Multi-criteria decision analysis tools for prioritising emerging or re-emerging infectious diseases associated with climate change in Canada

Global climate change is known to result in the emergence or re-emergence of some infectious diseases. Reliable methods to identify the infectious diseases of humans and animals and that are most likely to be influenced by climate are therefore required. Since different priorities will affect the decision to address a particular pathogen threat, decision makers need a standardised method of prioritisation. Ranking methods and Multi-Criteria Decision approaches provide such a standardised method and were employed here to design two different pathogen prioritisation tools. The opinion of 64 experts was elicited to assess the importance of 40 criteria that could be used to prioritise emerging infectious diseases of humans and animals in Canada. A weight was calculated for each criterion according to the expert opinion. Attributes were defined for each criterion as a transparent and repeatable method of measurement. Two different Multi-Criteria Decision Analysis tools were tested, both of which used an additive aggregation approach. These were an Excel spreadsheet tool and a tool developed in software 'M-MACBETH'. The tools were trialed on nine 'test' pathogens. Two different methods of criteria weighting were compared, one using fixed weighting values, the other using probability distributions to account for uncertainty and variation in expert opinion. The ranking of the nine pathogens varied according to the weighting method that was used. In both tools, using both weighting methods, the diseases that tended to rank the highest were West Nile virus, Giardiasis and Chagas, while Coccidioidomycosis tended to rank the lowest. Both tools are a simple and user friendly approach to prioritising pathogens according to climate change by including explicit scoring of 40 criteria and incorporating weighting methods based on expert opinion. They provide a dynamic interactive method that can help to identify pathogens for which a full risk assessment should be pursued.

Forging an agenda for suicide prevention in the United States

Suicide prevention must be transformed by integrating injury prevention and mental health perspectives to develop a mosaic of common risk public health interventions that address the diversity of populations and individuals whose mortality and morbidity contribute to the burdens of suicide and attempted suicide. Emphasizing distal preventive interventions, strategies must focus on people and places--and on related interpersonal factors and social contexts--to alter the life trajectories of people before they become suicidal. Attention also must be paid to those in the middle years--the age with the greatest overall burden. We need scientific and social processes that define priorities and assess their potential for reducing what has been a steadily increasing rate of suicide during the past decade.

What's happening at NICE?

From 1 April 2013, the National Institute for Health and Clinical Excellence (NICE) will be re-established under the provisions of the Health and Social Care Act 2012. Although its name will change to the National Institute for Health and Care Excellence, its acronym--NICE--has been written into the face of the Act. The new NICE will continue to provide the full range of guidance and other products with which the Institute has become associated. It will, though, have enhanced responsibilities in the development of quality standards and in the introduction of value-based pricing. In addition, it will be responsible for producing guidance for social care (hence the change in its name) and associated quality standards. The changes to the structure of NICE will not change its relationship with the professions and we are confident that it will continue to be relevant to all those working in the National Health Service.

Resources allocation in healthcare for cancer: a case study using generalised additive mixed models

Our aim is to develop a method for helping resources re-allocation in healthcare linked to cancer, in order to replan the allocation of providers. Ageing of the population has a considerable impact on the use of health resources because aged people require more specialised medical care due notably to cancer. We propose a method useful to monitor changes of cancer incidence in space and time taking into account two age categories, according to healthcar general organisation. We use generalised additive mixed models with a Poisson response, according to the methodology presented in Wood, Generalised additive models: an introduction with R. Chapman and Hall/CRC, 2006. Besides one-dimensional smooth functions accounting for non-linear effects of covariates, the space-time interaction can be modelled using scale invariant smoothers. Incidence data collected by a general cancer registry between 1992 and 2007 in a specific area of France is studied. Our best model exhibits a strong increase of the incidence of cancer along time and an obvious spatial pattern for people more than 70 years with a higher incidence in the central band of the region. This is a strong argument for re-allocating resources for old people cancer care in this sub-region.

Protecting Pakistan's health during the global economic crisis

The world is facing an unprecedented global economic crisis, with many countries needing to reconsider their level of health care spending. This paper explores the many consequences of the global economic turndown on Pakistan's health, including reduced government and donor spending and increased poverty with the consequent diversion of funds away from health. Nevertheless, these challenges may provide opportunities not only to mitigate the adverse effects of the economic crisis but also to institute some much-needed reforms that may not receive political support during more affluent times. Our suggestions focus on setting priorities based on the national disease burden, prioritizing prevention interventions, demanding results, curbing corruption, experimenting with innovative funding mechanisms, advocating for increased funding by presenting health spending as an investment rather than an expense and by selected recourse to civil society interventions and philanthropy to bridge the gap between available and needed resources.

