Consultation Decision Research Articles

Transmural collaborative care model for cardiovascular risk management and medication review in patients using antipsychotics in primary care (TACTIC): A study protocol of an incomplete stepped wedge cluster randomized trial.

It is well established that patients with severe mental illness and those treated with atypical antipsychotics (AAPs) are at an increased risk of cardiovascular disease. However, primary care currently lacks adequate monitoring of AAP usage, its effects, and the associated cardiovascular risk. We have developed TACTIC, a transmural collaborative care model for patients using AAPs prescribed by the general practitioner (GP) to address the issues of potential overtreatment with AAPs and undertreatment for cardiovascular risk. TACTIC comprises three steps: an informative video for patients, a multidisciplinary meeting, and a shared decision-making consultation with the GP. To evaluate TACTIC's effectiveness on cardiovascular risk and mental health and its cost-effectiveness. We will conduct an incomplete stepped wedge cluster randomized trial in the Netherlands.40GP-nurse clusters are randomized into four waves. Each cluster recruits adult patients (25-85 years), without prior diagnoses of dementia, delirium, or cardiovascular disease, for whom the GP prescribes AAPs. Every five months, a new wave starts with TACTIC. Measurements are taken before the intervention starts and every 5 months until the study concludes. Primary outcomes are cardiovascular risk and mental health as measured with the QRISK3 score and MHI5, respectively. The economic evaluation consists of two cost-utility analyses, one on the data collected alongside the trial and one based on a model extrapolating the trial data to a 10-year horizon. We will also evaluate the process of delivering TACTIC. This study will assess TACTIC's (cost)effectiveness and provide insights for successful delivery in general practice. clinicaltrials.gov NCT05647980.

A thematic analysis of shared decision-making in consultations with patients with a presumed brain tumor and neurosurgeons

Abstract Background Patients with brain tumors, family members, and healthcare professionals face complex healthcare decisions that can significantly impact everyday life. Engaging in shared decision-making (SDM) can help ensure treatment decisions align with patients’ preferences and goals. Little is known about the decision-making process in neurosurgical consultations. This study aims to qualitatively explore and describe the SDM process during neurosurgical consultations for patients with a presumed brain tumor. Methods The first consultation between patients with presumed glioma or meningioma and their neurosurgeons was audio-recorded and transcribed. Decision-making models were used as sensitization concepts, with coding carried out inductively. We employed a reflexive thematic analysis to develop themes and subthemes until saturation was beginning to emerge. Results Analyzing eleven consultations, we developed three main themes and twelve subthemes. The results depict decision-making guided by neurosurgeons (theme 1), with varying degrees of engagement from patients and family members (theme 2) and personalization of the decision-making process based on the medical situation and everyday life priorities (theme 3). The consultations lacked specific attention to the everyday life priorities of the patients. Conclusions The decision-making processes seemed to focus primarily on medically informing patients with a presumed brain tumor, in line with informed decision-making. However, less emphasis was placed on learning more about the patient’s everyday life and preferences to integrate into the decision-making process, which is key to SDM. Incorporating patient goals may lead to greater personalization and decisions that align with both the patient’s medical situation and their goals.

“I think we should wait and see”: A qualitative study of call-takers’ decision-making in consultations with patients suffering unrecognized myocardial infarction

ObjectivesCall-takers face a complex situation when assessing medical problems in emergency medical services calls. Patients with myocardial infarction experiencing atypical symptoms risk misinterpretation. We examined development in call-takers' decision-making process in telephone consultations with patients having imminent myocardial infarction. MethodsRecording of 38 calls among 19 patients (two per patient) who contacted Copenhagen Emergency Medical Services (Denmark) at least twice within one week before myocardial infarction diagnosis. The penultimate and last call were compared using qualitative content analysis. ResultsCall-takers’ assessment of the condition changed from symptom picture and dismissal of heart disease in penultimate call to severe condition, not heart-related, and possible heart disease in last call. Call-takers recommended watchful waiting in the penultimate call. Both calls involved response negotiation, while caution regarding misinterpretation was only seen in the penultimate call. ConclusionCall-takers used different decision-making approaches when the caller’s symptom descriptions appeared unclear and not corresponding with the medical understanding of severe conditions. Call-takers did not negotiate the condition's assessment but engaged in discussions about the response choice. Practice implicationsA protocol to negotiate response choice with callers having unclear clinical conditions should be developed. Clarifying watchful waiting as a recommendation may assist call-takers’ decision-making.

