Context Of Decision Research Articles

Expert consensus on pharmacoeconomic evaluations alongside clinical trials (2024 edition)

As a technical tool to guide the optimal allocation of healthcare resources, pharmacoeconomic evaluation has been gradually applied to national healthcare decisions, including the adjustment of the National Reimbursement Drug List in China. With the acceleration of drug market approval and access to insurance coverage, the demand for pharmacoeconomic evaluation in healthcare decision-making is also increasing. Designing a pharmacoeconomic evaluation alongside clinical trials has become an important research direction and the source of evidence. In order to facilitate the standardization of this research field, the current consensus focuses on the topic of how to conduct a pharmacoeconomic evaluation alongside clinical trials from the Chinese healthcare system and decision-making context. The consensus group reconciled expert opinions and developed recommendations covering the entire process of study design, data collection and management, data analysis, and methods and results reporting. A total of 24 recommendations regarding to methodology and practice were developed from eighteen aspects including target population, selection of comparators, calculation of sample size, data collection of healthcare resource utilization, data collection of health-related quality of life, cost analysis, health outcome analysis, addressing the missing and censored data, etc., with the aim to provide reference for scholars and decision makers in this research filed.

Beyond closed doors: Examining consumer reactions to public and private advice

ABSTRACT Frequently transmitted through word-of-mouth (WOM) communications, advice is viewed as a trustworthy source of information by consumers. Marketers value WOM marketing and invest resources to encourage consumer recommendations. Despite the value of interpersonal recommendations for consumers, an important research finding on advice-taking is ego-centric discounting (i.e. the phenomenon where individuals discount offered advice in favor of their own preferences). Prior work has explored mitigating factors of ego-centric discounting including characteristics of the recommender and the decision context. However, the role of interpersonal influence in advice exchange is understudied. This paper delves deeper into the role of interpersonal influence, evaluating how advice utilization is influenced by the presence of other consumers during the recommendation exchange. Across three experiments, we demonstrate that consumers are more likely to rely on advice when the recommendation is made public rather than in private. Moreover, we show that consumers readily integrate public advice in an attempt to appear appreciative for the recommendation (a self-presentation consideration). Finally, this research shows that consumers higher in need for social approval (NSA) rely more heavily on public advice. This research augments literature on consumer advice and highlights public vs. private advice as an essential factor curbing ego-centric advice discounting.

Outcomes of integrated knowledge translation: A comparative, multi-country case study

Abstract Background Integrated knowledge translation (IKT) seeks to establish continuous relationships between researchers and knowledge users, in particular decision-makers, to enhance evidence-informed decision-making in public health and healthcare. IKT is, however, difficult to evaluate and outcome evaluations remain scarce. The German-African Collaboration for Evidence-based Healthcare and Public Health in Africa (CEBHA+) undertook research on IKT and non-communicable diseases in Ethiopia, Malawi, Rwanda, South Africa, and Uganda. Over six years, we implemented an IKT approach and evaluated it according to a pre-defined programme theory. Methods We conducted qualitative interviews and surveys with CEBHA+ researchers and their decision-making partners at two stages (3/2020-2/2021; 9/2022-5/2023) and collected IKT-related documents (see protocol: https://rdcu.be/dyfBP). Transcripts and documents were analysed using qualitative content analysis and surveys were analysed descriptively, with subsequent integration, cross-case analysis, and revision of the programme theory. Results We collected 92 IKT-related documents; and 55 researchers and decision-makers participated in surveys, focus groups or interviews. Proximal outcomes were collaborative research; capacity-building related to research skills and evidence use; and relationship-building, establishing trust and partnerships. Intermediate outcomes were changes in attitudes and knowledge; decision-makers became attuned to research and researchers increased their understanding of the decision-making context, and developed a vision for research impact. Distal outcomes were the production of applicable research and the consideration of evidence by decision-makers. High opportunity costs associated with IKT implementation constituted unintended effects. Conclusions Our study presents rich, theory-informed insights into IKT outcomes, based in particular on the experience of researchers implementing the CEBHA+ IKT approach. Key messages • A multi-country research collaboration offered an opportunity to examine IKT implementation and investigate proximal, intermediate, and distal IKT outcomes based on a pre-defined programme theory. • Beyond our initial conceptualisation, the IKT approach was linked to researchers developing a vision for ‘research impact’ and gaining a better understanding of the decision-making context.

