An analysis of how health systems integrated priority-setting in the pandemic planning in a sample of Latin America and the Caribbean countries.

BACKGROUND: Latin America and the Caribbean (LAC) are among those regions most affected by the COVID-19 pandemic worldwide. The COVID-19 pandemic has strained health systems in the region. In this context of severe healthcare resource constraints, there is a need for systematic priority-setting to support decision-making which ensures the best use of resources while considering the needs of the most vulnerable groups. The aim of this paper was to provide a critical description and analysis of how health systems considered priority-setting in the COVID-19 response and preparedness plans of a sample of 14 LAC countries; and to identify the associated research gaps. METHODS: A documentary analysis of COVID-19 preparedness and response plans was performed in a sample of 14 countries in the LAC region. We assessed the degree to which the documented priority-setting processes adhered to established quality indicators of effective priority-setting included in the Kapiriri and Martin framework. We conducted a descriptive analysis of the degree to which the reports addressed the quality parameters for each individual country, as well as a cross-country comparison to explore whether parameters varied according to independent variables. RESULTS: While all plans were led and supported by the national governments, most included only a limited number of quality indicators for effective priority-setting. There was no systematic pattern between the number of quality indicators and the country's health system and political contexts; however, the countries that had the least number of quality indicators tended to be economically disadvantaged. CONCLUSION: This study adds to the literature by providing the first descriptive analysis of the inclusion of priority-setting during a pandemic, using the case of COVID-19 response and preparedness plans in the LAC region. The analysis found that despite the strong evidence of political will and stakeholder participation, none of the plans presented a clear priority-setting process, or used a formal priority-setting framework, to define interventions, populations, geographical regions, healthcare setting or resources prioritized. There is need for case studies that analyse how priority-setting actually occurred during the COVID-19 pandemic and the degree to which the implementation reflected the plans and the parameters of effective priority-setting, as well as the impact of the prioritization processes on population health, with a focus on the most vulnerable groups.

Is the end in sight? A study of how and why services are decommissioned in the English National Health Service.

The decommissioning of a health-care service is invariably a highly complex and contentious process which faces many implementation challenges. There has been little specific theorisation of this phenomena, although insights can be transferred from wider literatures on policy implementation and change processes. In this paper, we present findings from empirical case studies of three decommissioning processes initiated in the English National Health Service. We apply Levine's (1979, Public Administration Review, 39(2), 179-183) typology of decommissioning drivers and insights from the empirical literature on pluralistic health-care contexts, complex change processes and institutional constraints. Data include interviews, non-participant observation and documents analysis. Alongside familiar patterns of pluralism and political partisanship, our results suggest the important role played by institutional factors in determining the outcome of decommissioning processes and in particular the prior requirement of political vulnerability for services to be successfully closed. Factors linked to the extent of such vulnerability include the scale of the proposed changes and extent to which they are supported at the macrolevel.

Sustaining and spreading penicillin allergy delabelling: A narrative review of the challenges for service delivery and patient safety.

Many patients report allergies to penicillin, although in over 90% of these the label of penicillin allergy is shown to be incorrect following comprehensive testing. Inappropriate and inaccurate penicillin allergy labelling is a barrier to antimicrobial stewardship and can lead to patient harm. This review assesses an emergent evidence base and trend favouring delabelling using direct oral penicillin challenges following a stratified risk assessment of the likelihood and existence of true penicillin allergy, to identify and make recommendations for key components for implementation in standard practice. Research to date has focussed on the feasibility and clinical and financial outcomes of these direct delabelling strategies. There is a paucity of studies exploring the views and engagement of patients and healthcare professionals, and a gap in the evidence for prerequisites to safely deliver, sustain and spread the implementation of such services across health systems.

Publication and related biases in health services research: a systematic review of empirical evidence.