Development of a checklist for evaluation of shared decision-making in consultation for extremely preterm delivery.

Shared decision-making (SDM) between parents facing extremely preterm delivery and the medical team is recommended to develop the best course of action for neonatal care. We aimed to describe the creation and testing of a literature-based checklist to assess SDM practices for consultation with parents facing extremely preterm delivery. The checklist of SDM counseling behaviors was created after literature review and with expert consensus. Mock consultations with a standardized patient facing extremely preterm delivery were performed, video-recorded, and scored using the checklist. Intraclass correlation coefficients and Cronbach's alpha were calculated. The checklist was moderately reliable for all scorers in aggregate. Differences existed between subcategories within classes of scorer, and between scorer classes. Agreement was moderate between expert scorers, but poor between novice scorers. Internal consistency of the checklist was excellent (Cronbach's alpha = 0.93). This novel checklist for evaluating SDM shows promise for use in future research, training, and clinical settings.

More knowledge, more choices? How peer recognition of physicians' knowledge sharing affect patients' consultation in online health communities.

The advent of telemedicine has revolutionized healthcare consultations, primarily due to the digital era and global health concerns. Online healthcare communities (OHCs) have emerged as platforms for physicians to share health-related articles, promoting digital public health awareness and knowledge dissemination. The continuous dissemination of health knowledge by physicians online is considered a crucial driving force in attracting patients to seek online consultations. Based on the elaboration likelihood model and the information overload theory, this study explores how persuasive messages from other patients' peer recognition, including knowledge popularity and attractiveness, affect patients' consultation decisions. Additionally, the study examines the three-way interaction between knowledge popularity, attractiveness, and quantity in shaping patient consultations. Using data collected from 2,676 physicians on haodf.com, this study established an ordinary least squares (OLS) regression model with time and city fixed effects to test the hypothesis. The results show that: (1) peer recognition (knowledge popularity and attractiveness) from other patients positively impacts patients' consultation; (2) knowledge attractiveness positively moderate the relationship between knowledge popularity and patients' consultation; (3) there is a three-way effect of knowledge popularity, knowledge attractiveness, and knowledge quantity on patients' consultation. Our findings offer valuable guidance for platform design and healthcare practitioners, boosting patient-physician engagement in online healthcare communities.

Potential Bias in Social Work Consultations in the Pediatric Inpatient Setting.

Failure to thrive, brief resolved unexplained event, accidental ingestion, and drowning admissions commonly involve social work (SW) consultation. Care team biases likely influence SW consultation decisions. We examined whether SW consultations varied by patient race for these diagnoses. We conducted a retrospective cohort study of children <6 years of age admitted for failure to thrive, brief resolved unexplained event, accidental ingestion, and drowning between July 1, 2012 and June 30, 2020 at a single, academic, standalone children's hospital in an urban environment. The outcome was SW consultation; the predictor was patient race. We used multivariable logistic regression, adjusting for ethnicity, language, insurance, and diagnosis. We completed a supplemental chart review of a random sample of 10% of patients with SW consultation to determine the reasons that consultations were placed. We included 1199 unique patients; 64% identified as white, and 22% identified as Black. Black patients had 1.61 times higher adjusted odds of SW consultation compared with white patients (95% confidence interval 1.14-2.29). Publicly insured, compared with privately insured, patients had 6.10 times higher adjusted odds of SW consultation (95% confidence interval 4.28-8.80). Upon supplemental chart review, Black patients had SW consultations that focused more often on abuse, neglect, and safety; this was also found for publicly insured patients. There was parity in consultation for resource needs across groups. Black children were more likely than white children to receive SW consultation during hospitalization, as were publicly insured children compared with their privately insured peers; in supplemental review, this was not due to differences in consultations for resource needs. The standardization of SW consultation may promote equitable care.

