Priority Setting Research Articles

O-175 Ethical practices and policies for ART carbon reduction

Abstract Background The carbon emissions of global health care activities make up 4-5% of total world emissions, placing the health care industry on par with the food sector. Health care contributes to climate change and climate change health hazards. Safe amounts of carbon in the atmosphere have been exceeded—in part because of medical lifestyles in the industrialized world. A significant proportion of health care carbon comes from pharmaceuticals and clinical services in the developed world, including reproductive technologies. Since 1978, approximately 12 million babies have been born through IVF alone. Problem statement Reproductive technologies have an exceptional impact on the environment as they 1. expend carbon in the medical process, 2. increase population growth in mostly high-carbon countries, 3. impact earth’s carrying capacity, and 4. create a carbon legacy. This would not necessarily be ethically problematic, but in a climate crisis carbon emissions must be reduced in all areas of life. Objectives This presentation by an ethicist (PhD) will: 1. Highlight aspects of environmental ethics for reproductive technologies 2. Offer practices and policies to make reproductive technologies more sustainable. Takeaways • Prevention of infertility fits within basic health care. • Carbon emissions from reproductive technologies can be reduced by life cycle assessments (LCA) of the procedures and components. • Clinical evidence can inform ethical policies to reduce the number and kind of reproductive technologies, thereby lowering fertility industry carbon emissions. • New scientific and technological developments in reproduction must consider sustainability proactively, not reactively, thus putting ethics in the pipeline of reproductive medicine. Further Reading Bhopal A, and Norheim O. Priority setting and net zero healthcare: how much health can a tonne of carbon buy?. BMJ 2021; 375:e067199. Pichler, P.-P. et al., “International Comparison of Health Care Carbon Footprints,” Environmental Research Letters 14, no. 6 (2019): 064004. Richie, Cristina. Environmental Ethics and Medical Reproduction (Oxford University Press, 2024.

531 Research Priorities for Oesophageal Cancer : Results from a Priority Setting Partnership

Abstract Aim Oesophageal cancer is the seventh most common cancer worldwide and the sixth leading cause of cancer-related deaths, and it remains one of the hardest cancers to treat. Despite advances in the last decade, oesophageal cancer still has high morbidity and mortality burdens, and further research is needed to improve those outcomes. The aim of the Priority Setting Partnership was to bring together patients, family, caregivers, and the multidisciplinary healthcare team to identify and prioritise the most important unanswered questions for future research. Method Following the James Lind Alliance methodology, different stakeholders were asked to list their uncertainties about oesophageal cancer, which were then checked against existing evidence, categorised, and formed into questions. These then went through a survey for interim ranking, and those shortlisted were discussed at a final workshop to identify the Top 10 unanswered research questions. Results 230 responders to the initial survey, two-thirds of which were patients, revealed 365 uncertainties. After removing duplicates and previously answered questions, sixty-three remained for interim ranking, and twenty-five were shortlisted for the workshop. Participants agreed on their Top 10 priorities, which covered topics such as prevention, current and novel treatment options, nutrition, survivorship concerns, and risk factors for developing oesophageal cancer, particularly at a young age. Conclusions Patients, family members, carers, and healthcare professionals collaborated to identify the most important questions for oesophageal cancer research. The results can help direct funding and attention to the shared priorities of those with personal experiences living with and providing care for oesophageal cancer.

Dementia in-patient units in psychiatric hospitals: research priority setting

Aims and method Dementia in-patient units (DIU) are mental health wards that care for people living with dementia (PLWD) whose symptoms are causing severe distress or potential risk. DIUs look after some of the most vulnerable and unwell people in society, yet they are environments that are underresearched: a recent systematic review revealed only 36 articles worldwide relating to DIUs. To better understand research priorities in DIUs, we undertook a two-round online Delphi survey of PLWD with experience of DIUs, their carers and professionals who work in DIUs. Results Ten research priorities were described and ranked. The top three were how to use non-pharmacological techniques to manage non-cognitive symptoms of dementia, supporting families and better understanding of how to discharge PLWD safely and healthily. Clinical implications This is the first Delphi consensus to describe DIU research priorities. This paper will help researchers focus on the areas that matter most to people who use DIUs.

Reinforcement of research priority setting (RPS) in Ayurveda

Reinforcement of research priority setting (RPS) in Ayurveda

Epidemiology and Management of Pediatric Fractures in Malawi.

