers carried out a critical analysis of the literature and refined the recommendations, resulting in 11 recommendations that were put to a national vote, in which 222 physiotherapists took part. After a review by the Choosing Wisely Brazil team, five recommendations with an average agreement of 88.2% agreement were chosen for publication. CONCLUSIONS: The Choosing Wisely Brazil team in Physiotherapy in Women's Health/Pelvic Floor proposed a list of five recommendations that showed a high agreement among Brazilian physiotherapists working in the area.

An economic evaluation of the Prioritising Responses Of Nurses To deteriorating patient Observations (PRONTO) clinical trial.

BACKGROUND: Early recognition and response to clinical deterioration reduce the frequency of in-hospital cardiac arrests, mortality, and unplanned intensive care unit (ICU) admissions. This study aimed to investigate the impact of the Prioritising Responses Of Nurses To deteriorating patient Observations (PRONTO) intervention on hospital costs and patient length of stay (LOS). METHOD: The PRONTO cluster randomised control trial was conducted to improve nurses' responses to patients with abnormal vital signs. Hospital data were collected pre-intervention (T0) at 6 months (T1) and 12 months (T2) post-intervention. The economic evaluation involved a cost-consequence analysis from the hospital's perspective. Generalised estimating equations were used to estimate the parameters for regression models of the difference in costs and LOS between study groups and time points. RESULTS: Hospital admission data for 6065 patients (intervention group, 3102; control group, 2963) were collected from four hospitals for T0, T1 and T2. The intervention cost was 69.61 A$ per admitted patient, including the additional intervention training for nurses and associated labour costs. The results showed cost savings and a shorter LOS in the intervention group between T0 - T1 and T0 - T2 (cost differences T0 - T1: -364 (95% CI -3,782; 3049) A$ and T0 - T2: -1,710 (95% CI -5,162; 1,742) A$; and LOS differences T0 - T1: -1.10 (95% CI -2.44; 0.24) days and T0 & T2: -2.18 (95% CI -3.53; -0.82) days). CONCLUSION: The results of the economic analysis demonstrated that the PRONTO intervention improved nurses' responses to patients with abnormal vital signs and significantly reduced hospital LOS by two days at 12 months in the intervention group compared to baseline. From the hospital's perspective, savings from reduced hospitalisations offset the costs of implementing PRONTO.

Comparison of initial dental treatment decisions between in-person and asynchronous teledentistry examinations for people with special health care needs.

BACKGROUND: People with special health care needs in long-term care settings have difficulty accessing a traditional dental office. The goal of the authors was to assess initial treatment decision concordance between dentists conducting traditional in-person examinations using mobile equipment and additional dentists conducting examinations using asynchronous teledentistry technology. METHODS: Six dentists from Access Dental Care, a North Carolina mobile dentistry nonprofit, saw new patients on-site at 12 participating facilities or asynchronously off-site with electronic dental records, radiographs, and intraoral images, all captured by an on-site dental hygienist. Off-site dentists were masked to other dentists' treatment need decisions; 3 through 5 off-site examinations were conducted for each on-site examination. Demographic and binary treatment need category data were collected. For the 3 most prevalent treatment types needed (surgery, restorative, and new removable denture), the authors calculated the percentage agreement and κ statistics with bootstrapped CIs (1,000 replicates). RESULTS: The 100 enrolled patients included 47 from nursing homes, 45 from Programs of All-Inclusive Care for the Elderly, and 8 from group homes for those with intellectual and developmental disabilities. Mean (SD) age was 73.9 (16.5) years. Among dentate participants, the percentage agreement and bootstrapped κ (95% CI) were 87% and 0.74 (0.70 to 0.78) for surgery and 78% and 0.54 (0.50 to 0.58) for restorative needs, respectively, and among dentate and edentulous participants, they were 94% and 0.78 (0.74 to 0.83), respectively, for new removable dentures. CONCLUSIONS: The authors assessed the initial dental treatment decision concordance between on-site dentists conducting in-person examinations with a mobile oral health care delivery model and off-site dentists conducting examinations with asynchronous dentistry. Concordance was substantial for surgery and removable denture treatment decisions and moderate for restorative needs. Patient characteristics and facility type were not significant factors in the levels of examiner agreement. PRACTICAL IMPLICATIONS: This evidence supports teledentistry use for patients with special health care needs and could help improve their access to oral health care.

Cost-of-care discussions for individuals with advanced non-small cell lung cancer and melanoma: Findings from a large, population-based pilot study.