Public Health Policy and Advocacy: A Management Perspective

The division of authority and accountability between the federal government and the states is one of the public health governance system's most significant advantages and concurrent problems. The policy management suggests that the best course of action is to develop institutional frameworks for consultative decision-making, allocate resources in an equitable manner, and implement policies in a coordinated manner. The proposed methods include improved fiduciary risk management, capacity building, technical support for state-specific strategic plans, active local self-government engagement, and community-based health output monitoring. The idea put forth in this paper is that HR rules, which are centred around the requirement that individuals with a background in public health management hold high positions in the field, should be tightened.

A Multi‐Criteria Decision Support Tool for Shared Decision Making in Clinical Consultation

ABSTRACTIn clinical consultation, Shared Decision Making (SDM) between the patient and clinician can inform the patient about available treatment options, likely harms and benefits in order to reach a joint decision that accommodates the patient's preferences. Multi‐Criteria Decision Analysis (MCDA) can be beneficial for this complex problem by offering systematic approaches to elicit preferences for multiple conflicting criteria and evaluate alternatives accordingly. We propose an online SDM tool based on MCDA to guide decisions in clinical consultation where there are multiple treatment options whose outcomes in different factors vary according to the patient. The tool was designed with a panel of domain experts and it enables rapid elicitation of patient preferences and clinician judgements. It is based on Preference Ranking Organization Method for Enrichment Evaluations II (PROMETHEE II) to produce a comprehensive evaluation of the options. The patient‐specific outcomes used in the SDM tool are derived from predictive machine learning models or published evidence. The tool was firstly qualitatively evaluated using a fictitious shoulder pain scenario with three focus groups of consultant and specialist physiotherapists. It was evaluated further with patients via structured interview format. The general response was positive; stating that the tool was informative about options and their performance in multiple criteria, and also useful in making a joint decision. The tool is ready to be incorporated into clinical care and evaluated by clinicians and patients in parallel with existing processes.

Conceptions of democracy in China: New evidence from the structural topic model

This article investigates popular conceptions of democracy and its underlying factors in China. Democratic conceptions among Chinese citizens have long been debated, with most concluding that economic welfare and government performance dominate how the Chinese view democracy. This article offers a different picture, with new evidence drawn from text data. By employing the structural topic model to analyze the responses to open-ended questions from three waves of the Asian Barometer Survey between 2008 and 2015, this article delineates four democratic conceptions prevalent among the Chinese populace, namely ‘Political Participation’, ‘Political Rights’, ‘Consultative Decision-making’ and ‘Socioeconomic Performance’. The analysis shows that political participation has become the most prominent conception, closely followed by political rights. This finding suggests a shift in the Chinese interpretation of democracy, aligning more closely with western procedural notions while still retaining distinct Chinese characteristics. In addition to rising demands for freedom and equality, informed respondents ask for deeper involvement in public affairs and higher inclusion in the decision-making process. These trends underscore the necessity for the Chinese authorities to more effectively address public demands, especially in the context of the ongoing endeavor to cultivate China’s new model of whole-process people’s democracy.

Conjoint Behavioral Consultation Research and Practice: Taking Stock and Looking Toward the Future

ABSTRACT Family engagement and family–school partnership interventions present significant opportunities to support students who experience identified disabilities or academic or social-emotional challenges. One intervention that brings families and educators together via a collaborative problem-solving process and joint decision-making consultation framework is Conjoint Behavioral Consultation (CBC). Decades of research has documented the efficacy of CBC for promoting positive outcomes for students through the relationship established between teachers and parents. Parent and teacher competencies and practices also improve significantly as a function of CBC. In this paper, we summarize recent research related to CBC’s efficacy for students with or at risk for developing disabilities, articulate important practices aimed at promoting and supporting collaborative partnerships, and lay out an agenda for future work.