Guidance for unbiased predictive information for healthcare decision-making and equity (GUIDE): considerations when race may be a prognostic factor.

Clinical prediction models (CPMs) are tools that compute the risk of an outcome given a set of patient characteristics and are routinely used to inform patients, guide treatment decision-making, and resource allocation. Although much hope has been placed on CPMs to mitigate human biases, CPMs may potentially contribute to racial disparities in decision-making and resource allocation. While some policymakers, professional organizations, and scholars have called for eliminating race as a variable from CPMs, others raise concerns that excluding race may exacerbate healthcare disparities and this controversy remains unresolved. The Guidance for Unbiased predictive Information for healthcare Decision-making and Equity (GUIDE) provides expert guidelines for model developers and health system administrators on the transparent use of race in CPMs and mitigation of algorithmic bias across contexts developed through a 5-round, modified Delphi process from a diverse 14-person technical expert panel (TEP). Deliberations affirmed that race is a social construct and that the goals of prediction are distinct from those of causal inference, and emphasized: the importance of decisional context (e.g., shared decision-making versus healthcare rationing); the conflicting nature of different anti-discrimination principles (e.g., anticlassification versus antisubordination principles); and the importance of identifying and balancing trade-offs in achieving equity-related goals with race-aware versus race-unaware CPMs for conditions where racial identity is prognostically informative. The GUIDE, comprising 31 key items in the development and use of CPMs in healthcare, outlines foundational principles, distinguishes between bias and fairness, and offers guidance for examining subgroup invalidity and using race as a variable in CPMs. This GUIDE presents a living document that supports appraisal and reporting of bias in CPMs to support best practice in CPM development and use.

Soil-Based Emissions and Context-Specific Climate Change Planning to Support the United Nations (UN) Sustainable Development Goal (SDG) on Climate Action: A Case Study of Georgia (USA)

Soil-based emissions from land conversions are often overlooked in climate planning. The objectives of this study were to use quantitative data on soil-based greenhouse gas (GHG) emissions for the state of Georgia (GA) (USA) to examine context-specific (temporal, biophysical, economic, and social) climate planning and legal options to deal with these emissions. Currently, 30% of the land in GA has experienced anthropogenic land degradation (LD) primarily due to agriculture (64%). All seven soil orders were subject to various degrees of anthropogenic LD. Increases in overall LD between 2001 and 2021 indicate a lack of land degradation neutrality (LDN) in GA. Besides agricultural LD, there was also LD caused by increased development through urbanization, with 15,197.1 km2 developed, causing midpoint losses of 1.2 × 1011 kg of total soil carbon (TSC) with a corresponding midpoint social cost from carbon dioxide (CO2) emissions (SC-CO2) of USD $20.4B (where B = billion = 109, $ = U.S. dollars (USD)). Most developments occurred in the Metro Atlanta and Coastal Economic Development Regions, which indicates reverse climate change adaptation (RCCA). Soil consumption from developments is an important issue because it limits future soil or forest carbon (C) sequestration potential in these areas. Soil-based emissions should be included in GA’s carbon footprint. Understanding the geospatial and temporal context of land conversion decisions, as well as the social and economic costs, could be used to create incentives for land management that limit soil-based GHG emissions in a local context with implications for relevant United Nations (UN) initiatives.

