A multiple criteria approach for building a pandemic impact assessment composite indicator: The case of COVID-19 in Portugal

The COVID-19 pandemic has caused major damage and disruption to social, economic, and health systems (among others). In addition, it has posed unprecedented challenges to public health and policy/decision-makers who have been responsible for designing and implementing measures to mitigate its strong negative impact. The Portuguese health authorities have used decision analysis techniques to assess the impact of the pandemic and implemented measures for counties, regions, or across the entire country. These decision tools have been subject to some criticism and many stakeholders requested novel approaches. In particular, those which considered the dynamic changes in the pandemic's behaviour due to new virus variants and vaccines. A multidisciplinary team formed by researchers from the COVID-19 Committee of Instituto Superior Técnico at the University of Lisbon (CCIST analyst team) and physicians from the Crisis Office of the Portuguese Medical Association (GCOM expert team) collaborated to create a new tool to help politicians and decision-makers to fight the pandemic. This paper presents the main steps that led to the building of a pandemic impact assessment composite indicator applied to the specific case of COVID-19 in Portugal. A multiple criteria approach based on an additive multi-attribute value theory aggregation model was used to build the pandemic assessment composite indicator. The parameters of the additive model were devised based on an interactive socio-technical and co-constructive process between the CCIST and GCOM team members. The deck of cards method was the adopted technical tool to assist in the assessment the value functions as well as in the assessment of the criteria weights. The final tool was presented at a press conference and had a powerful impact on the Portuguese media and on the main health decision-making stakeholders in the country. In this paper, a completed mathematical and graphical description of this tool is presented.

A spatial indicator of environmental and climatic vulnerability in Rome

BACKGROUND

Urban areas are disproportionately affected by multiple pressures from overbuilding, traffic, air pollution, and heat waves that often interact and are interconnected in producing health effects. A new synthetic tool to summarize environmental and climatic vulnerability has been introduced for the city of Rome, Italy, to provide the basis for environmental and health policies.

METHODS

From a literature overview and based on the availability of data, several macro-dimensions were identified on 1,461 grid cells with a width of 1 km² in Rome: land use, roads and traffic-related exposure, green space data, soil sealing, air pollution (PM_2.5, PM₁₀, NO₂, C₆H₆, SO₂), urban heat island intensity. The Geographically Weighted Principal Component Analysis (GWPCA) method was performed to produce a composite spatial indicator to describe and interpret each spatial feature by integrating all environmental dimensions. The method of natural breaks was used to define the risk classes. A bivariate map of environmental and social vulnerability was described.

RESULTS

The first three components explained most of the variation in the data structure with an average of 78.2% of the total percentage of variance (PTV) explained by the GWPCA, with air pollution and soil sealing contributing most in the first component; green space in the second component; road and traffic density and SO₂ in the third component. 56% of the population lives in areas with high or very high levels of environmental and climatic vulnerability, showing a periphery-centre trend, inverse to the deprivation index.

CONCLUSIONS

A new environmental and climatic vulnerability indicator for the city of Rome was able to identify the areas and population at risk in the city, and can be integrated with other vulnerability dimensions, such as social deprivation, providing the basis for risk stratification of the population and for the design of policies to address environmental, climatic and social injustice.

MCDA-DEA approach to construct a composite indicator for effluents from WWTPs considering the influence of PPCPs

