Prioritization Practices Research Articles

Surgical waitlist management: Perspectives from surgeons on surgical prioritization at a paediatric hospital.

Globally exacerbated surgical waitlists have provided the opportunity to reflect on prioritization and resource allocation decisions. The unique circumstances of paediatric surgery and consequences of surgical delay prompted the study reported in this paper. As part of a larger project to attend to prioritization in our surgical waitlists, we conducted a Quality Improvement study, the purpose of which is to understand surgeon's perspectives regarding the ethical and practical realities of surgical prioritization at our institution. The study comprises semi-structured interviews with nine full-time paediatric surgeons from a variety of subspecialties conducted at our institution, which is a tertiary paediatric hospital with ten surgical subspecialties in a publicly funded healthcare system. Participants articulated how they prioritize their waitlists, and how they understand ethical prioritization. These findings resonate with the growing public concern for ethical practice in healthcare delivery and transparency in prioritization and resource allocation practices. Specifically, more transparency, consistency, and support is required in prioritization practices. This work highlights the importance of institutional dialogue regarding surgical case prioritization. Because quality improvement work is necessarily site-specific, concrete generalizations cannot be offered. However, the insights gleaned from these interviews and the process by which they were gleaned are a valuable knowledge-sharing resource for any institution that is interested in ongoing quality improvement work. The objectives here were to clarify the goals of prioritization within the institution, improve prioritization practices, and make them more ethical and transparent.

Prioritizing Use Cases: A Systematic Literature Review

The prioritization of software requirements is necessary for successful software development. A use case is a useful approach to represent and prioritize user-centric requirements. Use-case-based prioritization is used to rank use cases to attain a business value based on identified criteria. The research community has started engaging use case modeling for emerging technologies such as the IoT, mobile development, and big data. A systematic literature review was conducted to understand the approaches reported in the last two decades. For each of the 40 identified approaches, a review is presented with respect to consideration of scenarios, the extent of formality, and the size of requirements. Only 32.5% of the reviewed studies considered scenario-based approaches, and the majority of reported approaches were semiformally developed (53.8%). The reported result opens prospects for the development of new approaches to fill a gap regarding the inclusive of strategic goals and respective business processes that support scenario representation. This study reveals that existing approaches fail to consider necessary criteria such as risks, goals, and some quality-related requirements. The findings reported herein are useful for researchers and practitioners aiming to improve current prioritization practices using the use case approach.

PRIORITIZACIJA DIONIKA U UPRAVLJANJU KOMUNIKACIJOM S OBZIROM NA FINANCIJSKI RIZIK POSLOVANJA

Contemporary approach to risk management implies a stakeholder analysis in accordance with stakeholders’ influence on risk initiation along with their influence on risk outcomes. Communication with stakeholders/publics plays an important role in overall risk management. In the frame of wider implementation of stakeholder theory, it becomes a common practice to create different communication strategies that aim to the key stakeholders. From the point of stakeholder approach, risk analysis implies an assessment of stakeholders’ influence on financial stability of the business, or more generally, on reputation loss. In the given context, stakeholder analysis is a precondition for risk management as well as for creating risk communication strategies. A stakeholder prioritization approach to the risk communication is based on the managerial assessments of stakeholders’ importance in the risk situations. The main goal of this research was to provide an insight in the managerial communication practice with stakeholders in situations of financial risk. The risk communication management was explored using several criteria for stakeholders’ prioritization in risk situations: stakeholders’ actions or power linked to the risk situation, stakeholders’ legitimacy to demand communication/information about risk situations, urgency of response on stakeholders’ demand for communication/information about risk situations. Research was conducted using an online questionnaire method on the sample of managers from companies headquartered in the Federation of Bosnia and Herzegovina. From the results it can be concluded that company size is the variable with the greatest influence on managerial stakeholders’ prioritization and communication practice with different stakeholders in the situation of financial risk.

Referral Prioritization in Home Care Occupational Therapy: A Matter of Perspective.