Crash dilemmas and the ethical design of self-driving vehicles: implications from metaethics and pragmatic road marks

AbstractHow should self-driving vehicles react when an accident can no longer be averted in dangerous situations? The complex issue of designing crash algorithms has been discussed intensively in recent research literature. This paper refines the discourse around a new perspective which reassesses the underlying dilemma structures in the light of a metaethical analysis. It aims at enhancing the critical understanding of both the conceptual nature and specific practical implications that relate to the problem of crash algorithms. The ultimate aim of the paper is to open up a way to building a bridge between the inherent structural issues of dilemma cases on the one hand and the characteristics of the practical decision context related to driving automation scenarios on the other. Based on a reconstruction of the metaethical structure of crash dilemmas, a pragmatic orientation towards the ethical design of crash algorithms is sketched and critically examined along two central particularities of the practical problem. Firstly, pertinent research on the social nature of crash dilemmas is found to be merely heuristic. Secondly, existing work from ethics of risk hardly offers explicit ethical solutions to relevant and urgent challenges. Further investigation regarding both aspects is ultimately formulated as a research desideratum.

Framing the Default.

A key finding within nudging research is the default effect, where individuals are inclined to stay with a default option when faced with a decision, rather than exploring alternatives (e.g., a preselected job opportunity among two alternatives). Similarly, the study of framing effects delves into how the presentation and context of decisions influence choices (e.g., choosing vs. rejecting a job opportunity among two alternatives). Specifically, previous literature examining choosing versus rejecting decision frames in various situations has found that these frames do not invariably complement each other; therefore, individuals' preferences vary based on the task frame. Yet, simultaneous testing of multiple nudges remains relatively unexplored in the literature. In the current study involving 1,072 participants, we examined how framing and default effects can influence decision-making in hypothetical scenarios. The decision scenarios involved two different domains-work and health. We found that framing had a strong effect on decision-making in both work and health domains, whereas default setting contributed only to a limited extent in the work domain and no effect was found in the health domain, mirroring related recent research findings. We argue for a more careful design of nudge interventions when multiple overlapping nudges are used and for a contextual approach to applying behavioral science to citizens.

Pre-choice midbrain fluctuations affect self-control in food choice: A functional magnetic resonance imaging (fMRI) study.

Recent studies have shown that spontaneous pre-stimulus fluctuations in brain activity affect higher-order cognitive processes, including risky decision-making, cognitive flexibility, and aesthetic judgments. However, there is currently no direct evidence to suggest that pre-choice activity influences value-based decisions that require self-control. We examined the impact of fluctuations in pre-choice activity in key regions of the reward system on self-control in food choice. In the functional magnetic resonance imaging (fMRI) scanner, 49 participants made 120 food choices that required self-control in high and low working memory load conditions. The task was designed to ensure that participants were cognitively engaged and not thinking about upcoming choices. We defined self-control success as choosing a food item that was healthier over one that was tastier. The brain regions of interest (ROIs) were the ventral tegmental area (VTA), putamen, nucleus accumbens (NAc), and caudate nucleus. For each participant and condition, we calculated the mean activity in the 3-s interval preceding the presentation of food stimuli in successful and failed self-control trials. These activities were then used as predictors of self-control success in a fixed-effects logistic regression model. The results indicate that increased pre-choice VTA activity was linked to a higher probability of self-control success in a subsequent food-choice task within the low-load condition, but not in the high-load condition. We posit that pre-choice fluctuations in VTA activity change the reference point for immediate (taste) reward evaluation, which may explain our finding. This suggests that the neural context of decisions may be a key factor influencing human behavior.

Enough but not too many: A bi-threshold model for behavioral diffusion.

Behavioral diffusion is commonly modeled with the linear threshold model, which assumes that individuals adopt a behavior when enough of their social contacts do so. We observe, however, that in many common empirical settings individuals also appear to abandon a behavior when too many of their close contacts exhibit it. The bi-threshold model captures this tendency by adding an upper threshold, which, when exceeded, triggers behavioral disadoption. Here we report an empirical test of the bi-threshold model. We overcome the significant challenge of estimating individuals' heterogeneous thresholds by extending a recently introduced decision-tree based algorithm to the bi-threshold setting. Using the context of the spread of news about three different topics on social media (the Higgs boson, the Melbourne Cup horse race, and the COVID-19 vaccination campaign in China), we show that the bi-threshold model predicts user engagement with the news orders of magnitude more accurately than the linear threshold model. We show that the performance gains are due especially to the bi-threshold model's comparative advantage in predicting behavioral decline, an important but previously overlooked stage of the behavioral diffusion cycle. Overall, the results confirm the existence of the second upper threshold in some contexts of diffusion of information and suggest that a similar mechanism may operate in other decision-making contexts.