Considering current water situation, reuse is an effective solution to meet water demand and reduce pressure on conventional water sources. However, pharmaceutical and personal care products (PPCPs) in effluents from wastewater treatment plants (WWTPs) decrease their quality and suitability. With the aim of identifying and monitoring both the influence of PPCPs and the suitability of effluents to be reused, this study proposes the development of a composite indicator (CI) related to PPCP presence in WWTPs, through the common weight multi-criteria decision analysis (MCDA)-data envelopment analysis (DEA) model. Obtaining a CI for PPCPs is a novel approach in the published literature, showing a new perspective in PPCP management and their influence in wastewater treatment. Furthermore, this study proposes an improvement on MCDA-DEA model which maintains the initial hierarchy obtained for the units analyzed. The development of CI is based on information about the technological, environmental, social, and biological issues of WWTPs. Results show that 4 of the 33 WWTPs analysed had the best CI values, meaning that their effluents have lower environmental impact. The development of a CI related to PPCPs in WWTPs suggests that further steps are needed to manage the WWTP effluents. Hence, the need to implement preventive measures in WWTPs has been shown, even though the removal of PPCPs is not yet part of European law. This work highlights the importance of considering PPCPs as priority pollutants in wastewater management and reuse frameworks, to guarantee low environmental impact and adapt wastewater reuse based on a circular economy approach. HIGHLIGHTS: Emerging contaminants (PPCPs) are used as effluent quality indicators. A composite indicator for PPCPs performance has been developed through MCDA-DEA model. Indicator obtained allow decision makers implementing concrete actions to assess effluent quality. Results show the improvement capacity of the effluents quality through PPCPs removing.

Observed heterogeneity in players' football performance analysis using PLS-PM

Nowadays, data science is applied in several areas of daily life. There have been many applications to sports. In this context, the attention will be focused on football (i.e. 'soccer' for Americans): the making of strategic choices, whether by the scouting department of the football club, or the technical staff, up to the management, is crucial. It has been measured and monitored football players' performance in the season 2018/2019, for the top five European Leagues, using data provided by Electronic Arts (EA) experts and available on the Kaggle data science platform. For this purpose, with the help of football experts, a third-order partial least-squares path model (PLS-PM) approach was adopted to the sofifa key performance indices in order to compute a composite indicator differentiated by role and compare it with the well-known overall indicator from EA Sports. It has been taken into account players' observed heterogeneity (i.e. roles and leagues), since often experts refer to differences in these features, and so the objective is to verify their importance scientifically. The results are very consistent with this because they underline how some sub-areas of performance have different significance weights depending on the role.

A Multi-modelling Approach for Assessing Sustainable Tourism

Academics, institutions and policymakers advocate systematic assessments to design sustainable development and implement proper environmental management; however, practical measurements in tourism research based on composite indicators are still in progress. This paper aims to build and validate a composite indicator of sustainable tourism (SusTour-Index), which recognises the economic, environmental and social dimensions as the three main interrelated facets of tourism sustainability. The SusTour-Index is composed of 75 elementary indicators, adequately structured in pillars and sub-pillars within each economic (34), environmental (21) and social dimension (20). A multi-modelling approach tests the hierarchical structure of the SusTour-Index by combining different weighting and aggregation methods within each sustainability dimension to choose the most appropriate model once the uncertainty analysis has been performed. The structure of the SusTour-Index is validated in all 21 Italian regions by performing 23 different models of the same composite indicator. The paper presents theoretical and methodological contributions for future research and advances in practical assessments, supporting policymakers and institutions in planning and managing sustainable tourism development.

Combining education and income into a socioeconomic position score for use in studies of health inequalities

Background

In studies of social inequalities in health, there is no consensus on the best measure of socioeconomic position (SEP). Moreover, subjective indicators are increasingly used to measure SEP. The aim of this paper was to develop a composite score for SEP based on weighted combinations of education and income in estimating subjective SEP, and examine how this score performs in predicting inequalities in health-related quality of life (HRQoL).

Methods

We used data from a comprehensive health survey from Northern Norway, conducted in 2015/16 (N = 21,083). A composite SEP score was developed using adjacent-category logistic regression of subjective SEP as a function of four education and four household income levels. Weights were derived based on these indicators’ coefficients in explaining variations in respondents’ subjective SEP. The composite SEP score was further applied to predict inequalities in HRQoL, measured by the EQ-5D and a visual analogue scale.