BACKGROUND: Publication and related biases (including publication bias, time-lag bias, outcome reporting bias and p-hacking) have been well documented in clinical research, but relatively little is known about their presence and extent in health services research (HSR). This paper aims to systematically review evidence concerning publication and related bias in quantitative HSR. METHODS: Databases including MEDLINE, EMBASE, HMIC, CINAHL, Web of Science, Health Systems Evidence, Cochrane EPOC Review Group and several websites were searched to July 2018. Information was obtained from: (1) Methodological studies that set out to investigate publication and related biases in HSR; (2) Systematic reviews of HSR topics which examined such biases as part of the review process. Relevant information was extracted from included studies by one reviewer and checked by another. Studies were appraised according to commonly accepted scientific principles due to lack of suitable checklists. Data were synthesised narratively. RESULTS: After screening 6155 citations, four methodological studies investigating publication bias in HSR and 184 systematic reviews of HSR topics (including three comparing published with unpublished evidence) were examined. Evidence suggestive of publication bias was reported in some of the methodological studies, but evidence presented was very weak, limited in both quality and scope. Reliable data on outcome reporting bias and p-hacking were scant. HSR systematic reviews in which published literature was compared with unpublished evidence found significant differences in the estimated intervention effects or association in some but not all cases. CONCLUSIONS: Methodological research on publication and related biases in HSR is sparse. Evidence from available literature suggests that such biases may exist in HSR but their scale and impact are difficult to estimate for various reasons discussed in this paper. SYSTEMATIC REVIEW REGISTRATION: PROSPERO 2016 CRD42016052333.

Developing a framework of quality indicators for healthcare business cases: a qualitative document analysis consolidating insight from expert guidance and current practice.

BACKGROUND: Business cases are used to provide a structured justification in favour of investing in new projects, services or interventions. Despite the use of business cases in determining how limited resources will be allocated within England's National Health Service (NHS), guidance concerning how to develop and evaluate business cases in the context of healthcare is inconstant and of varying relevance. This study aimed to develop a new framework of quality indicators for healthcare-related business cases by analysing the content of expert guidance documents and a sample of NHS business cases. METHODS: Qualitative document analysis was conducted on guidance documents (n = 7) and existing NHS business case documents (n = 18). Documents were purposefully sampled using criteria to ensure the framework reflected a diverse spread of expert opinion, and a varied sample of example business cases from current practice. Data were analysed using thematic and content analysis, and are presented in a visualised framework. RESULTS: Seven themes were identified within the qualitative document analysis (purpose, strategic priorities, options, benefits, costs, risks and evaluation). These themes were described and presented with a framework of quality indicators for healthcare-related business cases. CONCLUSION: To ou`r knowledge, this is the first framework of business case quality indicators designed specifically for use in a healthcare context. The framework presented in this study has implications for how business cases are developed and evaluated by decision makers. In the future it would be beneficial to investigate how the framework could be used in practice as a tool for critical appraisal.

What is a 'National' 'Health' 'Service'? A keyword analysis of policy documents leading to the formation of the UK NHS.

This paper explores the keywords of 'National', 'Health' and Service' in the road to the NHS in 1948. It uses a form of Qualitative Content Analysis to analyse key documents in the period leading to the 'Appointed Day' when the NHS was created in 1948. In terms of 'national', most documents favoured Local Authorities, with 'National' coming rather late in the day. For 'health', most of the documents 'talk' of a broad or 'positive' health, but they lack any specific details, and seem to focus on a narrower curative medical service. Finally, most proposals relating to 'service' are based on insurance and a '90% service', with the free and universal (100%) service arriving rather late in the period. Clearly, the three keywords could be combined in many ways, resulting in many possible types of NHS. However, bringing them together suggests that it was probably only with Beveridge onwards that the three keywords of national, health and service (citizenship) combined to form Bevan's NHS.

A matter of (good) faith? Understanding the interplay of power and the moral agency of managers in healthcare service reconfiguration.