Decoding decision delegation to artificial intelligence: A mixed-methods study on the preferences of decision-makers and decision-affected in surrogate decision contexts

Organizations are increasingly opting to use decision-making systems based on artificial intelligence (AI) to increase decision quality and speed and free up resources. However, delegating decisions to AI is challenging, especially in contexts that go beyond classical optimization problems. Current research has so far largely neglected to include the viewpoints of the decision-affected and of surrogate decision-makers in the discussion. To address these gaps, in this study we rely on two experimental designs and complement our findings with qualitative interview data to shed light on both sides: the perspective of those affected by the decision and that of the decision maker in surrogate and ethically complex decision contexts. Findings reveal that the individual decision-making perspective may lead to opposing perceptions. Whereas the willingness to delegate an ethically challenging decision to AI in a surrogate decision context is lower than that in a non-surrogate context (decision-maker perspective), people affected by the decision do not generally prefer humans to AI (decision-affected perspective). By these findings, we contribute to the literature on AI-enabled decision-making and decision delegation to non-human entities.

Use of the value-focused thinking methodology to understand health care waste management under the perspective of occupational and environmental health

The increasing generation of healthcare waste has greatly accelerated the concern about its potential negative environmental and public health effects. In this sense, the application of decision-making methods and techniques at a strategic level has become increasingly indispensable for the management of health units. This article aimed to understand the challenges in healthcare waste management (HCWM), the main mechanisms of action and values. The Value-Focused Thinking methodology was used to evidence important gaps and propose improvements in the context of decision on occupational safety and environmental protection, leading to the creation of alternatives not seen previously and guaranteeing the good ideas would be converted into actions. The structure was developed by semi-structured questionnaires, observation lists and interviews, conducted to expose the values of the main stakeholders (managers, health professionals, and cleaning professionals) of 10 public health units selected in Caruaru (Brazil). As a result, the investigation evidenced four fundamental goals for the decision context: improvement in work and environmental safety; improvement in HCWM practices; improvement in resource management; strengthening of the stakeholder communication network. From the analysis of the attributes associated with the fundamental goals, it was possible to identify actions that should be implemented with a higher priority and, in the short term, aiming at obtaining positive results, especially in the management practices and the safe management of health waste. The study resulted from an investigation that awakened the participants about aspects little questioned in everyday life. Implementing actions to segregate and recycle materials, with data monitoring and sharing, will increase the population's trust and the environment's and professionals' safety. The alternatives derived from the VFT method consider the perspectives of key stakeholders in HCWM, helping decision-makers and policymakers develop more assertive and grounded management strategies.

Factors Guiding Clinical Decision-Making in Genitourinary Oncology.

Clinical decision-making in oncology is a complex process, with the primary goal of identifying the most effective treatment tailored to individual cancer patients. Many factors influence the treatment decision: disease- and patient-specific criteria, the increasingly complex treatment landscape, market authorization and drug availability, financial aspects, and personal treatment expertise. In the domain of genitourinary cancers, particularly prostate cancer, decision-making is challenging. Despite the prevalence of this malignancy, there are few in-depth explorations of these factors within real-world scenarios. Understanding and refining this intricate decision-making process is essential for future successful clinical decisions and the integration of computerized decision support into clinicians' workflows. The objective of this study is to improve the current knowledge base and evidence of the factors that influence treatment decision-making for patients with genitourinary cancers. Assessment of how routine treatment decisions are made for genitourinary cancers was performed by a mixed-methods study, encompassing field observations and focus group discussions. In total, we identified 59 factors that influence clinical decision-making in oncology, specifically for genitourinary and prostate cancer. Of these, 23 criteria can be classified as decision-maker-related criteria encompassing personal, cognitive, and emotional attributes and factors of both, healthcare professionals and patients. Moreover, 20 decision-specific criteria have been identified that refer to clinical and disease-related factors, followed by 16 contextual decision factors that describe the relevant criteria introduced by the specific circumstances and environment in which the treatment decision is made. By presenting an exhaustive set of decision factors and providing specific examples for genitourinary cancers, this observational study establishes a possible framework for a better understanding of decision-making. Moreover, we specify and expand the set of decision factors, while emphasizing the importance of cognitive, emotional, and human factors, as well as the quality and accessibility of decision-relevant information.