Results

Education seemed to influence SEP the most, while income added weight primarily for the highest income category. The weights demonstrated clear non-linearities, with large jumps from the middle to the higher SEP score levels. Analyses of the composite SEP score indicated a clear social gradient in both HRQoL measures.

Conclusions

We provide new insights into the relative contribution of education and income as sources of SEP, both separately and in combination. Combining education and income into a composite SEP score produces more comprehensive estimates of the social gradient in health. A similar approach can be applied in any cohort study that includes education and income data.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13366-8.

The daily urban dynamic indicator: Gauging the urban dynamic in Porto during the COVID-19 pandemic

The SARS-CoV-2 outbreak motivated the development of a myriad of weekly and daily indicators that track economic activity to estimate and predict the consequences of the pandemic. With some exceptions, these indicators are calculated at the country level and are mainly focused on tracking economic factors, disregarding local urban phenomena. To address this, we present the Urban Dynamic Indicator (UDI), a novel composite indicator designed to measure a city's daily urban dynamic. The UDI is applied to Porto municipality, in Portugal, and it corresponds to a latent factor obtained through a factor analysis over seasonal adjusted daily data regarding traffic intensity, public transportation usage, internet usage in public buses, NO₂ emissions and noise level. The UDI's values show that, by the end of 2020, despite the approach of economic activity to its pre-pandemic values, as suggested by the Portuguese Daily Economic Indicator (DEI), Porto urban dynamic did not recover completely. The UDI enriches the information available for Porto city planners and policymakers to respond to crisis situations and to gauge the application of local policies that contribute to urban sustainable planning. Furthermore, the methodology defined in this work can be followed for the development of daily urban dynamic indicators elsewhere.

Analysis of Ecuador's SCOPUS scientific production during the 2001-2020 period by means of standardized citation indicators

An analysis of the scientific production of Ecuador is performed by means of the composite indicator computed for Ecuador-based authors as compared to their counterparts of other South American countries. The dataset employed was obtained from the Databricks platform of the ELSEVIER's International Center for Science Research, ICSR. Therefore, this analysis is limited to the metadata of the documents published in journals indexed in SCOPUS. Comparison of the results obtained for two decades: 2001-2010 and 2011-2020 showed that the number of Ecuador-based researchers has significantly increased in different areas of knowledge. Moreover, comparison between the total number of authors that worked in Ecuador at any given year of the 2011-2020 period and the number of authors that are still working in this country up to the date of the data extraction (i.e., June 2021) showed an average of ∼68% of permanency. Analysis of the percentage distribution in terms of range quarters of the composite indicator (i.e., Q4: 0-1.5, Q3: 1.5-3.0, Q2: 3.0-4.5, and Q1: 4.5-6.0) showed that nearly the totality of the Ecuador-based researchers has composite indicators that lay in the Q4 and Q3 ranges for all the scientific fields considered. The latter was observed to be an effect of the scientific impact of South American countries, with larger investments in science and technology in comparison to Ecuador (i.e., Argentina, Brazil, and Chile). Exclusion of this group of countries in the calculation of the composite indicator of Ecuador-based authors resulted in a noticeable increment of scientists with composite indicators within Q2. Finally, our results suggest, in agreement with previous studies, a correlation between the sustained growth of scientific productivity in the decade 2011-2020 with the scientific programs and policies created by the state, where the initiative of scientific culture is shown as a strategy for growth and development.

Factors that most expose countries to COVID-19: a composite indicators-based approach

Studies carried out in different countries correlate social, economic, environmental, and health factors with the number of cases and deaths from COVID-19. However, such studies do not reveal which factors make one country more exposed to COVID-19 than other. Based on the composite indicators approach, this research identifies the factors that most impact the number of cases and deaths of COVID-19 worldwide and measures countries' exposure to COVID-19. Three composite indicators of exposure to COVID-19 were constructed through Principal Component Analysis, Simple Additive Weighting, and k-means clustering. The number of cases and deaths from COVID-19 is strongly correlated ( R  > 0.60) with composite indicator scores and moderately concordant ( K  > 0.4) with country clusters. Factors directly or indirectly associated with the age of the population are the ones that most expose countries to COVID-19. The population of countries most exposed to COVID-19 is 12 years older on average. The proportion of the elderly population in these countries is at least twice that of countries less exposed to COVID-19. Factors that can increase the population's life expectancy, such as Gross Domestic Product per capita and the Human Development Index, are four times and 1.3 times higher in more exposed countries to COVID-19. Providing better living conditions increases both the population's life expectancy and the country's exposure to COVID-19.