Pediatric fractures are common in Malawi, and surgical care, when needed, remains inaccessible to many. Understanding which children in Malawi receive surgery or nonsurgical treatment would help set priorities for trauma system development. We used multivariate logistic regression to evaluate associations between surgical treatment and age, sex, school enrollment, injury mechanism, fracture type, open fracture, referral status, hospital of presentation, delayed presentation (≥2 days), healthcare provider, and inpatient vs outpatient treatment. From 2016 to 2020, 10,400 pediatric fractures were recorded in the Malawi Fracture Registry. Fractures were most commonly of the wrist (26%), forearm (17%), and elbow (14%). Surgical fixation was performed on 4.0% of patients, and 24 (13.0%) open fractures were treated nonsurgically, without débridement or fixation. Fractures of the proximal and diaphyseal humerus (odds ratio [OR], 3.72; 95% confidence interval [CI], 2.36 to 5.87), knee (OR, 3.16; 95% CI, 1.68 to 5.95), and ankle (OR, 2.63; 95% CI, 1.49 to 4.63) had highest odds of surgery. Odds of surgical treatment were lower for children referred from another facility (OR, 0.62; 95% CI, 0.49 to 0.77). Most Malawian children with fractures are treated nonsurgically, including many who may benefit from surgery. There is a need to increase surgical capacity, optimize referral patterns, and standardize fracture management in Malawi.

Exploring Health Research Priority Setting in a South African Province: A Nominal Group Technique Approach.

In August 2022, the Free State Provincial Health Research Committee used the online nominal group technique (NGT) for Health Research Priority Setting (HRPS) for the Free State Department of Health (FSDoH) and the research community, considering various stakeholders' perspectives. This paper explores and describes the identified health research priorities. It also assesses their alignment with the National Health Research Strategy. Additionally, it provides an opinion on the feasibility of using the online NGT for collaborative co-creation of provincial-level health research priorities. Most of the identified health research priorities resonate with the national health research priorities identified by the National Health Research Committee. However, research to "strengthen surveillance" was uniquely perceived to be a priority by the participants in the Free State HRPS exercise. A plausible reason for this might be their heightened awareness of the vital role optimal surveillance systems play in coordinating intersectoral responses to pandemics, particularly considering the serious challenges emerging during the initial stages of the COVID-19 outbreak.

Co-designing complex therapy interventions with parents as partners in the care of children with cerebral palsy: An Experience-based Co-design study in England

BackgroundParents of children with hemiplegic cerebral palsy are increasingly involved in therapy intervention delivery. Enhancing the ways that parents are supported in delivery is key to optimising outcomes. This study aimed to refine an existing programme in England to better support parents partnering in their child’s intervention delivery. Methods and proceduresExperience-based Co-design (EBCD) fostered collaboration between parents and therapists to identify shared improvement priorities and develop solutions. The study included eighteen interviews and sixteen co-design meetings involving twenty parents and eight therapists in total. Intervention development followed the MRC Framework for developing and evaluating complex interventions. Outcomes and resultsThemes from parent and therapist interviews informed priority setting for the co-design work. Three key shared priorities emerged a) accessing rehabilitation; b) fostering partnership and c) parent learning. Aligned with these priorities, three mixed parent and therapist co-design teams produced a) a parent booklet; an education outline for healthcare professionals; b) partnership principles; adaptations to intervention logbooks c) an online parent education session. Conclusions and implicationsEngaging parents and therapists in a structured co-design process using EBCD yielded innovative interventions supporting parents in delivering therapy for children with hemiplegia. This collaborative approach is anticipated to enhance programme implementation and effectiveness.

Co-creating a global shared research agenda on violence against women in low- and middle-income countries

BackgroundDespite a large growth in evidence on violence against women (VAW) over the last 25 years, VAW persists, as do gaps in the field’s knowledge of how to prevent and respond to it. To ensure that research on VAW in low- and middle-income countries (LIMCs) is addressing the most significant gaps in knowledge, and to prioritise evidence needs to reduce VAW and better support victims/survivors, the Sexual Violence Research Initiative (SVRI) and Equality Institute (EQI) led a process of developing a global shared research agenda (GSRA) on VAW in LMICs.MethodsThe GSRA was developed through a six-stage adaptation of the Child Health and Nutrition Research Initiative (CHNRI) method, which draws on the principle of the ‘wisdom of the crowd’. These steps included: a review of the literature on VAW in LMICs and development of domains; the generation of research questions within four domains by an Advisory Group; the consolidation of research questions; scoring of research questions by a Global Expert Group and the Advisory Group according to three criteria (applicability, effectiveness and equity); consultation and validation of the findings with the Advisory Group; and wide dissemination of the findings.ResultsThe highest ranked research questions in the GSRA pertain to the domain of Intervention research, with some highly ranked questions also pertaining to the domain of Understanding VAW in its multiple forms. Questions under the other two domains, Improving existing interventions, and Methodological and measurement gaps, were not prioritised as highly by experts. There was strong consistency in top ranked research questions according to experts’ characteristics, albeit with some important differences according to experts’ gender, occupation and geographical location.ConclusionsThe GSRA findings suggest that currently the VAW field is shifting towards intervention research after several decades of building evidence on understanding VAW, including prevalence, drivers and impacts of violence. The findings also suggest a strong emphasis on under-served populations, and under-researched forms of VAW. Future priority setting exercises in LMICs that seek to decolonise knowledge should ensure that methodologies, and modalities of engagement, put diverse voices at the centre of engagement.Trial registration Not applicable

Optimizing peripheral regional anaesthesia: strategies for single shot and continuous blocks.