Previous studies of service reconfiguration in healthcare have explored the influence of power on processes and outcomes. However, in these accounts the moral agency of managers is often underemphasised. This paper draws on the theoretical tools provided by the sociology of morality to help deepen understanding of the interaction between power and moral agency in service reconfiguration in healthcare. It presents results from a qualitative study of a pan-organisational service reconfiguration in the NHS in England, involving nineteen in-depth interviews with those leading the change and the analysis of twelve programme documents. We combine concepts of the moral background and epistemic governance to interpret participants' conviction that the service change was 'the right thing to do'. The paper shows how epistemic work carried out by service change regulations shaped the moral background within which participants worked. This, in turn, channelled their moral agency - specifically their commitment to patient care - in a way that also reflected central priorities. The paper adds to sociological understandings of service reconfiguration through considering the interaction of structure, agency and power, while also developing the concept of the moral background to show how power relations can influence moral beliefs.

Was priority setting considered in COVID-19 response planning? A global comparative analysis.

Background: The COVID-19 pandemic forced governments across the world to consider how to prioritize resource allocation. Most countries produced pandemic preparedness plans that guide and coordinate healthcare, including how to allocate scarce resources such as ventilators, human resources, and therapeutics. The objective of this study was to compare and contrast the extent to which established parameters for effective priority setting (PS) were incorporated into COVID-19 pandemic response planning in several countries around the world. Methods: We used the Kapriri and Martin framework for effective priority setting and performed a quantitative descriptive analysis to explore whether and how countries' type of health system, political, and economic contexts impacted the inclusion of those parameters in their COVID-19 pandemic plans. We analyzed 86 country plans across six regions of the World Health Organization. Results: The countries sampled represent 40% of nations in AFRO, 54.5% of EMRO, 45% of EURO, 46% of PAHO, 64% of SEARO, and 41% of WPRO. They also represent 39% of all HICs in the world, 39% of Upper-Middle, 54% of Lower-Middle, and 48% of LICs. No pattern in attention to parameters of PS emerged by WHO region or country income levels. The parameters: evidence of political will, stakeholder participation, and use of scientific evidence/ adoption of WHO recommendations were each found in over 80% of plans. We identified a description of a specific PS process in 7% of the plans; explicit criteria for PS in 36.5%; inclusion of publicity strategies in 65%; mention of mechanisms for appealing decisions or implementing procedures to improve internal accountability and reduce corruption in 20%; explicit reference to public values in 15%; and a description of means for enhancing compliance with the decisions in 5%. Conclusion: The findings provide a basis for policymakers to reflect on their prioritization plans and identify areas that need to be strengthened. Overall, there is little consideration for explicit prioritization processes and tools and restricted attention to equity considerations; this may be a starting point for policymakers interested in improving future preparedness and response planning. Although the study focused on the COVID-19 pandemic, priority setting remains one of the policymakers' most prominent challenges. Policymakers should consider integrating systematic priority setting in their routine decision-making processes.

How did European countries set health priorities in response to the COVID-19 threat? A comparative document analysis of 24 pandemic preparedness plans across the EURO region.

The COVID-19 pandemic has forced governments across the world to consider how to prioritise the allocation of scarce resources. There are many tools and frameworks that have been designed to assist with the challenges of priority setting in health care. The purpose of this study was to examine the extent to which formal priority setting was evident in the pandemic plans produced by countries in the World Health Organisation's EURO region, during the first wave of the COVID-19 pandemic. This compliments analysis of similar plans produced in other regions of the world. Twenty four pandemic preparedness plans were obtained that had been published between March and September 2020. For data extraction, we applied a framework for identifying and assessing the elements of good priority setting to each plan, before conducting comparative analysis across the sample. Our findings suggest that while some pre-requisites for effective priority setting were present in many cases - including political commitment and a recognition of the need for allocation decisions - many other hallmarks were less evident, such as explicit ethical criteria, decision making frameworks, and engagement processes. This study provides a unique insight into the role of priority setting in the European response to the onset of the COVID-19 pandemic.

Centre variation in home dialysis uptake: A survey of kidney centre practice in relation to home dialysis organisation and delivery in England.