BACKGROUND: Costs of cancer care can result in patient financial hardship; many professional organizations recommend provider discussions about treatment costs as part of high-quality care. In this pilot study, the authors examined patient-provider cost discussions documented in the medical records of individuals who were diagnosed with advanced non-small cell lung cancer (NSCLC) and melanoma-cancers with recently approved, high-cost treatment options. METHODS: Individuals who were newly diagnosed in 2017-2018 with stage III/IV NSCLC (n = 1767) and in 2018 with stage III/IV melanoma (n = 689) from 12 Surveillance, Epidemiology, and End Results regions were randomly selected for the National Cancer Institute Patterns of Care Study. Documentation of cost discussions was abstracted from the medical record. The authors examined patient, treatment, and hospital factors associated with cost discussions in multivariable logistic regression analyses. RESULTS: Cost discussions were documented in the medical records of 20.3% of patients with NSCLC and in 24.0% of those with melanoma. In adjusted analyses, privately insured (vs. publicly insured) patients were less likely to have documented cost discussions (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.37-0.80). Patients who did not receive systemic therapy or did not receive any cancer-directed treatment were less likely to have documented cost discussions than those who did receive systemic therapy (OR, 0.39 [95% CI, 0.19-0.81] and 0.46 [95% CI, 0.30-0.70], respectively), as were patients who were treated at hospitals without residency programs (OR, 0.64; 95% CI, 0.42-0.98). CONCLUSIONS: Cost discussions were infrequently documented in the medical records of patients who were diagnosed with advanced NSCLC and melanoma, which may hinder identifying patient needs and tracking outcomes of associated referrals. Efforts to increase cost-of-care discussions and relevant referrals, as well as their documentation, are warranted.

"I Didn't Know What I Didn't Know": Assessment of Adolescent Oncology Patient Engagement in Decision-Making.

INTRODUCTION: Little is known about the best way to engage an adolescent oncology patient in decision-making. To integrate adolescent oncology patients most effectively in decision-making, it is important to understand their perceptions not only as adolescents but also as adult survivors who have had time to reflect upon their experience. The purpose of this study is to explore perceptions of survivors of pediatric cancer to better understand their attitudes toward participation in decision-making, decisional regret, and use of decision-support tools. METHODS: An electronic survey tool, containing open- and closed-ended responses, was distributed to adult cancer survivors diagnosed and treated for cancer between the ages of 9 and 18 at a Midwestern, Comprehensive Cancer Center within a tertiary care academic hospital. RESULTS: Seventy responses were received. Nearly all respondents (96%) reported that decisions made on their behalf were consistent with their desires most/all the time. Almost one-fifth felt that increased involvement would have intensified their anxiety. Eighty-five percent did not regret choices made about their cancer treatment, and 88% would have made the same choices again. Respondents desired more targeted information on the long-term impacts of treatment (i.e., infertility, memory difficulties, mental health concerns), and they highlighted the importance of communication in the decision-making process. CONCLUSIONS: Adolescents want to participate in the decision-making process in a way that accommodates their understanding of the pathology and potential impacts of treatment. Our results suggest that developing a simple intervention to help facilitate provision of such anticipatory guidance may be helpful.

Household-level data on well-being, inequalities, and social capital in Western Province, Zambia.

This article presents survey data from households from the Muoyo-Mukukutu area in Western Province, Zambia based on stratified sampling. Data from 411 households were collected using a questionnaire survey from 2022. Understanding the complexities of well-being is crucial for informing policies to enhance the quality of life and reduce multidimensional poverty in developing countries. Hence, the survey focuses on subjective and objective well-being and their determinants. Survey data contains details on various dimensions of objective well-being, such as living standards, health, and nutrition. It also covers the issue of subjective well-being (life satisfaction), including the related concept of freedom of choice. Moreover, we collected detailed information about diverse forms of inequalities and deprivations at the societal and intra-household level, paying particular attention to the areas of social capital and decision-making power. Additionally, the data contain details about the relationships with and attitudes to traditional leaders and statutory government representatives, respondents' economic activities and aspirations (with a special focus on agriculture), and their various socio-demographic characteristics. Individual survey results can be compared with a robust set of data as we intentionally used questions applied in other international surveys when possible.

Assessment of Entrustable Professional Activities Among Dutch Endocrine Supervisors.