Background.Prioritizing referrals for home care occupational therapy is somewhat subjective, and public and patient perspectives on waiting list priorities are unknown.Purpose.To explore the views of home care occupational therapists (OTs), older persons (OPs) and adults with disabilities on waiting list priorities, as well as issues and challenges underlying these priorities.Method.We conducted in-depth interviews with 11 OTs, 10 OPs and 9 adults with disabilities. Participants were asked to prioritize referral scenarios while explaining their choices. Directed and conventional content analysis allowed the identification of themes for each group of participants.Findings.OTs experienced conflicts of values but mainly prioritized referrals based on client safety. OPs sought to maximize client’s independence, and persons with disabilities aimed to improve clients’ social participation.Implications.OTs should seek the perspectives of their target clientele on referral prioritization criteria and strive to adjust prioritization practices accordingly.

Identifying targets of potential concern by a screening level ecological risk assessment of human use pharmaceuticals in China

The pollution of pharmaceuticals has attracted a lot of concerns during recent years. The goal of this study was to identify targets of ecological concern considering human use pharmaceuticals marketed in China. We constructed a database for 593 active pharmaceutical ingredients (APIs) by collecting their information on use and emission (e.g. production, human excretion, and removal by wastewater treatment) to calculated predicted environmental concentrations (PECs) by using an adapted European Medicines Agency method. PECs were comparable to the reported measurements for most APIs, demonstrating that the adapted method is reliable for the prioritization practice. Then PECs were compared to toxicity thresholds of three aquatic taxa (algae, daphnia, and fish). As a result, a total of 31 APIs, which were potentially risky and should be taken into consideration in future studies, were identified. Three APIs would pose a high risk with risk quotient (RQ) greater than 10. Six APIs were identified with moderate risks (1 < RQ < 10), and four of them were not reported before: rifaximin, griseofulvin, amikacin, and niclosamide. Of the 22 APIs with low risks (0.1 < RQ < 1), 17 have never been monitored previously in China and even worldwide. This study has yielded some probable antibiotics that should be considered as monitoring targets in China in the future.

Agile Requirements Prioritization in Practice: Results of an Industrial Survey

Abstract Agile software development stresses the importance of providing the customer with a product of a maximized business value. To achieve that, requirements prioritization is used. Agile development methods like Scrum define guidelines for prioritization, however practitioners do not necessarily have to follow them. Our goal was to investigate the industry practice related to requirements prioritization process, including its timing, participants, criteria used and prioritization techniques applied. We designed an on-line questionnaire (based on literature review) and conducted a survey involving practitioners from Polish IT industry. We received 69 valid responses indicating requirements prioritization practices in industrial Agile projects. We found out that despite the fact that business value is the most common criterion used to prioritize requirements, other criteria like complexity, stability and mutual interdependencies are considered as well. Other findings indicate that consideration of such multiple criteria requires different viewpoints, thus making requirements prioritization a process that has to involve many participants of different roles and competencies.

Prioritization of Referrals in Outpatient Physiotherapy Departments in Québec and Implications for Equity in Access

In the context of long waiting time to access rehabilitation services, a large majority of settings use referral prioritization to help manage waiting lists. Prioritization practices vary greatly between settings and there is little consensus on how best to prioritize referrals. This paper describes the prioritization processes for physiotherapy services in Québec and its potential implications in terms of equity in access to services. This is a secondary analysis of a survey of outpatient physiotherapy departments (n=98; proportion of participation was 99%) conducted in 2015 across publicly funded hospitals in Québec. In many settings, persons with acute orthopaedic conditions were prioritized while chronic conditions were given a lower priority. There were 72 different combinations of prioritization criteria used in outpatient physiotherapy departments. Variability was also observed in the type of personnel involved in the prioritization process, the number of priority levels used to rank the referrals and the source of information used to prioritize referrals. These results highlight potential issues regarding equity in access to physiotherapy services: the prioritization of persons with acute conditions to the detriment of those with chronic conditions, the lack of consensus on a fair prioritization process and the importance to adequately assess patients’ needs for treatment. Further research and interventions on prioritization criteria and processes are needed to ensure equitable access to physiotherapy services, especially in the public sector.