BACKGROUND: Disparities in home dialysis uptake across England suggest inequity and unexplained variation in access. We surveyed staff at all English kidney centres to identify patterns in service organisation/delivery and explore correlations with home therapy uptake, as part of a larger study ('Inter-CEPt'), which aims to identify potentially modifiable factors to address observed variations. METHODS: Between June and September 2022, staff working at English kidney centres were surveyed and individual responses combined into one centre-level response per question using predetermined data aggregation rules. Descriptive analysis described centre practices and their correlation with home dialysis uptake (proportion of new home dialysis starters) using 2019 UK Renal Registry 12-month home dialysis incidence data. RESULTS: In total, 180 responses were received (50/51 centres, 98.0%). Despite varied organisation of home dialysis services, most components of service delivery and practice had minimal or weak correlations with home dialysis uptake apart from offering assisted peritoneal dialysis and 'promoting flexible decision-making about dialysis modality'. Moderate to strong correlations were identified between home dialysis uptake and centres reporting supportive clinical leadership (correlation 0.32, 95% Confidence Interval (CI): 0.05-0.55), an organisational culture that values trying new initiatives (0.57, 95% CI: 0.34-0.73); support for reflective practice (0.38, 95% CI: 0.11-0.60), facilitating research engagement (0.39, 95% CI: 0.13-0.61) and promoting continuous quality improvement (0.29, 95% CI: 0.01-0.53). CONCLUSIONS: Uptake of home dialysis is likely to be driven by organisational culture, leadership and staff attitudes, which provide a supportive clinical environment within which specific components of service organisation and delivery can be effective.

Priority setting in times of crises: an analysis of priority setting for the COVID-19 response in the Western Pacific Region.

BACKGROUND: While priority setting is recognized as critical for promoting accountability and transparency in health system planning, its role in supporting rational, equitable and fair pandemic planning and responses is less well understood. This study aims to describe how priority setting was used to support planning in the initial stage of the pandemic response in a subset of countries in the Western Pacific Region (WPR). METHODS: We purposively sampled a subset of countries from WPR and undertook a critical document review of the initial national COVID-19 pandemic response plans. A pre-specified tool guided data extraction and the analysis examined the use of quality parameters of priority setting, and equity considerations. RESULTS: Nine plans were included in this analysis, from the following countries: Papua New Guinea, Tonga, The Philippines, Fiji, China, Australia, New Zealand, Japan, and Taiwan. Most commonly the plans described strong political will to respond swiftly, resource needs, stakeholder engagement, and defined the roles of institutions that guided COVID-19 response decision-making. The initial plans did not reflect strong evidence of public engagement or considerations of equity informing the early responses to the pandemic. CONCLUSION: This study advances an understanding of how priority setting and equity considerations were integrated to support the development of the initial COVID-19 responses in nine countries in WPR and contributes to the literature on health system planning during emergencies. This baseline assessment reveals evidence of the common priority setting parameters that were deployed in the initial responses, the prioritized resources and equity considerations and reinforces the importance of strengthening health system capacity for priority setting to support future pandemic preparedness.

Multiple environmental stressors affect predation pressure in a tropical freshwater system.

Environmental change can alter predator-prey dynamics. However, studying predators in the context of co-occurring environmental stressors remains rare, especially under field conditions. Using in situ filming, we examined how multiple stressors, including temperature and turbidity, impact the distribution and behaviour of wild fish predators of Trinidadian guppies (Poecilia reticulata). The measured environmental variables accounted for 17.6% of variance in predator species composition. While predator species differed in their associations with environmental variables, the overall prevalence of predators was greatest in slow flowing, deeper, warmer and less turbid habitats. Moreover, these warmer and less turbid habitats were associated with earlier visits to the prey stimulus by predators, and more frequent predator visits and attacks. Our findings highlight the need to consider ecological complexity, such as co-occurring stressors, to better understand how environmental change affects predator-prey interactions.

Factors influencing implementation and adoption of direct oral penicillin challenge for allergy delabelling: a qualitative evaluation.