Entrustable Professional Activities (EPAs) are an important tool to support individualisation of medical training in a competency-based setting and are increasingly implemented in the clinical speciality training for endocrinologist. This study aims to assess interrater agreement and factors that potentially impact EPA scores. Five known factors that affect entrustment decisions in health profesions training (capability, integrity, reliability, humility, agency) were used in this study. A case-vignette study using standardised written cases. Case vignettes (n = 6) on the topics thyroid disease, pituitary disease, adrenal disease, calcium and bone disorders, diabetes mellitus, and gonadal disorders were written by two endocrinologists and a medical education expert and assessed by endocrinologists experienced in the supervision of residents in training. Primary outcome is the inter-rater agreement of entrustment decisions for endocrine EPAs among raters. Secondary outcomes included the dichotomous interrater agreement (entrusted vs. non-entrusted), and an exploration of factors that impact decision-making. The study protocol was registered and approved by the Ethical Review Board of the Netherlands Association for Medical Education (NVMO-ERB # 2020.2.5). Nine endocrinologists from six different academic regions participated. Overall, the Fleiss Kappa measure of agreement for the EPA level was 0.11 (95% CI: 0.03-0.22) and for the entrustment decision 0.24 (95% CI 0.11-0.37). Of the five features that impacted the entrustment decision, capability was ranked as the most important by a majority of raters (56%-67%) in every case. There is a considerable discrepancy between the EPA levels assigned by different raters. These findings emphasise the need to base entrustment decisions on multiple observations, made by a team of supervisors and enriched with factors other than direct medical competence.

Advancing equity in access to school mental health through multiple informant decision-making.

There has been a substantial increase in the number of students with mental health needs, yet significant discrepancies exist in access to timely intervention. Traditional gatekeeping to intervention has been the provenance of single information sources. Multi-informant decision-making is a promising mechanism to improve equitable access. However, critical advancements are necessary to improve decision-making relating to (a) who is identified, (b) what type of need is determined, (c) the type of intervention necessary, and (d) where or under what circumstances to implement the intervention. We review critical components of effective mental health decision-making, contributors to inequities in school mental health services, and offer future directions for research and practice to increase equitable student outcomes.

Effects of a multicomponent communication training to involve older people in decisions to DEPRESCRIBE cardiometabolic medication in primary care (CO-DEPRESCRIBE): protocol for a cluster randomized controlled trial with embedded process and economic evaluation.

BACKGROUND: Deprescribing of medication for cardiovascular risk factors and diabetes has been incorporated in clinical guidelines but proves to be difficult to implement in primary care. Training of healthcare providers is needed to enhance deprescribing in eligible patients. This study will examine the effects of a blended training program aimed at initiating and conducting constructive deprescribing consultations with patients. METHODS: A cluster-randomized trial will be conducted in which local pharmacy-general practice teams in the Netherlands will be randomized to conducting clinical medication reviews with patients as usual (control) or after receiving the CO-DEPRESCRIBE training program (intervention). People of 75 years and older using specific cardiometabolic medication (diabetes drugs, antihypertensives, statins) and eligible for a medication review will be included. The CO-DEPRESCRIBE intervention is based on previous work and applies models for patient-centered communication and shared decision making. It consists of 5 training modules with supportive tools. The primary outcome is the percentage of patients with at least 1 cardiometabolic medication deintensified. Secondary outcomes include patient involvement in decision making, healthcare provider communication skills, health/medication-related outcomes, attitudes towards deprescribing, medication regimen complexity and health-related quality of life. Additional safety and cost parameters will be collected. It is estimated that 167 patients per study arm are needed in the final intention-to-treat analysis using a mixed effects model. Taking loss to follow-up into account, 40 teams are asked to recruit 10 patients each. A baseline and 6-months follow-up assessment, a process evaluation, and a cost-effectiveness analysis will be conducted. DISCUSSION: The hypothesis is that the training program will lead to more proactive and patient-centered deprescribing of cardiometabolic medication. By a comprehensive evaluation, an increase in knowledge needed for sustainable implementation of deprescribing in primary care is expected. TRIAL REGISTRATION: The study is registered at ClinicalTrials.gov (identifier: NCT05507177).

From unstructured accident reports to a hybrid decision support system for occupational risk management: The consensus converging approach.