Discrepancy between pulmonary arterial wedge pressure and left ventricular end diastolic pressure in patients with interstitial lung disease

BackgroundRight heart catheterization (RHC) is the gold standard for diagnosing pulmonary hypertension (PH) in patients with interstitial lung disease (ILD). However, discrepancies between pulmonary arterial wedge pressure (PAWP) and left ventricular end-diastolic pressure (LVEDP) remain understudied in this population. MethodsWe conducted a retrospective analysis of data from ILD patients who underwent RHC and had concomitant LVEDP measurements. Pulmonary vascular resistance (PVR) was calculated using both PAWP and LVEDP. Patients were categorized based on PAWP and LVEDP values using a threshold of 15 mmHg and PVR values using a threshold of 2 or 3 Wood Units. After that patients were categorized as concordant or discordant if both values were on the same or opposite sides of these thresholds, respectively. A discordantly higher PAWP group (left atrial dysfunction, LAD) was defined as patients with a PAWP-LVEDP difference of more than 3mmHg. ResultsAmong 87 ILD patients, 9 patients (10.3%) showed discordance between PAWP and LVEDP. LAD was observed in 12 patients (13.8%) and was associated with lower forced vital capacity (Odd ratio [OR]: 0.956, p = 0.049) and a larger left atrium diameter (OR: 3.205, p = 0.033). Discordance in PVR values was also noted, with potential treatment targets for PH-specific therapy differing in 9 patients (22.0%) depending on whether PAWP or LVEDP was used. ConclusionsThis study highlights the clinical significance of PAWP-LVEDP discrepancies in suspected PH-ILD patients, emphasizing the need for comprehensive assessments incorporating LVEDP and clinical context for accurate diagnosis, risk stratification, and treatment decisions.

Clients prefer collaborative decision-making with veterinarians regardless of appointment type.

To determine clients' preferences for veterinarians' communication during decision-making in relation to 3 clinical contexts: preventive care, general problem (eg, illness or injury), and urgent appointments. A cross-sectional online questionnaire was distributed by use of snowball sampling to veterinary clients owning a pet. Demographic information was collected, and participants were then randomly assigned to a scenario reflecting one of the following clinical contexts (appointment types): preventive, general problem, or urgent. Discrete choice exercises were used to solicit client preferences for 5 aspects of veterinarians' communication approach to decision-making with clients in clinical contexts: amount of information, presentation of plan (options or a recommendation), communication of value, nature of client involvement, and communication of financial cost. Relative-preference scores were calculated using hierarchical bayesian modeling. Responses for 1,614 participants were included in the final analysis. The majority were female, lived in Canada, and were financially stable. Across clinical decision-making contexts, participants preferred to collaborate with the veterinarian, be offered options with a clear recommendation, be informed of present and future costs, and have benefits of any action regarding their pet's health explained to them. For the general-problem context, participants preferred veterinarians' communication to focus solely on concerns; in contrast, in preventive care and urgent contexts, participants preferred that communication include both normal findings and concerns. Irrespective of clinical decision-making context, participants preferred collaborative decision-making with a veterinarian. Veterinary professionals should consider, when possible, communication that supports a collaborative approach to decision-making with clients.

Punishment after Life: How Attitudes about Longer-than-Life Sentences Expose the Rules of Retribution.