BACKGROUND: Over 95% of penicillin allergy labels are inaccurate and may be addressed in low-risk patients using direct oral penicillin challenge (DPC). This study explored the behaviour, attitudes and acceptability of patients, healthcare professionals (HCPs) and managers of using DPC in low-risk patients. METHODS: Mixed-method, investigation involving patient interviews and staff focus groups at three NHS acute hospitals. Transcripts were coded using inductive and deductive thematic analysis informed by the Theoretical Domains Framework. FINDINGS: Analysis of 43 patient interviews and three focus groups (28 HCPs: clinicians and managers) highlighted themes of 'knowledge', 'beliefs about capabilities and consequences', 'environmental context', 'resources', 'social influences', 'professional role and identity', 'behavioural regulation and reinforcement' and a cross-cutting theme of digital systems. Overall, study participants supported the DPC intervention. Patients expressed reassurance about being in a monitored, hospital setting. HCPs acknowledged the need for robust governance structures for ensuring clarity of roles and responsibilities and confidence. CONCLUSION: There were high levels of acceptability among patients and HCPs. HCPs recognised the importance of DPC. Complexities of penicillin allergy (de)labelling were highlighted, and issues of knowledge, risk, governance and workforce were identified as key determinants. These should be considered in future planning and adoption strategies for DPC.

A multicentre observational study to investigate feasibility of a direct oral penicillin challenge in de-labelling 'low risk' patients with penicillin allergy by non-allergy healthcare professionals (SPACE study): Implications for healthcare systems.

OBJECTIVE: The huge burden of inaccurate penicillin allergy labels (PALs) is an important driver of antimicrobial resistance. This is magnified by insufficient allergy specialists and lack of 'point-of-care' tests. We investigated the feasibility of non-allergy healthcare professionals (HCPs) delivering direct oral penicillin challenges (DPCs) for penicillin allergy de-labelling. METHODS: This prospective observational study was conducted in three hospitals in England across three settings (acute medical, pre-surgical and haematology-oncology). Patients with a PAL were screened and stratified as low risk/high risk. Low risk patients (non-immune mediated symptoms, benign rash, tolerated amoxicillin since and family history) underwent a DPC. RESULTS: N = 2257 PALs were screened, 1054 were eligible; 643 were approached, 373 declined, 270 consented and 259 risk stratified (low risk = 155; high risk = 104). One hundred and twenty-six low risk patients underwent DPC, 122 (96.8%) were de-labelled with no serious allergic reactions. Conversion rate from screening-to-consent was 12% [3.3% and 17.9% in acute and elective settings respectively; odds ratios for consent were 3.42 (p < 0.001) and 5.53 (p < 0.001) in haematology-oncology and pre-surgical setting respectively. Common reasons for failure to progress in the study included difficulty in reaching patients, clinical instability/medical reasons, lacking capacity to consent and psychological factors. INTERPRETATION: DPCs can be delivered by non-allergy HCPs. A high proportion of patients with PALs did not progress in the study pathway. Strategies to deliver DPC at optimal points of the care pathway are needed to enhance uptake. Elective settings offer greater opportunities than acute settings for DPC. The safety and simplicity of DPCs lends itself to adoption by healthcare systems beyond the UK, including in resource-limited settings.

Tackling disinvestment in health care services. The views of resource allocators in the English NHS.

PURPOSE: The aims of this paper are to explore the experiences of budget holders within the English National Health Service (NHS), in their attempts to implement programmes of disinvestment, and to consider factors which influence the success (or otherwise) of this activity. DESIGN/METHODOLOGY/APPROACH: Between 24 January and 15 March 2011 semi-structured, telephone interviews were conducted with representatives of 12 Primary Care Trusts in England. Interviews focussed on: understanding of the term "disinvestment"; current activities, and perceived determinants of successful disinvestment decision making and implementation. Data were organised into themes according to standard qualitative data coding practices. FINDINGS: Findings indicate that experiences of disinvestment are varied and that organisations are currently adopting a range of approaches. There are a number of apparently influential determinants of disinvestment which relate to both health system features and organisational characteristics. According to the experiences of the interviewees, many of the easier disinvestment options have now been taken and more ambitious plans, which require wider engagement and more thorough project management, will be required in the future. RESEARCH LIMITATIONS/IMPLICATIONS: Findings from the research suggest that issues around understanding and usage of disinvestment terminology should be addressed and that a more in-depth and ethnographic research agenda will be of most value in moving forward both the theory and practice of disinvestment. ORIGINALITY/VALUE: This research suggests that, in the English NHS at least, there is a disjuncture between common usage of the term "disinvestment" and the way that it has previously been understood by the wider research community. In addition to this, the research also highlights a broader range of potential determinants of disinvestment than are considered in the extant literature.