INTRODUCTION: Workplace accidents in the petroleum industry can cause catastrophic damage to people, property, and the environment. Earlier studies in this domain indicate that the majority of the accident report information is available in unstructured text format. Conventional techniques for the analysis of accident data are time-consuming and heavily dependent on experts' subject knowledge, experience, and judgment. There is a need to develop a machine learning-based decision support system to analyze the vast amounts of unstructured text data that are frequently overlooked due to a lack of appropriate methodology. METHOD: To address this gap in the literature, we propose a hybrid methodology that uses improved text-mining techniques combined with an un-bias group decision-making framework to combine the output of objective weights (based on text mining) and subjective weights (based on expert opinion) of risk factors to prioritize them. Based on the contextual word embedding models and term frequencies, we extracted five important clusters of risk factors comprising more than 32 risk sub-factors. A heterogeneous group of experts and employees in the petroleum industry were contacted to obtain their opinions on the extracted risk factors, and the best-worst method was used to convert their opinions to weights. CONCLUSIONS AND PRACTICAL APPLICATIONS: The applicability of our proposed framework was tested on the data compiled from the accident data released by the petroleum industries in India. Our framework can be extended to accident data from any industry, to reduce analysis time and improve the accuracy in classifying and prioritizing risk factors.

An ecological assessment of decision-making under risk and ambiguity through the virtual serious game Kalliste Decision Task.

Traditional methods for evaluating decision-making provide valuable insights yet may fall short in capturing the complexity of this cognitive capacity, often providing insufficient for the multifaceted nature of decisions. The Kalliste Decision Task (KDT) is introduced as a comprehensive, ecologically valid tool aimed at bridging this gap, offering a holistic perspective on decision-making. In our study, 81 participants completed KDT alongside established tasks and questionnaires, including the Mixed Gamble Task (MGT), Iowa Gambling Task (IGT), and Stimulating & Instrumental Risk Questionnaire (S&IRQ). They also completed the User Satisfaction Evaluation Questionnaire (USEQ). The results showed excellent usability, with high USEQ scores, highlighting the user-friendliness of KDT. Importantly, KDT outcomes showed significant correlations with classical decision-making variables, shedding light on participants' risk attitudes (S&IRQ), rule-based decision-making (MGT), and performance in ambiguous contexts (IGT). Moreover, hierarchical clustering analysis of KDT scores categorized participants into three distinct profiles, revealing significant differences between them on classical measures. The findings highlight KDT as a valuable tool for assessing decision-making, addressing limitations of traditional methods, and offering a comprehensive, ecologically valid approach that aligns with the complexity and heterogeneity of real-world decision-making, advancing research and providing insights for understanding and assessing decision-making across multiple domains.

The Structure of Clinical Ethical Decision-Making: A Hospital System Needs Assessment.

Bioethical dilemmas can emerge in research and clinical settings, from end-of-life decision-making to experimental therapies. The COVID-19 pandemic raised serious ethical challenges for healthcare organizations, highlighting the need to conduct needs assessments of the bioethics infrastructures of healthcare organizations. Clinical ethics committees (CECs) also create equitable policies, train staff on ethics issues, and play a consultative role in resolving the difficulty of complex individual cases. The main objective of this project was to conduct a needs assessment of the bioethics infrastructure within a comprehensive hospital system. A cross-sectional anonymous online survey, including quantitative and qualitative formatted questions. The survey was sent to five key leaders from the organization's hospitals. Survey questions focused on the composition, structure, function, and effectiveness of their facilities' bioethics infrastructure and ethics-related training and resources. Positive findings included that most facilities have active CECs with multidisciplinary membership; CECs address critical issues and encourage team members to express clinical ethics concerns. Areas of concern included uncertainty about how CECs function and the process for resolving clinical ethics dilemmas. Most reported no formal orientation process for CEC members, and many said there was no ongoing ethics education process. The authors conclude that if CECs are a critical institutional resource where the practice of medicine and mission intersect, having well-functioning ethics committees with trained and oriented members demonstrates an essential commitment to the mission. The survey revealed that more needs to be done to bolster the bioethics infrastructure of this institution.

Use of Real-World FHIR Data Combined with Context-Sensitive Decision Modeling to Guide Sentinel Biopsy in Melanoma.