Prison sentences that exceed the natural lifespan present a puzzle because they have no more power to deter or incapacitate than a single life sentence. In three survey experiments, we tested the extent to which participants support these longer-than-life sentences under different decision contexts. In Experiment 1, 130 undergraduates made hypothetical prison sentence-length recommendations for a serious criminal offender, warranting two sentences to be served either concurrently or consecutively. Using a nationally representative sample (N = 182) and an undergraduate pilot sample (N = 260), participants in Experiments 2 and 3 voted on a hypothetical ballot measure to either allow or prohibit the use of consecutive life sentences. Results from all experiments revealed that, compared to concurrent life sentences participants supported the use of consecutive life sentences for serious offenders. In addition, they adjusted these posthumous years in response to mitigating factors in a manner that was indistinguishable from ordinary sentences (Experiment 1), and their support for consecutive life sentencing policies persisted, regardless of the default choice and whether the policy was costly to implement (Experiments 2 and 3). These judgment patterns were most consistent with retributive punishment heuristics and have implications for sentencing policy and for theories of punishment behavior.

The erosion of rationality in high vulnerability conditions: A cognitive‐disruption perspective

AbstractThis research examines how a decision‐maker's perceived vulnerability influences their susceptibility to the “anecdotal bias,” a phenomenon where statistical evidence is disregarded in favor of anecdotal information. Across six studies, our research shows that high vulnerability aggravates the anecdotal bias instead of reducing it. Study 1 provides preliminary evidence that high vulnerability exacerbates the anecdotal bias among individuals seeking decision‐relevant information in the context of the COVID‐19 pandemic. Studies 2A and 2B demonstrate that high vulnerability intensifies the anecdotal bias in different decision contexts. Study 3 replicates these findings and identifies negative emotional arousal as a key mechanism underlying this effect. Study 4 examines the moderating role of personal relevance, showing that when individuals make decisions for others (vs. themselves), high vulnerability does not lead to the anecdotal bias. Moreover, it is cognitive disruption and intuitive thinking caused by negative emotional arousal that increases reliance on anecdotal (vs. statistical) information. Finally, Study 5 demonstrates the moderating effect of mindfulness meditation, highlighting its role as a preemptive safeguard against this biased behavior. Theoretical contributions and practical implications of these findings are discussed.

Upgrading of Grade Group 1 Prostate Cancer at Prostatectomy: Germline Risk Factors in a Prospective Cohort.

Localized prostate tumors show significant spatial heterogeneity, with regions of high-grade disease adjacent to lower-grade disease. Consequently, prostate cancer biopsies are prone to sampling bias, potentially leading to underestimation of tumor grade. To study the clinical, epidemiologic and molecular hallmarks of this phenomenon, we conducted a prospective study of grade upgrading: differences in detected prostate cancer grade between biopsy and surgery. We established a prospective, multi-institutional cohort of men with Grade Group 1 (GG1) prostate cancer on biopsy who underwent radical prostatectomy. Upgrading was defined as detection of GG2+ in the resected tumor. Germline DNA from 192 subjects was subjected to whole-genome sequencing to quantify ancestry, pathogenic variants in DNA damage response genes and polygenic risk. Of 285 men, 67% upgraded at surgery. PSA density and percent of cancer in pre-prostatectomy positive biopsy cores were significantly associated with upgrading. No assessed genetic risk factor was predictive of upgrading, including polygenic risk scores for prostate cancer diagnosis. In a cohort of low-grade prostate cancer patients, a majority upgraded at radical prostatectomy. PSA density and percent of cancer in pre-prostatectomy positive biopsy cores portended the presence of higher-grade disease, while germline genetics was not informative in this setting. Patients with low-risk prostate cancer, but elevated PSA density or percent cancer in positive biopsy cores, may benefit from repeat biopsy, additional imaging or other approaches to complement active surveillance. Further risk stratification of patients with low-risk prostate cancer may provide useful context for active surveillance decision-making.

Exploring How Values of Colorectal Cancer Patients and their Caregivers Influence Treatment Decision-Making.