Nexus between fiscal imbalance and emissions reduction: New evidence from developing economies

The triple components of energy consumption, carbon dioxide emissions, and economic expansion are important to achieving sustained economic activity and sound ecological advancement. This study aims to estimate the impact of wide-ranging parameters on environmental circumstances in South Asian countries. This analysis required two approaches: 1)quantile autoregressive distributed lag (QARDL) as an econometric model, and 2) data envelopment analysis (DEA) non-parametric comparable composite index to examine concurrently South Asian nations' data for the 2000-2018 period. The underscored category of the parameters were grouped into four key indices, namely financial, fiscal, human, and energy. The DEA's mathematical composite findings reveal varied circumstances regarding environmental self-maintenance in South Asian nations. India and Pakistan are doing quite well; Afghanistan is abysmal. In addition, the QARDL approach findings reveal that energy use and fiscal indicators abate pollution. Furthermore, the correlation between fiscal decentralization and ecological attributes is strengthened by the excellent level of institutions and human capital progress. There is a unidirectional impact emanating from fiscal devolution, gross domestic product, human capital, eco-innovation, and institutional excellence on carbon dioxide pollution, although different from the other correlations obtained.

Dataset for multidimensional assessment to incentivise decentralised energy investments in Sub-Saharan Africa

In this data article, we present datasets from the construction of a composite indicator, the Photovoltaic Decentralised Energy Investment (PV-DEI) index, presented in detail in [1]. This article consists of a comprehensive energy-related data collected in practice from several sources, and from the outputs of the methodology described in [1]. The PV-DEI was designed and developed to measure the multidimensional factors that currently direct decentralised renewable energy investments. The PV-DEI index includes 52 indicators and was constructed because factors stimulating investment cannot be captured by a single indicator, e.g. competitiveness, affordability, or governance [1]. The PV-DEI index was built in alignment with a theoretical framework guided by an extensive review of the literature surrounding investment in decentralised Photovoltaic (PV), which led to the selection of its indicators. The structure of the PV-DEI was evaluated for its soundness using correlational assessments and principal component analyses (PCA). The raw data provided in this article can enable stakeholders to focus on specific country indicators, and how scores on these indicators contributed to a countries overall rank within the PV-DEI index. The data can be used to weight indicators depending on the specifications of several different stakeholders (such as NGOs, private sector or international institutions).

Does tradeoff between financial and social indicators matters in environmental consideration: evidence from G7 region

The study tries to discover the impact of financial and social indicators' growth towards environmental considerations to understand the drivers of economic growth and carbon dioxide emissions change in G7 countries. The DEA-like composite index has been used to examine the tradeoff between financial and social indicator matters in environmental consideration by using a multi-objective goal programming approach. The data from 2008 to 2018 is collected from G-7 countries. The results from the DEA-like composite index reveals that there is a mixed condition of environmental sustainability in G-7 countries where the USA is performing better and Japan is performing worse among the set of other countries. The further result shows that the energy and fiscal indicators help to decrease the dangerous gas emissions. Divergent to that, the human and financial index positively contributes to greenhouse gas emissions. Fostering sustainable development is essential to successfully reduce emissions, meet established objectives, and ensure steady development. The study provides valuable information for policymakers.