Background: To support clinical decision-making at the point of care, the "best next step" based on Standard Operating Procedures (SOPs) and actual accurate patient data must be provided. To do this, textual SOPs have to be transformed into operable clinical algorithms and linked to the data of the patient being treated. For this linkage, we need to know exactly which data are needed by clinicians at a certain decision point and whether these data are available. These data might be identical to the data used within the SOP or might integrate a broader view. To address these concerns, we examined if the data used by the SOP is also complete from the point of view of physicians for contextual decision-making. Methods: We selected a cohort of 67 patients with stage III melanoma who had undergone adjuvant treatment and mainly had an indication for a sentinel biopsy. First, we performed a step-by-step simulation of the patient treatment along our clinical algorithm, which is based on a hospital-specific SOP, to validate the algorithm with the given Fast Healthcare Interoperability Resources (FHIR)-based data of our cohort. Second, we presented three different decision situations within our algorithm to 10 dermatooncologists, focusing on the concrete patient data used at this decision point. The results were conducted, analyzed, and compared with those of the pure algorithmic simulation. Results: The treatment paths of patients with melanoma could be retrospectively simulated along the clinical algorithm using data from the patients' electronic health records. The subsequent evaluation by dermatooncologists showed that the data used at the three decision points had a completeness between 84.6% and 100.0% compared with the data used by the SOP. At one decision point, data on "patient age (at primary diagnosis)" and "date of first diagnosis" were missing. Conclusions: The data needed for our decision points are available in the FHIR-based dataset. Furthermore, the data used at decision points by the SOP and hence the clinical algorithm are nearly complete compared with the data required by physicians in clinical practice. This is an important precondition for further research focusing on presenting decision points within a treatment process integrated with the patient data needed.

Alcohol's Role in Sexual Decision Making in First-Year College Women: An Event-Level Assessment.

Sexual decision making is often grounded in social scripts that can be detrimental to women's healthy relationship and sexual development during the transition to college. Little is known about the malleable decision-making processes and drinking behaviors that influence sexual behaviors from day-to-day. We examined whether women were more likely to engage in sexual behaviors on days they had higher intentions and willingness to engage in sex or drink alcohol. We also explored interactions between sex- and alcohol-related decision constructs. Eighty-two first-year college women completed 14-days of ecological momentary assessment, reporting on alcohol- and sex-related intentions and willingness (3x daily) and daily drinking and sexual behaviors. We found partial support for our hypotheses: intentions and willingness to have sex were positively associated with sex behaviors, but willingness to drink was negatively associated with sex behaviors. Heavy drinking was associated with sexual behavior, even when women indicated no prior willingness to engage in sexual behavior on those days. Findings highlight the need to address event-level variability in sexual decision making, with a particular focus on how alcohol impacts these processes. Further, the robust association between sexual intentions and behavior suggests intention setting may be a particularly useful sexual empowerment education tool.

Health and Financial Literacy and the Acquisition of COVID-19 Knowledge in Older Adults.

Knowledge about COVID-19 enters into many aspects of decision making, especially for older people who are at increased risk of severe disease or death. Yet little is known about the resources that supported older people's uptake of COVID-19 knowledge. Here, we hypothesized that higher pre-pandemic health and financial literacy was associated with higher COVID-19 knowledge. Participants were 434 community-based older people without dementia. COVID-19 knowledge was assessed via a 5-item measure, and health and financial literacy was assessed via a 32-item measure. In an ordinal regression model adjusted for age, gender, and education, higher literacy was associated with higher COVID-19 knowledge (p < .0001), and this association persisted after further adjusting for robust measures of global cognition or one of five specific cognitive domains (all p's ≤ .0001). These findings suggest that literacy plays a key role in supporting older people's acquisition of impactful knowledge in the real world.

Interdisciplinary assessment and treatment of paediatric drooling: two decades of experience by the Nijmegen saliva control team reflected in a stepwise algorithm.

Anterior and posterior drooling are prevalent comorbidities in children with neurodevelopmental disabilities. Considering the heterogeneity of the patient population and the multifactorial aetiology of drooling, an interdisciplinary and individualised treatment approach is indispensable. However, no tool for stepwise decision-making in the treatment of paediatric drooling has been developed previously. Within the Radboudumc Amalia Children's Hospital, care for children with anterior and/or posterior drooling secondary to neurodevelopmental disabilities is coordinated by a saliva control team with healthcare professionals from six disciplines. In alignment with international literature, published guidelines, and evidence gained from two decades of experience and research by our team, this paper proposes an algorithm reflecting the assessment and treatment approach applied in our clinic. First, directions are provided to decide on the necessity of saliva control treatment, taking type of drooling, the child's age, and the severity and impact of drooling into account. Second, the algorithm offers guidance on the choice between available treatment options, highlighting the importance of accounting for child characteristics and child and caregiver preferences in clinical (shared) decision-making. CONCLUSIONS: With this algorithm, we aim to emphasise the importance of repeated stepwise decision-making in the assessment and treatment of drooling in children during their childhood, encouraging healthcare professionals to apply a holistic approach. WHAT IS KNOWN: • Children with anterior or posterior drooling secondary to neurodevelopmental disabilities comprise a heterogeneous group, necessitating an individualised treatment approach. • No stepwise decision-making tool is available for the treatment of paediatric drooling. WHAT IS NEW: • Deciding on the necessity of saliva control treatment should be a conscious process, based on type of drooling, age, and drooling severity and impact. • Type of drooling, age, cognition, oral motor skills, self-awareness, posture, diagnosis, and child/caregiver preferences need to be considered to decide on the optimal treatment.