The Pervasiveness of Power: Dilemmas for Researchers of Major System Change in Healthcare Comment on "'Attending to History' in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration".

To study major system change (MSC) in healthcare, it is crucial to consider the influence of power. Despite this, dominant perspectives on MSC in healthcare present these as relatively neutral processes, where reconfigurations are logical solutions to clearly defined problems. Perry and colleagues' paper adds to a growing body of research which challenges the presentation of MSC as neutral, managerial processes, instead identifying how power dynamics lie at the heart of why service change happens, how it unfolds, and its outcomes. However, the introduction of power considerations raises several overlapping methodological and ethical dilemmas for researchers, and questions regarding research design and dissemination. In this commentary, we use the insights generated by Perry et al to further explore these issues.

Did the evidence-based intervention (EBI) programme reduce inappropriate procedures, lessen unwarranted variation or lead to spill-over effects in the National Health Service?

BACKGROUND: Health systems are under pressure to maintain services within limited resources. The Evidence-Based Interventions (EBI) programme published a first list of guidelines in 2019, which aimed to reduce inappropriate use of interventions within the NHS in England, reducing potential harm and optimising the use of limited resources. Seventeen procedures were selected in the first round, published in April 2019. METHODS: We evaluated changes in the trends for each procedure after its inclusion in the EBI's first list of guidelines using interrupted time series analysis. We explored whether there was any evidence of spill-over effects onto related or substitute procedures, as well as exploring changes in geographical variation following the publication of national guidance. RESULTS: Most procedures were experiencing downward trends in the years prior to the launch of EBI. We found no evidence of a trend change in any of the 17 procedures following the introduction of the guidance. No evidence of spill-over increases in substitute or related procedures was found. Geographic variation in the number of procedures performed across English CCGs remained at similar levels before and after EBI. CONCLUSIONS: The EBI programme had little success in its aim to further reduce the use of the 17 procedures it deemed inappropriate in all or certain circumstances. Most procedure rates were already decreasing before EBI and all continued with a similar trend afterwards. Geographical variation in the number of procedures remained at a similar level post EBI. De-adoption of inappropriate care is essential in maintaining health systems across the world. However, further research is needed to explore context specific enablers and barriers to effective identification and de-adoption of such inappropriate health care to support future de-adoption endeavours.

Economic evaluation and the Jordan Rational Drug List: an exploratory study of national-level priority setting.

OBJECTIVES: To explore the extent of and barriers to the use of economic evaluation in compiling the Jordan Rational Drug List in the health care system of Jordan. METHODS: The research reported in this article involved a case study of the Jordan Rational Drug List. Data collection methods included semi-structured interviews with decision makers and analysis of secondary documentary sources. The case study was supplemented by additional interviews with a small number of Jordanian academics involved in the production of economic evaluation. RESULTS: The research found that there was no formal requirement for cost-effectiveness information submitted as part of the decision-making process for the inclusion of new technologies on the Jordan Rational Drug List. Both decision makers and academics suggested that economic evidence was not influential in formulary decisions. This is unusual for national formulary bodies. The study identified a number of barriers that prevent substantive and routine use of economic evaluation. While some of these echo findings of previous studies, others-notably the extent to which the sectional interests of clinical groups and commercial (pharmaceutical) industry exert undue influence over decision making-more obviously result from the specific Jordanian context. CONCLUSIONS: Economic evaluation was not found to be influential in the Jordan Rational Drug List. Recommendations for improvement include enhancing capacity in relation to generating, accessing, and/or applying health economic analysis to priority setting decisions. There is a further need to incentivize the use of economic evaluation, and this requires that organizational and structural impediments be removed.