MCDA Index Tool: an interactive software to develop indices and rankings

A web-based software, called MCDA Index Tool (https://www.mcdaindex.net/), is presented in this paper. It allows developing indices and ranking alternatives, based on multiple combinations of normalization methods and aggregation functions. Given the steadily increasing importance of accounting for multiple preferences of the decision-makers and assessing the robustness of the decision recommendations, this tool is a timely instrument that can be used primarily by non-multiple criteria decision analysis (MCDA) experts to dynamically shape and evaluate their indices. The MCDA Index Tool allows the user to (i) input a dataset directly from spreadsheets with alternatives and indicators performance, (ii) build multiple indices by choosing several normalization methods and aggregation functions, and (iii) visualize and compare the indices' scores and rankings to assess the robustness of the results. A novel perspective on uncertainty and sensitivity analysis of preference models offers operational solutions to assess the influence of different strategies to develop indices and visualize their results. A case study for the assessment of the energy security and sustainability implications of different global energy scenarios is used to illustrate the application of the MCDA Index Tool. Analysts have now access to an index development tool that supports constructive and dynamic evaluation of the stability of rankings driven by a single score while including multiple decision-makers' and stakeholders' preferences.

MCDA Index Tool: an interactive software to develop indices and rankings

A web-based software, called MCDA Index Tool (https://www.mcdaindex.net/), is presented in this paper. It allows developing indices and ranking alternatives, based on multiple combinations of normalization methods and aggregation functions. Given the steadily increasing importance of accounting for multiple preferences of the decision-makers and assessing the robustness of the decision recommendations, this tool is a timely instrument that can be used primarily by non-multiple criteria decision analysis (MCDA) experts to dynamically shape and evaluate their indices. The MCDA Index Tool allows the user to (i) input a dataset directly from spreadsheets with alternatives and indicators performance, (ii) build multiple indices by choosing several normalization methods and aggregation functions, and (iii) visualize and compare the indices’ scores and rankings to assess the robustness of the results. A novel perspective on uncertainty and sensitivity analysis of preference models offers operational solutions to assess the influence of different strategies to develop indices and visualize their results. A case study for the assessment of the energy security and sustainability implications of different global energy scenarios is used to illustrate the application of the MCDA Index Tool. Analysts have now access to an index development tool that supports constructive and dynamic evaluation of the stability of rankings driven by a single score while including multiple decision-makers’ and stakeholders’ preferences.

A composite indicator approach to assess the sustainability and resilience of wastewater management alternatives

Evaluating the sustainability of wastewater management alternatives is a challenging task. This paper proposes an innovative methodology to assess and compare the sustainability of four wastewater management alternatives: a) centralised water resource recovery facility (WRRF) based on activated sludge (AS); b) centralised WRRF with membrane bioreactors (MBR); c) decentralised WRRFs with upflow anaerobic sludge blanket reactors and trickling filters; d) centralised-decentralised hybrid system. In doing so, a composite indicator embracing total annual equivalent costs, carbon emission intensity, eutrophication and resilience (based on robustness and rapidity metrics) was developed using the analytic hierarchy process (AHP) method. The results show that decentralised and hybrid systems contribute less to carbon emission and eutrophication because of energy and fertilizer harvest and with a trade-off of higher costs of 7-17% than the ones of AS and MBR. In addition, decentralised and hybrid systems are more resilient, contributing to lower environmental impacts facing natural disasters. Based on the weights obtained by AHP, the decentralised alternative appears to be the most sustainable option due to its best performance in terms of carbon emission intensity and resilience. By contrast, the MBR alternative appeared the least sustainable evaluated wastewater management alternative. However, this alternative is sustainable option when the eutrophication criterion is heavily prioritized. The proposed approach contributes to the selection of the most sustainable wastewater management alternative from a holistic perspective.