Designing an evidence-informed package of essential health services for Universal Health Coverage: lessons learnt and challenges to implementation in Liberia.

Liberia developed an evidence-informed package of health services for Universal Health Coverage (UHC) based on the Disease Control Priorities 3 evidence. This paper describes the policy decisions, methods and processes adopted for prioritisation, key features of the package and lessons learnt, with special emphasis on feasibility of implementation. Package design was led by the Ministry of Health. Prioritisation of essential services was based on evidence on disease burden, cost-effectiveness, financial risk, equity, budget impact, and feasibility of implementation. Fiscal space analysis was used to assess package affordability and options for expanding the budget envelope. The final adopted package focuses on primary healthcare and comprises a core subpackage of 78 publicly financed interventions and a complementary subpackage of 50 interventions funded through cost-sharing. The estimated per capita cost to the government is US$12.28, averting around 1.2 million DALYs. Key lessons learnt are described: (1) priority setting is essential for designing affordable packages of essential services; (2) the most realistic and affordable option when domestic resources are critically limited is to focus on basic, high-impact primary health services; (3) Liberia and many other countries will continue to rely on donor funding to expand the range of essential services until more domestic resources become available; (4) national leadership and effective engagement of key stakeholders are critical for a successful package design; (5) effective implementation is less likely unless the package cost is affordable and the health system gaps are assessed and addressed. A framework of action was employed to assess the consistency with the prerequisites for an appropriate package design. Based on the framework, Liberia developed a transparent and affordable package for UHC, but the challenges to implementation require further action by the government.

Modelling years of life lost due to acute type A aortic dissection in the German healthcare setting: a predictive study.

OBJECTIVES: This study aimed to develop a patient-centred approach to the burden of acute type A aortic dissection (ATAAD) through modelling. The main objective was to identify potential improvements in managing this life-threatening cardiovascular condition and to provide evidence-based recommendations to optimise outcomes. DESIGN: We developed a predictive model along patient pathways to estimate the burden of ATAAD through the years of life lost (YLLs) metric. The model was created based on a systematic review of the literature and was parameterised using demographic data from the German healthcare environment. The model was designed to allow interactive simulation of different scenarios resulting from changes in key impact factors. SETTING: The study was conducted using data from the German healthcare environment and results from the literature review. PARTICIPANTS: The study included a comprehensive modelling of ATAAD cases in Germany but did not directly involve participants. INTERVENTIONS: There were no specific interventions applied in this study based on the modelling design. PRIMARY AND SECONDARY OUTCOME MEASURES: The single outcome measure was the estimation of YLL due to ATAAD in Germany. RESULTS: Our model estimated 102 791 YLL per year for ATAAD in Germany, with 62 432 and 40 359 YLL for men and women, respectively. Modelling an improved care setting yielded 93 191 YLL or 9.3% less YLL compared with the current standard while a worst-case scenario resulted in 113 023 or 10.0% more YLL. The model is accessible at https://acuteaorticdissection.com/ to estimate custom scenarios. CONCLUSIONS: Our study provides an evidence-based approach to estimating the burden of ATAAD and identifying potential improvements in the management of pathways. This approach can be used by healthcare decision-makers to inform policy changes aimed at optimising patient outcomes. By considering patient-centred approaches in any healthcare environment, the model has the potential to improve efficient care for patients suffering from ATAAD.

A Case Study in Application of the Risk Knowledge Infinity Cycle.

The Risk Knowledge Infinity (RKI) Cycle Framework was featured as part of the ICH-sanctioned training materials supporting the recent issuance of ICH Q9(R1) Quality Risk Management To support ICH Q9(R1) understanding and adoption, this paper presents a case study on the application of the RKI Cycle, based on an underlying out-of-specification investigation. This case study provides a stepwise walk-through of the cycle to illustrate how key concepts within the ICH Q9(R1) revision can be achieved through better connecting quality risk management and knowledge management with a framework such as the RKI Cycle.