Gender transformative innovation: Women's inclusion in livestock vaccine systems in northern Ghana

CONTEXTOwning livestock can support women's empowerment and progress toward gender-equitable agri-food systems. Gender inequality, however, can reduce women's ownership of livestock and access to animal vaccines. Gender accommodative approaches (GAAs), and more recently gender transformative approaches (GTAs), are increasingly implemented in development interventions. However, their impact on women's empowerment has not been systematically tested. Here, we describe the ‘Women Rear Project’, implemented in northern Ghana between 2019 and 2023, and assess the impact of GTAs and GAAs on women's empowerment, ownership of livestock, and access to animal vaccines. OBJECTIVEWe sought to systematically assess changes conferred by GAAs and GTAs on gender norms and women's empowerment and access to animal vaccines. METHODSUsing a mixed-methods approach, in 2021 and 2023 we collected quantitative and qualitative data regarding women's empowerment, gender norms, and access to animal vaccines. Qualitative data regarding women's and men's conceptualizations of gender norms and women's empowerment were obtained via focus group discussions and key informant interviews. Quantitative survey data were obtained from 500 households, using the Women's Empowerment in Livestock Index (WELI). Quantitative data on livelihood indicators were also collected, using the Rural Household Multi-Indicator Survey (RHoMIS) tool. We systematically assessed changes between baseline (2021) and endline (2023) in local conceptualizations of empowerment in the livestock sector, the effects of GTAs and GAAs on such conceptualizations, and how empowerment was experienced by women and men and the implications for women's access to animal vaccines. RESULTS AND CONCLUSIONLocal conceptualizations of empowerment in 2021, among both women and men, emphasized financial independence, decision-making autonomy, self-reliance, and problem-solving skills. In 2023, this conceptualization of empowerment had expanded to include the ability to act without external restrictions; women were empowered by managing resources, running successful businesses, and making decisions in consultation with their husbands. Furthermore, women in communities where GTAs had been enacted scored significantly higher in empowerment compared with women in communities where only GAAs had been introduced. Gender norms impacted empowerment indicators, with respect among household members and autonomy in income both contributing to disempowerment. Gender norms also affected respondents' reporting. Women's access to livestock vaccines was more positive in GTA/GAA communities. We recommend efforts are made to reduce restrictive gender norms and enhance women's empowerment and access to resources such as animal vaccines. SIGNIFICANCEWe offer recommendations for pathways toward women's empowerment and healthy livestock via inclusive innovations in agri-food systems.

INTEGRASI PERILAKU DAN KOMPETENSI KEPEMIMPINAN TRANSFORMASIONAL DALAM MENUNJANG KINERJA ORGANISASI ( Studi organisasi Kantor “x”)

Abstract. This case study explores the influence of transformational leadership style in facilitating innovation and synergy in an institution. Through the analysis of conceptual relationship diagrams among various operational elements within the organization, this study demonstrates how transformational leadership impacts decision-making processes, innovation, and competency enhancement. In this context, leadership acts not only as a decision maker but also as a motivator inspiring active participation and commitment from team members. The emphasis on consultation and coordination in decision-making illustrates the implementation of democratic practices supporting a collaborative and inclusive work environment. Furthermore, the study identifies innovation as a central pillar driving the institution to adapt to changes and meet the dynamic market needs. Initiatives such as the implementation of modern technology and new approaches in human resource management are illustrated as key components in the organization’s innovative strategy. The findings of this case study underscore that transformational leadership is effective in triggering organizational growth and sustainability by integrating innovation and collaboration. The implications of these findings provide important insights for other institutional leaders in designing leadership strategies that not only direct the organization to achieve its targets but also ensure ongoing adaptation and growth in a continually changing environment. This study offers valuable contributions to the literature on organizational leadership, particularly in the context of institutions operating in the era of globalization and digital transformation.