Assessing the quality of service for drinking water supplies in rural settings: A synthetic index approach

In rural settings, the presence of water supply infrastructure does not guarantee that people will have access to dependable and high-quality drinking water. To evaluate deficiencies, an assessment of quality of service of rural drinking water supply systems (RDWSS) should be examined from a multi-criteria perspective, one that integrates economic, technical, administrative, and operational components of supplying water, which includes a variety of stakeholders to integrate their preferences in the development of a synthetic index. In this study, we followed a pioneering approach to evaluate the quality of service for RDWSS based on analytic hierarchy process (AHP) and Monte Carlo simulations. We empirically applied the approach to 40 RDWSS in Chile. The weights of a set of 14 performance indicators were allocated by representatives of the communities that manage the RDWSS and experts on technical and administrative issues revelling the different preferences of decision-makers. We found that there are significant differences in the quality of service provided by the RDWSS evaluated. The information provided by the synthetic indicator would be very helpful in supporting decision makers needing to prioritize investments among drinking water supplies in rural settings.

Assessment of UASB-DHS technology for sewage treatment: a comparative study from a sustainability perspective

This paper assesses the technical and economic sustainability of a combined system of an up-flow anaerobic sludge blanket (UASB)-down-flow hanging sponge (DHS) for sewage treatment. Additionally, this study compares UASB-DHS with current technologies in India like trickling filters (TF), sequencing batch reactor (SBR), moving bed biofilm reactor (MBBR), and other combinations of UASB with post-treatment systems such as final polishing ponds (FPU) and extended aeration sludge process (EASP). The sustainability of the sewage treatment plants (STPs) was evaluated using a composite indicator, which incorporated environmental, societal, and economic dimensions. In case of the individual sustainability indicator study, the results showed that UASB-FPU was the most economically sustainable system with a score of 0.512 and aeration systems such as MBBR, EASP, and SBR were environmentally sustainable, whereas UASB-DHS system was socially sustainable. However, the overall comparative analysis indicated that the UASB-DHS system scored the highest value of 2.619 on the global sustainability indicator followed by EASP and MBBR with scores of 2.322 and 2.279, respectively. The highlight of this study was that the most environmentally sustainable treatment plants were not economically and socially sustainable. Moreover, sensitivity analysis showed that five out of the seven scenarios tested, the UASB-DHS system showed good results amongst the treatment system.

Data on cities that are benchmarked with the sustainable development of energy, water and environment systems index and related cross-sectoral scenario

The data set of this article is related to an original research article entitled “Benchmarking the sustainability of urban energy, water and environment systems and envisioning a cross-sectoral scenario for the future” Kılkış, 2019. The data article provides data compilations in the context of benchmarking studies based on the composite indicator of the Sustainable Development of Energy, Water and Environment Systems City Index. Data tables for the seven dimensions of the index are provided for 35 main indicators and related sub-indicators for the newly benchmarked cities while those for other cities are monitored. In addition to periodic updates in the common data sources, some cities released updated reports for the Sustainable Energy and/or Climate Action Plans and/or relevant local statistics since the initial benchmarking. Normalized and aggregated values per dimension of the index for 120 cities are provided as an appendix for groups of 30 cities that are characterized as the pioneering, transitioning, solution-seeking, and challenged cities of the sample. The data compilation for the sources of residual energy from the industry, thermal power generation, the wastewater sector and urban biowaste are further provided for 60 cities as the basis of a scenario to encourage the integration of cross-sectoral measures in urban systems to improve benchmarked performances. The data that is contained in this data article thus enables the original application of the index to 120 cities and the analysis of a scenario in which cities reduce primary energy spending and carbon dioxide emissions.

Performance and convergence in municipal waste treatment in the European Union

This paper assesses performance and convergence in the treatment of municipal waste by the members of the European Union-27 (EU-27) during the period 1995-2016. First, a composite indicator of performance -including landfill, incineration, recycling, and composting and digestion as treatment operations- is computed with Data Envelopment Analysis and Multi-Criteria-Decision-Making techniques at country and year levels. Then, convergence is assessed using the techniques proposed by Phillips and Sul (2007, 2009) and, more recently, by Kong et al. (2017). The best performers are Central and Northern European countries such as Denmark, Austria and Germany, whereas the worst are some Eastern European countries that joined the European Union in the 2000s. Furthermore, performance has largely converged among EU-27 countries since the enactment of the current Waste Framework Directive in 2008.