Medium-Range Narratives as a Complementary Tool to Principle-Based Prioritization in Sweden: Test Case \u201cADHD\u201d

In this paper, for the benefit of reflection processes in clinical and in local, regional, and national priority-setting, we aim to develop an ethical theoretical framework that includes both ethical principles and medium-range narratives. We present our suggestion in the particular case of having to choose between treatment interventions for attention deficit hyperactivity disorder (ADHD) and treatment interventions for other conditions or diseases, under circumstances of scarcity. In order to arrive at our model, we compare two distinct ethical approaches: a generalist (principles) approach and a particularist (narratives) approach. Our focus is on Sweden, because in Sweden prioritization in healthcare is uniquely governmentally regulated by the “ethics platform.” We will present a (fictional) scenario to analyse the strengths and weaknesses of the generalist principled perspective of the ethics platform and the particularist perspective of narrative ethics. We will suggest an alternative (moderately particularist) approach to prioritization, which we dub a “principles plus medium-range narratives” approach. Notwithstanding the undeniably central role of principles in distributive justice, we claim that medium-range narratives concerning individuals or groups who stand to benefit or lose from ADHD prioritization practices should also be read or listened to and taken into account at all levels of priority-setting. These narratives are expected to ethically optimize clinical priority-setting, as well as that undertaken at local, regional, and national levels.

Sustainable Disaster and Safety Management of Government: Integrated Disaster and Safety Budget System in Korea

The budget for disaster and safety management can be characterized as a large-scale public asset in which the government has a significant role. However, this budget has been managed in a somewhat scattered and inconsistent manner by different government ministries, until the Sewol ferry incident in Korea 2014. After the Sewol incident, the Ministry of Public Safety and Security has introduced a prior consultation system for budget allocation in the field of disaster and safety management, so that the budget can be reviewed in a holistic manner, effectively managed, and invested according to agreeable priorities. This study introduces the prior consultation system for the budget in disaster and safety management, which has been implemented since 2015, analyzes budget allocation procedures, and provides possible solutions to improve the current status of the prior consultation system for classification and prioritization. (1) The issues that were found in the budget plans for the fiscal years of 2016 to 2017 are, firstly, unclear classification criteria that made it hard to differentiate much more disaster-related programs and projects from less-related ones. Secondly, investment priorities of projects and programs for disaster and safety management are controversial, due to the lack of objective standards and procedures. To firmly settle down the prior consultation system, several possible solutions to these two main issues are suggested. (2) To improve actual budget classification, the current classification system needs to be reviewed at first, and social issues will be analyzed to be included as a criterion and, finally, authors will propose additional criteria and items based on the Disaster and Safety Management Framework Act. In order to improve prioritization procedures for budget allocation, disaster damage and loss are compiled to find implications and other related prioritization practices, such as prioritization in natural disaster-prone area improvement programs, which need to be analyzed to provide suggestions on improvement in prioritization. Through the proposed improvement of the classification system, projects that are not related to disaster safety are not included in the disaster safety project. Projects that are deeply related to disaster safety can be further explored. It is also recommended that an investment direction be established in consideration of damage characteristics through the investment priority improvement plan, and that qualitative assessment criteria should be considered in the criteria for similar projects, and weights should be required. The improvement measures derived can be used as follows: the scale can be clearly identified by clarifying the subject of the disaster safety budget. This gives a sense of where investment is lacking, and where it is sufficient. Investment priority is reviewed in a variety of ways, preventing budgetary bias in advance. As a result, these two improvements enable efficient operation of the disaster safety budget.

The influence of a “green” loyalty program on service encounter satisfaction

PurposePresently, loyalty programs often offer preferential treatment to the firm’s best customers, and recently, service firms started to incorporate corporate social responsibility (CSR) initiatives into the loyalty reward programs (e.g. Starwood’s “Make A Green Choice”). However, academic research advancing the understanding of the effectiveness of CSR-focused loyalty programs is lacking. To bridge that gap, this paper aims to examine the influence of a “green” loyalty program on members’ and bystanders’ service encounter satisfaction in light of preferential treatment. Furthermore, this paper investigates the psychological mechanisms (prosociality perceptions and status perceptions) that underlie these effects.Design/methodology/approachThis study used a 2 (loyalty program: green vs standard) × 2 (customer type: member vs bystander) × 2 (observability of preferential treatment: low vs high) between-subjects experimental design. Respondents were asked to read a hotel check-in scenario and then completed scales that measured their perceptions and evaluations of the service encounter.FindingsResults from this study suggest that a green loyalty program can buffer the negative effect of preferential treatment on bystanders’ service encounter satisfaction. An examination of the underlying mechanism reveals that prosociality perceptions of the firm mediate the impact of loyalty programs on bystanders’ satisfaction. As expected, the results show that a green loyalty program is as effective as a standard program in elevating members’ satisfaction. Furthermore, findings from a moderated mediation analysis indicate that status perceptions mediate the impact of customer type on satisfaction. However, status perceptions have a greater leveraging power in satisfaction when observability of preferential treatment is high.Originality/valueThe results of this study have significant implications for service firms with loyalty programs and customer prioritization practices. By incorporating CSR into their loyalty programs, firms may be able to mitigate the negative bystander effect while maintaining the positive effects of preferential treatment on members’ service encounter satisfaction.