Clinical context and communication in shared decision-making about major surgery: Findings from a qualitative study with colorectal, orthopaedic and cardiac patients.

Increasing numbers of older people undergo major surgery in the United Kingdom (UK), with many at high risk of complications due to age, co-morbidities or frailty. This article reports on a study of such patients and their clinicians engaged in shared decision-making. Shared decision-making is a collaborative approach that seeks to value and centre patients' preferences, potentially addressing asymmetries of knowledge and power between clinicians and patients by countering medical authority with greater patient empowerment. We studied shared decision-making practices in the context of major surgery by recruiting 16 patients contemplating either colorectal, cardiac or joint replacement surgery in the UK National Health Service (NHS). Over 18 months 2019-2020, we observed and video-recorded decision-making consultations, studied the organisational and clinical context for consultations, and interviewed patients and clinicians about their experiences of making decisions. Linguistic ethnography, the study of communication and interaction in context, guided us to analyse the interplay between interactions (during consultations between clinicians, patients and family members) and clinical and organisational features of the contexts for those interactions. We found that the framing of consultations as being about life-saving or life-enhancing procedures was important in producing three different genres of consultations focused variously on: resolving problems, deliberation of options and evaluation of benefits of surgery. We conclude that medical authority persists, but can be used to create more deliberative opportunities for decision-making through amending the context for consultations in addition to adopting appropriate communication practices during surgical consultations.

Reducing use of seclusion on a male medium secure forensic ward

The reduction of restrictive practices is a priority for mental health inpatient services. Often such practices are considered to increase patients’ feelings of anger, loneliness, hopelessness and vulnerability. Moreover, such...

P830 The potential role of artificial intelligence in selecting the modality of biological therapy in patients with inflammatory bowel disease

Abstract Background Selecting an appropriate treatment strategy for inflammatory bowel disease (IBD) is an important task that can significantly alter the clinical course of the disease. Advanced artificial intelligence language models, such as ChatGPT, represent a potential future option that can assist practitioners. ChatGPT can help search the internet for medical facts by summarizing information from medical sources and providing concise explanations, simplifying the process of accessing and understanding medical information. Methods A ChatGPT-guided analysis of 89 IBD patients treated at the Clinical Department of Gastroenterology and Hepatology at University Medical Center "Zvezdara", Belgrade was conducted, considering further treatment with some biological drugs. A treatment modality proposal was obtained through communication with the interactive software ChatGPT (OpenAI, CA USA) and providing complete clinical and laboratory data. The alignment of decisions was analyzed, along with an assessment of treatment success in the group with matching and differing choices. Results In 72 patients (81%), there was concordance in the choice of therapy between ChatGPT and the medical consultation, while in 17 patients, ideas about the treatment approach differed. The most common difference in the choice of therapeutic modality related to the software's selection of ustekinumab compared to our choice of vedolizumab in patients with Crohn's disease who were not biologically naive, affecting seven patients with these characteristics. In 4 patients with severe ulcerative colitis, ChatGPT recommended using cyclosporine in combination with vedolizumab, contrary to the medical consultation's decision to use Anti-TNFα therapy. The group of patients in whom the artificial intelligence advice differed from the medical consultation was in a clinically more severe stage of the disease (CRP 10.4 vs. 9.1, p=0.0293), with worse endoscopic findings (proportion of severe endoscopic disease SES CD≥33/Mayo score&amp;gt;2, 53% vs. 24%, p=0.019). Taking into account the baseline differences in these patient groups, multiple analyses of covariance did not reveal a significant difference in the ultimate treatment outcome - proportions of endoscopic (p=0.773) and clinical remission (p=0.296) between patient groups. Conclusion The integration of advanced artificial intelligence language models may represent a future tactic with the potential to assist practitioners in making decisions about the treatment modality for IBD patients, but clinical experience should be considered.