Gender differences in job quality and job satisfaction among doctors in rural western China

Background

Few studies about gender differences in job quality and job satisfaction among medical professionals have been carried out in China. So the objectives of this study were to examine whether and to what extent gender differences existed in job quality and job satisfaction of doctors in rural western China.

Methods

From 2009 to 2011, a total of 1472 doctors from 103 selected county-level health care facilities in rural western China were recruited into the study. Information about the doctors’ demographic characteristics, job quality, and job satisfaction was collected through a designed questionnaire. Besides examining gender differences in single dimensions of job quality and job satisfaction, principal component analysis was used to construct a composite job quality index to measure the differences in the comprehensive job quality, and exploratory factor analysis was applied to evaluate the differences in the overall job satisfaction. Chi-square test was used to calculate differences between proportions, and t-test was used to compare differences between means.

Results

Among the doctors, there were 705 males and 767 females (ratio 1:1.09). Male doctors had significantly higher monthly salaries, longer working hours, more times of night shifts per month, longer continuous working hours, and longer years of service at current facilities, and marginally significantly higher hourly wage and longer years of service in current professions. However, female doctors showed greater overall job qualities. Significant and marginally significant gender differences were only found in satisfaction with remuneration compared to workload, the chance of promotion and working environment. But female showed greater satisfaction in the overall job satisfaction and the factor including sub-aspects of working environment, remuneration compared to workload, the chance of promotion, utilization of subjective initiative, and sense of achievement.

Conclusions

Gender differences in job quality and job satisfaction did exist among doctors in rural western China. The participating female doctors were shown to have better job quality and greater job satisfaction.

Electronic supplementary material

The online version of this article (doi: 10.1186/s12913-017-2786-y) contains supplementary material, which is available to authorized users.

A composite indicator to assess the quality of care in the management of patients with rheumatoid arthritis in outpatient rheumatology clinics

OBJECTIVE

The current guidelines in the treatment of rheumatoid arthritis (RA) include the early diagnosis and early use of disease modifying drugs to achieve remission or low disease activity level, known as "Treat to Target" (T2T). The objective of this study is to develop a composite indicator (CI) to evaluate the quality of care in the management of patients with RA, according to the T2T strategy and other general recommendations concerning the management of these patients.

MATERIAL AND METHOD

The phases of the construction of the CI were: 1) selection of quality criteria through expert judgment; 2) prioritization of the criteria, according to relevance and feasibility, applying the Delphi methodology (two rounds) involving 20 experts; 3) design of quality indicators; and 4) calculation of the weighted CI, using the mean value in relevance and feasibility granted by the experts. The source of information for the calculation of the CI are the medical records of patients with RA.

RESULTS

Twelve criteria out of 37 required a second Delphi round. Thirty-one criteria were prioritized. These criteria presented a median in relevance and feasibility greater than or equal to 7.5, with an interquartile range of less than 3.5, and a level of agreement (score greater than or equal to 8) greater than or equal to 80%.

CONCLUSIONS

The constructed CI allows us to evaluate the quality of care of patients with RA following the T2T strategy in the rheumatology units of Spanish hospitals, offering a valid and easily interpretable summary measure.

A pressure ulcer and fall rate quality composite index for acute care units: A measure development study

BACKGROUND

Composite indices are single measures that combine the strengths of two or more individual measures and provide broader, easy-to-use measures for evaluation of provider performance and comparisons across units and hospitals to support quality improvement.

OBJECTIVE

The study objective was to develop a unit-level inpatient composite nursing care quality performance index-the Pressure Ulcer and Fall Rate Quality Composite Index.

DESIGN

Two-phase measure development study.