As we adopt value models to inform drug reimbursement, coverage, clinical trials, and treatment choices, aligning these models to reflect patient values and preferences becomes increasingly relevant. In this study, we focus on colorectal cancer (CRC), which is highly prevalent and a leading cause of death in Canada, and new drug treatment options are costly. The aim of this study was to understand how the values and experiences of people with CRC and their caregivers inform their perspectives about new and emerging colorectal cancer drug treatments. We applied qualitative methods to identify key personal, social, and system factors about how the values of people with CRC and their caregivers' values influence their treatment decision-making in a more holistic manner. Canadian adults (>18 years) living with non-metastatic or metastatic CRC and caregivers were recruited from oncology clinics and Colorectal Cancer Canada (CCC) using purposive sampling. Participants engaged in structured interviews by telephone. Interviews were transcribed verbatim and analyzed thematically guided by a qualitative phenomenological approach and Sherwin's ethical theory of relational autonomy using NVivo software. We conducted structured interviews with 12 people with CRC and six of their caregivers, and elicited patient and caregiver values and their influence on treatment decision-making context of key personal, social, and system factors. Thematic analysis of transcripts led to the development of four overarching and intersecting themes that were identified as influencing people with CRC and their caregivers' treatment decision-making: treatment outcomes and effectiveness, intrapersonal and interpersonal factors, quality of life, and survivorship and prognosis. Our findings suggest intersecting influences of patient-, community-, and social network-, and systemic-level factors that influence patients' decisions on treatment. Perceived clinical benefit, requirements of treatment, available information, the impact of treatment on social relationships and daily life, and the impact of social support were key factors described by participants. To our knowledge, this is the first study to utilize the theory of relational autonomy to understand patient and caregiver values in the context of treatment decisions in CRC. Using these findings, a continued exploration of people with CRC's values in treatment decision-making and how much patients value or weight the different aspects of treatment would help further advance patient care and guide healthcare system decision-making.

Actors in the spotlight: scrutinising how actors affect strategic environmental assessment towards sustainability in municipal master plans

ABSTRACT Changing the paradigm towards sustainability falls implicitly in transforming the urban systems, as most of the world's population lives in cities. The Strategic Environmental Assessment (SEA) process is relevant in this context because it supports the evaluation of the sustainability of the plans and promotes open and accountable decision-making. However, SEA processes are embedded in a broader decision-making context, where the different roles of the actors and their impacts on the planning process remain unclear. This study explores the contributions of the SEA actors and how they influence the outcomes of SEA towards sustainability, employing a case study research design and a content analysis on the SEA of 12 Municipal Master Plans (MMP) in Portugal. Results show that public participation tends to be weak and is only sought after all decisions have been made in the planning process. The study revealed that the SEA practitioner’s role is distanced from the MMP planning team, constraining their capacity to influence the plan development. The results highlighted the significance of initiating actors’ involvement at the beginning of the assessment process and improving the knowledge exchange between the actors. These strategies have the potential to foster collaboration, transparency, and a more integrated approach to SEA.

Shaping coastal nature-based solutions: Perceptions and policy priorities of living shorelines

Coastal nature-based solutions, such as living shorelines, are promoted as shoreline stabilization alternatives to hard infrastructure in the United States. In the state of Florida, where sea level rise and increasing storms impact coastal areas, living shorelines are a state research priority to support coastal risk reduction and resilience goals. However, while the ecological benefits of living shorelines are well-documented, few studies have examined the social and institutional factors that hinder or support the design and implementation of living shorelines in Florida.Our study applies an integrated framework combining results from expert interviews with a policy analysis to evaluate decision-making contexts and considerations related to living shorelines in Florida. We present barriers and enablers of living shorelines as perceived by practitioners and marine contractors. Key barriers to adoption of living shorelines include rule or permitting-related mismatches, community-level use and access concerns, and environmental design uncertainties. Enablers include community-level education and incentives, increased demonstration projects, and criteria or policy standardization for living shorelines. We then connect these barriers and enablers to policy priority patterns drawn from coastal management plans in select Florida counties. These policy priority patterns involve defining nature-based and hard solutions, addressing public and private access concerns, and resolving restoration and conservation goals when considering living shorelines as an appropriate coastline stabilization and protection measure. By connecting on-the-ground practical experiences with insights from coastal management policies, our study provides a socio-institutional methodology and contextual baseline for the planning and implementation of living shorelines in Florida and similar coastal areas.