Role of Intuition, Social Consultation, and Emotional Stability: Rethinking Economic Decision-Making

This research investigates the role of intuition, social consultation, and emotional stability in economic decision-making. Such research always questions the existing models on rational- agent models. While adopting the cross-sectional approach that compares two different age groups adults (18-25 years) and adults (26-45 years)-the way cognitive biases, emotions, and social influences actually shape choices in economic decision-making was examined. In this research, a quantitative research approach was used after collecting data using structured surveys and exploring them using regression and correlation analysis. The key findings of this research suggest that the majority of the sample population makes use of intuitive and heuristic- based strategies, especially when situations present uncertainty. Findings also come in line with behavioral economic theories such as Prospect Theory and Social Influence Theory. In a nutshell, it was discovered that emotional factors as well as social validation are significant in framing decision-making behaviors, and further, economic models must account for these non- rational influences to provide a richer understanding of human behavior in an economic context. This research fits into the discussion on behavioral economics by shedding light on psychological elements in economic decisions and their implications on policy design.

Ultrasonographic and clinicopathological features of pelvic yolk sac tumors in women: a single-center retrospective analysis.

Yolk sac tumors (YSTs) are rare and highly malignant ovarian malignancies that have a very poor prognosis. The aim of this study is to delineate the ultrasound and clinicopathological features of female pelvic YSTs to better understand the disease. This study was a retrospective analysis of the clinicopathological and ultrasound imaging data from 16 YST patients who received treatment at our hospital between January 2012 and August 2023. Then, the ultrasound imaging characteristics were compared with pathological findings. Among the 16 patients, various degrees of serum AFP increase were observed, and CA125 levels increased in 58.33% (7 out of 12) of patients. Thirteen patients (81.25%) had tumors located in ovary, two patients (12.5%) had tumors located in the sacrococcygeal region, and one patient (6.25%) had tumors located in the mesentery. Pathologically, nine patients presented with simple yolk sac tumors and seven with mixed germ cell tumors. According to the ultrasound manifestations, YST lesions can be classified into three types. (1) the cystic type, was diagnosed in two patients who presented with a large cystic mass with regular morphology and clear boundary and dense liquid within the cyst; and (2) the cystic-solid mixed type, was diagnosed in 4 patients. On 2D ultrasound, the lesions showed a cystic-solid mixed echo, and color Doppler showed a rich blood flow signal in the solid region and cystic separation. made up of four cases. (3) In ten patients with the solid type, 2D ultrasound showed solid uniform echoes with clear boundaries. The "fissure sign" was observed in the lesion. Color Doppler displayed rich blood flow in the solid part, and PW showed low to moderate resistance index of artery (RI:0.21-0.63). On contrast-enhanced ultrasound (CEUS), rapid and high enhancement in the solid part and cystic separation was observed in 2 patients. Combining ultrasound features with clinical information and tumor markers provides reliable clues for the diagnosis of YST. The application of two-dimensional ultrasound and CEUS combined with patient tumor marker levels can provide a robust reference for determining the necessity of fertility-preserving surgery and postoperative chemotherapy, which can improve clinical decision-making and patient consultation.