Leveraging ecological theory to guide natural product discovery.

Technological improvements have accelerated natural product (NP) discovery and engineering to the point that systematic genome mining for new molecules is on the horizon. NP biosynthetic potential is not equally distributed across organisms, environments, or microbial life histories, but instead is enriched in a number of prolific clades. Also, NPs are not equally abundant in nature; some are quite common and others markedly rare. Armed with this knowledge, random 'fishing expeditions' for new NPs are increasingly harder to justify. Understanding the ecological and evolutionary pressures that drive the non-uniform distribution of NP biosynthesis provides a rational framework for the targeted isolation of strains enriched in new NP potential. Additionally, ecological theory leads to testable hypotheses regarding the roles of NPs in shaping ecosystems. Here we review several recent strain prioritization practices and discuss the ecological and evolutionary underpinnings for each. Finally, we offer perspectives on leveraging microbial ecology and evolutionary biology for future NP discovery.

Updating conservation priorities over 111 years of species observations

Observations of species occurrences are often used to inform spatial prioritizations for the effective use of limited conservation resources. Additional species observations have the potential to change where a conservation group plans to invest. But by how much? How different would conservation priorities be if planners updated current observations with the information they will have next year? We sought to address these questions using a 111-year data set that reflects commonly used collection and prioritization practices. We quantify changes in the ranking of Tennessee watersheds brought on by annual additions of species observations made between 1900 and 2010. We ranked watersheds by their complementary contribution to overall species richness. We examine the sensitivity of our results to the number of watersheds prioritized. We expected the effect of new observations to diminish as the data set grew, and we found this to be the case. Importantly, however, additional observations may continue to significantly change conservation priorities in the future if current data collection trends continue. We found that, overall, additional observations can greatly affect priorities and that this result is sensitive to the number of watersheds ranked. Thus, the extent of planning activities moderates the effect of including additional data. Synthesis and applications. Long-term, opportunistically collected data of species locations are commonly used in conservation planning. We find that when using such data, additional species observations significantly affect subsequent priorities. This effect is most pronounced when data are sparse. As such, data collection should be a focus of very early conservation actions in new areas. Even in well-studied areas, however, additional observations may continue to change spatial priorities into the future, and so while data collection can decrease in well-studied areas, it should continue at a lower intensity. Our methods could also be used to determine the balance of data collection and conservation action in a new location.

Optimized spatial priorities for biodiversity conservation in China: a systematic conservation planning perspective.

By addressing several key features overlooked in previous studies, i.e. human disturbance, integration of ecosystem- and species-level conservation features, and principles of complementarity and representativeness, we present the first national-scale systematic conservation planning for China to determine the optimized spatial priorities for biodiversity conservation. We compiled a spatial database on the distributions of ecosystem- and species-level conservation features, and modeled a human disturbance index (HDI) by aggregating information using several socioeconomic proxies. We ran Marxan with two scenarios (HDI-ignored and HDI-considered) to investigate the effects of human disturbance, and explored the geographic patterns of the optimized spatial conservation priorities. Compared to when HDI was ignored, the HDI-considered scenario resulted in (1) a marked reduction (∼9%) in the total HDI score and a slight increase (∼7%) in the total area of the portfolio of priority units, (2) a significant increase (∼43%) in the total irreplaceable area and (3) more irreplaceable units being identified in almost all environmental zones and highly-disturbed provinces. Thus the inclusion of human disturbance is essential for cost-effective priority-setting. Attention should be targeted to the areas that are characterized as moderately-disturbed, <2,000 m in altitude, and/or intermediately- to extremely-rugged in terrain to identify potentially important regions for implementing cost-effective conservation. We delineated 23 primary large-scale priority areas that are significant for conserving China's biodiversity, but those isolated priority units in disturbed regions are in more urgent need of conservation actions so as to prevent immediate and severe biodiversity loss. This study presents a spatially optimized national-scale portfolio of conservation priorities – effectively representing the overall biodiversity of China while minimizing conflicts with economic development. Our results offer critical insights for current conservation and strategic land-use planning in China. The approach is transferable and easy to implement by end-users, and applicable for national- and local-scale systematic conservation prioritization practices.