Communicable diseases prioritized for surveillance and epidemiological research: results of a standardized prioritization procedure in Germany, 2011

Introduction

To establish strategic priorities for the German national public health institute (RKI) and guide the institute's mid-term strategic decisions, we prioritized infectious pathogens in accordance with their importance for national surveillance and epidemiological research.

Methods

We used the Delphi process with internal (RKI) and external experts and a metric-consensus approach to score pathogens according to ten three-tiered criteria. Additional experts were invited to weight each criterion, leading to the calculation of a median weight by which each score was multiplied. We ranked the pathogens according to the total weighted score and divided them into four priority groups.

Results

127 pathogens were scored. Eighty-six experts participated in the weighting; “Case fatality rate” was rated as the most important criterion. Twenty-six pathogens were ranked in the highest priority group; among those were pathogens with internationally recognised importance (e.g., Human Immunodeficiency Virus, Mycobacterium tuberculosis, Influenza virus, Hepatitis C virus, Neisseria meningitides), pathogens frequently causing large outbreaks (e.g., Campylobacter spp.), and nosocomial pathogens associated with antimicrobial resistance. Other pathogens in the highest priority group included Helicobacter pylori, Respiratory Syncytial Virus, Varicella zoster virus and Hantavirus.

Discussion

While several pathogens from the highest priority group already have a high profile in national and international health policy documents, high scores for other pathogens (e.g., Helicobacter pylori, Respiratory syncytial virus or Hantavirus) indicate a possible under-recognised importance within the current German public health framework. A process to strengthen respective surveillance systems and research has been started. The prioritization methodology has worked well; its modular structure makes it potentially useful for other settings.

Age as a criterion for setting priorities in health care? A survey of the German public view

Although the German health care system has budget constraints similar to many other countries worldwide, a discussion on prioritization has not gained the attention of the public yet. To probe the acceptance of priority setting in medicine, a quantitative survey representative for the German public (n = 2031) was conducted. Here we focus on the results for age, a highly disputed criterion for prioritizing medical services. This criterion was investigated using different types of questionnaire items, from abstract age-related questions to health care scenarios, and discrete choice settings, all performed within the same sample. Several explanatory variables were included to account for differences in preference; in particular, interviewee's own age but also his or her sex, socioeconomic status, and health status. There is little evidence that the German public accepts age as a criterion to prioritize health care services.

Target for improvement: a cluster randomised trial of public involvement in quality-indicator prioritisation (intervention development and study protocol)

BACKGROUND

Public priorities for improvement often differ from those of clinicians and managers. Public involvement has been proposed as a way to bridge the gap between professional and public clinical care priorities but has not been studied in the context of quality-indicator choice. Our objective is to assess the feasibility and impact of public involvement on quality-indicator choice and agreement with public priorities.

METHODS

We will conduct a cluster randomised controlled trial comparing quality-indicator prioritisation with and without public involvement. In preparation for the trial, we developed a 'menu' of quality indicators, based on a systematic review of existing validated indicator sets. Participants (public representatives, clinicians, and managers) will be recruited from six participating sites. In intervention sites, public representatives will be involved through direct participation (public representatives, clinicians, and managers will deliberate together to agree on quality-indicator choice and use) and consultation (individual public recommendations for improvement will be collected and presented to decision makers). In control sites, only clinicians and managers will take part in the prioritisation process. Data on quality-indicator choice and intended use will be collected. Our primary outcome will compare quality-indicator choice and agreement with public priorities between intervention and control groups. A process evaluation based on direct observation, videorecording, and participants' assessment will be conducted to help explain the study's results. The marginal cost of public involvement will also be assessed.

DISCUSSION

We identified 801 quality indicators that met our inclusion criteria. An expert panel agreed on a final set of 37 items containing validated quality indicators relevant for chronic disease prevention and management in primary care. We pilot tested our public-involvement intervention with 27 participants (11 public representatives and 16 clinicians and managers) and our study instruments with an additional 21 participants, which demonstrated the feasibility of the intervention and generated important insights and adaptations to engage public representatives more effectively. To our knowledge, this study is the first trial of public involvement in quality-indicator prioritisation, and its results could foster more effective upstream engagement of patients and the public in clinical practice improvement.

TRIAL REGISTRATION

NTR2496 (Netherlands National Trial Register, http://www.trialregister.nl).