Implementation of School-Based Management at SD GMIM KOHA

This study aims to explore the implementation of school-based management in GMIM Ko Elementary School. The main focus of this study is the role played by school principals, school committees, and education commissions in managing and improving the quality of education in those schools. This study used a qualitative approach by adopting Miles and Huberman data analysis techniques. The data collection method involved in-depth interviews with principals, school committee members, and education commission members. Direct observation is also conducted to understand the dynamics of interaction between the three parties in the context of decision making and implementation of school-based management programs. The results of the study are expected to provide a clear picture of how principals, school committees and education commissions collaborate to achieve school-based management goals at GMIM Ko Elementary School. The implications of these research findings can be used as a basis for improving school-based management policies and practices in similar schools as well as contributing to the literature on the implementation of school-based management. Based on the results of the study revealed differences in understanding of the concept of School Based Management among school principals, education committees and education commissions. School principals focus more independently on managing resources, while education committees and commissions emphasize comprehensive management. This incomprehension can hinder SBM implementation, so training and modules are needed to improve understanding of concepts. Regarding the role of the principal, it is necessary to improve as educators, supervisors, and managers involving all stackholders. School committees need a greater focus on academic programs, while education committees play an important role as mediators and patrons of school ptograms. Obstacles to SBM implementation involve coordination constraints, lack of effective communication and busy stakeholders. Solutions include improved communication, understanding of roles and a culture of cooperation. The principal's proactive strategy with direct monitoring, limited consultation, efficient communication and quick decision making, plays a vital role in ensuring the effectiveness of SBM. This approach demonstrates pragmatism and flexibility in managing resources to achieve school goals.

Survival After Wait-and-See Approach in Older Patients With Unexplained Iron Deficiency Anemia in Primary Care: A Practice Evaluation

ObjectivesGuidelines recommend upper and lower gastrointestinal endoscopic evaluation for patients without a clear physiological explanation for iron deficiency anemia (IDA). However, the consequences of watchful waiting in older patients with unexplained IDA in general practice are unknown. The aim of this study was to investigate characteristics and survival of patients with an unexplained IDA in general practice who refrain from medical specialist evaluation. DesignHistorical prospective study. Setting and ParticipantsPatients aged ≥70 years with IDA coded in their medical records were selected from the Dutch Academic General Practitioner Development Network (AHON) database. MethodsBased on their medical records, patients with an unexplained IDA were classified as (1) referred for medical specialist evaluation, or (2) no or noninvasive evaluation in general practice. ResultsCompared to patients who were referred for medical specialist evaluation (n = 235, 47.8%), patients who had no or noninvasive evaluation (n = 257; 52.5%) were older (median respectively 79 vs 82 years old, P < .01) and more likely to have congestive heart failure (respectively 17.4% and 26.1%, P = .02) and dementia (respectively 2.6% and 8.9%, P < .01). Two-year survival was significantly higher in patients who were referred for medical specialist evaluation compared to patients who had no or noninvasive evaluation (respectively, 83.9% and 75.5%, P = .02). Conclusions and ImplicationsAlthough mortality was significantly higher in the older and more comorbid patients who had no or noninvasive evaluation in general practice, survival was still high in this patient group. Therefore, non–guideline adherence and a wait-and-see approach could be discussed in a shared–decision-making consultation.

Revision of Malawi’s Health Benefits Package: A Critical Analysis of Policy Formulation and Implementation

ObjectivesHealth benefits packages (HBPs), which define specific health services that can be offered for free or at a reduced cost to fit within public revenues, have been recommended for over 30 years to maximize population health in resource-limited settings. However, there remain gaps in defining and operationalizing HBPs. We propose a combination of design and prioritization methods along with practical strategies to improve the implementation of future iterations of the HBP in Malawi. MethodsFor HBP development for Malawi’s Third Health Sector Strategic Plan, we combined cost-effectiveness analysis with a quantitative, consultative multicriteria decision analysis. Throughout the process of development, we documented challenges and opportunities to improve HBP design and application. ResultsThe primary and secondary HBP included 115 interventions. However, the definition of an HBP is just one step toward focusing limited resources, with functional operationalization as the most critical component. Full implementation of previous HBPs has been limited by challenges in aid coordination with the misalignment of nonfungible vertical donor funding for the HBP without accounting for the complexity and interconnectedness of the health system. Opportunities for improved application include creation of a complementary minimum health service package to guide overall resource inputs through an integrative approach. ConclusionsWe believe that expanded participatory HBP methods that consider value, equity, and social considerations, along with a shift to providing integrated health service packages at all levels of care, will improve the efficiency of using scarce resources along the journey to universal health coverage.