Prioritization Model for Rehabilitation of Public School Buildings in California

The condition of the nation's kindergarten through 12th (K-12) grade public school buildings is considered to be in bad shape. To bring back the condition of the American K-12 schools to an acceptable level, it is estimated that about $320 billion may be required. As a starting effort, $40 billion was allocated by the Federal Government to improve the current condition of public school buildings. To properly manage the expenditure of this fund, a prioritization system is required. Existing school prioritization systems in the State of California are based on the subjective judgment of decision-makers and their manual interpretation and manipulation of data collected by their subordinates. This current prioritization practice lacks a structured methodology that rationalizes its outcomes. It may also lead to misleading conclusions, and accordingly, misuse of available resources, especially in challenging cases where the conditions of multiple school buildings may be very similar. This article presents a computer-based prioritization system for the rehabilitation of school buildings in the State of California. The system augments the current school condition data collection process, uses the experience of industry experts, and assists in allocating rehabilitations funds in a rational manner that assures addressing the most deteriorated schools.

Agile requirements prioritization in large-scale outsourced system projects: An empirical study

The application of agile practices for requirements prioritization in distributed and outsourced projects is a relatively recent trend. Hence, not all of its facets are well-understood. This exploratory study sets out to uncover the concepts that practitioners in a large software organization use in the prioritization process and the practices that they deem good. We seek to provide a rich analysis and a deep understanding of three cases in an exploratory study that was carried out in a large and mature company, widely recognized for its excellence and its engagement in outsourced software development. We used in-depth interviews for data collection and grounded theory techniques for data analysis. Our exploration efforts yielded the following findings: (i) understanding requirements dependencies is of paramount importance for the successful deployment of agile approaches in large outsourced projects. (ii) Next to business value, the most important prioritization criterion in the setting of outsourced large agile projects is risk. (iii) The software organization has developed a new artefact that seems to be a worthwhile contribution to agile software development in the large: ‘delivery stories’, which complement user stories with technical implications, effort estimation and associated risk. The delivery stories play a pivotal role in requirements prioritization. (iv) The vendor's domain knowledge is a key asset for setting up successful client-developer collaboration. (v) The use of agile prioritization practices depends on the type of project outsourcing arrangement. Our findings contribute to the empirical software engineering literature by bringing a rich analysis of cases in agile and distributed contexts, from a vendor's perspective. We also discuss the possible implications of the results for research and in practice.

Analysis of the aetiology of diarrhoea in outpatients in 2007, Henan province, China

The purpose of this study was to determine the aetiology of acute diarrhoea and improve knowledge of gastrointestinal pathogens in China. Faecal specimens from 1526 outpatients with diarrhoea were collected from 20 hospitals in Henan province and the prevalence of seven bacterial and five viral diarrhoeagenic pathogens were determined. Bacterial pathogens were recovered from 279/1526 (18·3%) stool specimens and viral pathogens were detected in 178/1526 (11·7%) stool specimens. The top five pathogenic species were diarrhoeagenic E. coli (n = 140, 9·2%), rotavirus (n = 79, 5·2%), Shigella spp. (n = 69, 4·5%), Salmonella spp. (n = 66, 4·3%) and norovirus (n = 56, 3·7%). The prevalence of pathogens showed correlation with age, season and clinical symptoms. Several dominant serotypes were identified in Shigella and Salmonella isolates, and high prevalence of multiple drug-resistant isolates was observed in both species. This important information will have a significant effect on public health policy development and resource prioritization practices.