SETTINGS

5144 patient care units in 857 United States hospitals participating in the National Database of Nursing Quality Indictors^® during the year 2013.

METHODS

The Pressure Ulcer and Fall Rate Quality Composite Index was developed in two phases. In Phase 1 the formula was generated using a utility function and generalized penalty analysis. Experts with experience in healthcare quality measurement provided the point of indicator equivalence. In Phase 2 initial validity evidence was gathered based on hypothesized relationships between the Pressure Ulcer and Fall Rate Quality Composite Index and other variables using two-level (unit, hospital) hierarchical linear mixed modeling.

RESULTS

The Pressure Ulcer and Fall Rate Quality Composite Index=100-PUR-FR, where PUR is pressure ulcer rate and FR is total fall rate. Higher scores indicate better quality. Bland-Altman plots demonstrated agreement between pairs of experts and provided evidence for inter-rater reliability of the formula. The validation process demonstrated that higher registered nurse skill mix, higher percent of registered nurses with a baccalaureate in nursing or higher degree, higher percent of registered nurses with national specialty certification, and lower percent of hours supplied by agency staff were significantly associated with higher Pressure Ulcer and Fall Rate Quality Composite Index scores. Higher percentages of unit patients at risk for a hospital-acquired pressure ulcer and higher unit rates of physical restraint use were not associated with higher Pressure Ulcer and Fall Rate Quality Composite Index scores.

CONCLUSIONS

The Pressure Ulcer and Fall Rate Quality Composite Index is a step toward providing a more holistic perspective of unit level nursing quality than individual measures and may help nurses nursing administrators obtain a broader view of which patient care units are the higher and lower performers. Further study is needed to examine the usability of the Pressure Ulcer and Fall Rate Quality Composite Index.

Assessing the sustainability of small wastewater treatment systems: a composite indicator approach

The assessment of the sustainability of wastewater treatment (WWT) systems has gained interest in recent years. However, most previous studies have focused on environmental and/or economic dimensions ignoring social aspects. Moreover, they tend to be based on sets of indicators rather than providing a holistic assessment. To overcome this limitation, this paper proposes an innovative methodology to assess the sustainability of WWT systems based on the development of a composite indicator embracing economic, environmental and social issues. Subsequently, the global sustainability of seven WWT technologies for secondary treatment in small communities is compared. The joint application of the analytical hierarchical process (AHP) to assign weights to each indicator allows the incorporation of the preferences of experts. Initially, the global sustainability of the WWT technologies evaluated is quite similar. However, a scenario analysis illustrates that constructed wetlands technology is the most sustainable in five out of the seven scenarios evaluated. Moreover, extended aeration and rotating biological contactors are identified as the technologies with the lowest variability in their sustainability. Hence, in an uncertain context, they might be considered the preferred options. The proposed approach contributes to ease of interpretation of a complex problem such as the selection of the most sustainable WWT alternative.

Civic Competence of Youth in Europe: Measuring Cross National Variation Through the Creation of a Composite Indicator

This article develops a composite indicator to monitor the levels of civic competence of young people in Europe using the IEA ICCS 2009 study. The measurement model combines the traditions in Europe of liberal, civic republican and critical/cosmopolitan models of citizenship. The results indicate that social justice values and citizenship knowledge and skills of students are facilitated within the Nordic system that combines a stable democracy and economic prosperity with a democratically based education systems in which teachers prioritise promoting autonomous critical thinking in citizenship education. In contrast, medium term democracies with civic republican tradition, such as Italy and Greece gain more positive results on citizenship values and participatory attitudes. This is also the case for some recent former communist countries that retain ethnic notions of citizenship. In a final step we go on to argue that the Nordic teachers' priority on developing critical and autonomous citizens perhaps facilitates 14 years olds qualities of cognition on citizenship and the values of equality but may not be the most fruitful approach to enhance participatory attitudes or concepts of a good citizen which may be better supported by the Italian teachers' priority on civic responsibility.