Collaborative prioritization of architectural concerns

Efficient architecture work involves balancing the degree of architecture documentation with attention to needs, costs, agility and other factors. This paper presents a method for prioritizing architectural concerns in the presence of heterogeneous stakeholder groups in large organizations that need to evolve existing architecture. The method involves enquiry, analysis, and deliberation using collaborative and analytical techniques. Method outcomes are action principles directed to managers, and assessment of user needs directed to architects, along with evidence. The method results from 4 years of action research at Ericsson AB with the purpose of adding missing views to architecture documentation and removing superfluous ones. It is illustrated on a case where 29 senior engineers and managers within Ericsson prioritized 37 architectural concerns areas to arrive at 8 action principles, 5 prioritized improvement areas, and 24 improvement suggestions. Feedback from the organization is that the method has been effective in prioritizing architectural concerns, that data collection and analysis is more extensive compared to traditional prioritization practices, but that extensive analysis seems inevitable in architecture improvement work.

Procurement of Human Tissues for Research Banking in the Surgical Pathology Laboratory: Prioritization Practices at Washington University Medical Center

Academic hospitals and medical schools with research tissue repositories often derive many of their internal human specimen acquisitions from their site's surgical pathology service. Typically, such acquisitions come from appropriately consented tissue discards sampled from surgical resections. Because the practice of surgical pathology has patient care as its primary mission, competing needs for tissue inevitably arise, with the requirement to preserve adequate tissue for clinical diagnosis being paramount. A set of best-practice gross pathology guidelines are summarized here, focused on the decision for tissue banking at the time specimens are macroscopically evaluated. These reflect our collective experience at Washington University School of Medicine, and are written from the point of view of our site biorepository. The involvement of trained pathology personnel in such procurements is very important. These guidelines reflect both good surgical pathology practice (including the pathologic features characteristic of various anatomic sites) and the typical objectives of research biorepositories. The guidelines should be helpful to tissue bank directors, and others charged with the procurement of tissues for general research purposes. We believe that appreciation of these principles will facilitate the partnership between surgical pathologists and biorepository directors, and promote both good patient care and strategic, value-added banking procurements.

Etiology of Diarrhea in Young Children and Patterns of Antibiotic Resistance in Cambodia

Little is known about diarrhea etiology and antibiotic resistance in developing countries where diarrhea is a major public health problem. To describe diarrhea etiology and antibiotic resistance patterns in Cambodia, 600 children aged 3 months to 5 years with acute diarrhea (cases) and 578 children without diarrhea (controls) were enrolled from a hospital in Phnom Penh. Stool samples were collected, and pathogens and antibiotic resistance patterns were described. The most frequently isolated pathogens in these cases were enteroaggregative Escherichia coli (20%) and rotavirus (26%). Enterotoxigenic E. coli, enteroaggregative E. coli, Shigella, Aeromonas, rotavirus, and adenovirus were statistically significantly associated with diarrhea. Among cases, vomiting was associated with viral infections, whereas bloody stool was associated with Shigella. Enterotoxigenic E. coli isolates were highly resistant to ampicillin, sulfonamides, and tetracycline. Approximately 50% of Campylobacter coli and 30% of Campylobacter jejuni isolates were resistant to nalidixic acid and ciprofloxacin. Over 33% of Salmonella isolates were resistant to ampicillin and tetracycline, and almost 100% of Shigella isolates were resistant to trimethoprim/sulfamethoxazole. These data on the etiology of diarrhea and antibiotic resistance patterns in Cambodia will have significant effect on local public health policies and on local resource prioritization practices.

Prioritization and patients' rights: Analysing the effect of a reform in the Norwegian hospital sector

The right to equal treatment, irrespective of age, gender, ethnicity, socio-economic status and place of residence, is an important principle for several health care systems. A reform of the Norwegian hospital sector of 2002 may be used as a relevant experiment for investigating whether centralization of ownership and management structures will lead to more equal prioritization practices over geographical regions. One concern was variation in waiting times across the country. The reform was followed up in subsequent years by some other policy initiatives that also aimed at reducing waiting lists. We measure prioritization practice by a method that takes departure in recommended maximum waiting times from medical guidelines. We merge the information from the guidelines with individual patient data on actual waiting times for the period 1999-2005. This way we can monitor whether each patient in the available register of actual hospital visits has waited shorter or longer than what is considered medically acceptable by the guideline. The results indicate no equalization between the five new health regions, but we find evidence of more equal prioritization within four of the health regions. Our method of measuring prioritizations allows us to analyse how prioritization practice evolved over time after the reform, thus covering some further initiatives with the same objective. The results indicate that an observed reduction in waiting times after the reform have favoured patients of lower prioritization status, something we interpret as a general worsening of prioritization practices over time.