Regional anaesthesia is increasingly prominent within anaesthesia, offering alternative analgesic options amidst concerns over opioid-based analgesia. Since Halsted's initial description, the field has burgeoned, with ultrasound visualization revolutionizing local anaesthetic spread assessment, leading to the development of numerous novel techniques. The benefits of regional anaesthesia have gained increasing evidence to support their application, leading to changes within training curricula. Consequently, regional anaesthesia is at a defining moment, embracing the development of core skills for the general anaesthesiologist, whilst also continuing the advancement of the specialty. Recent priority setting projects have focussed attention on key aspects of regional anaesthesia delivery, including pain management, conduct and efficacy, education, and technological innovation. Developments in our current understanding of anatomy and pharmacology, combined with strategies for optimizing the conduct and maximizing efficacy of techniques, minimizing complications, and enhancing outcomes are explored. In addition, advancements in education and training methodologies and the integration of progress in novel technologies will be reviewed. This review highlights recent scientific advances in optimizing both single-shot and continuous peripheral regional anaesthesia techniques. By synthesizing these developments, this review offers valuable insights into the evolving landscape of regional anaesthesia, aiming to improve clinical practice and patient care.

Identifying research priorities for improving information and support for patients undergoing breast cancer surgery: a UK patient-centred priority setting project

PurposeTo use robust consensus methods with individuals with lived breast cancer experience to agree the top 10 research priorities to improve information and support for patients undergoing breast cancer surgery in the UK.MethodsResearch uncertainties related to information and support for breast cancer surgery submitted by patients and carers were analysed thematically to generate summary questions for inclusion in an online Delphi survey. Individuals with lived breast cancer experience completed two Delphi rounds including feedback in which they selected their top 10 research priorities from the list provided. The most highly ranked priorities from the survey were discussed at an in-person prioritisation workshop at which the final top 10 was agreed.ResultsThe 543 uncertainties submitted by 156 patients/carers were categorised into 63 summary questions for inclusion in the Delphi survey. Of the 237 individuals completing Round 1, 190 (80.2%) participated in Round 2. The top 25 survey questions were carried forward for discussion at the in-person prioritisation workshop at which 17 participants from across the UK agreed the final top 10 research priorities. Key themes included ensuring patients were fully informed about all treatment options and given balanced, tailored information to support informed decision-making and empower their recovery. Equity of access to treatments including contralateral mastectomy for symmetry was also considered a research priority.ConclusionThis process has identified the top 10 research priorities to improve information and support for patients undergoing breast cancer surgery. Work is now needed to develop studies to address these important questions.

Structured expert judgement approach of the health impact of various chemicals and classes of chemicals.

Chemical contamination and pollution are an ongoing threat to human health and the environment. The concern over the consequences of chemical exposures at the global level continues to grow. Because resources are constrained, there is a need to prioritize interventions focused on the greatest health impact. Data, especially related to chemical exposures, are rarely available for most substances of concern, and alternate methods to evaluate their impact are needed. A Structured Expert Judgment (Research Outreach, 2021) process was performed to provide plausible estimates of health impacts for 16 commonly found pollutants: asbestos, arsenic, benzene, chromium, cadmium, dioxins, fluoride, highly hazardous pesticides (HHPs), lead, mercury, polycyclic-aromatic hydrocarbons (PAHs), polychlorinated biphenyls (PCBs), Per- and Polyfluorinated Substances (PFAs), phthalates, endocrine disrupting chemicals (EDCs), and brominated flame retardants (BRFs). This process, undertaken by sector experts, weighed individual estimations of the probable global health scale health impacts of each pollutant using objective estimates of the expert opinions' statistical accuracy and informativeness. The foremost substances, in terms of mean projected annual total deaths, were lead, asbestos, arsenic, and HHPs. Lead surpasses the others by a large margin, with an estimated median value of 1.7 million deaths annually. The three other substances averaged between 136,000 and 274,000 deaths per year. Of the 12 other chemicals evaluated, none reached an estimated annual death count exceeding 100,000. These findings underscore the importance of prioritizing available resources on reducing and remediating the impacts of these key pollutants. Based on the evidence available, experts concluded some of the more notorious chemical pollutants, such as PCBs and dioxin, do not result in high levels of human health impact from a global scale perspective. However, the chemical toxicity of some compounds released in recent decades, such as Endocrine Disrupters and PFAs, cannot be ignored, even if current impacts are limited. Moreover, the impact of some chemicals may be disproportionately large in some geographic areas. Continued research and monitoring are essential; and a preventative approach is needed for chemicals. These results, and potential similar analyses of other chemicals, are provided as inputs to ongoing discussions about priority setting for global chemicals and pollution management. Furthermore, we suggest that this SEJ process be repeated periodically as new information becomes available.

Governance of automated mobilities transition in Aotearoa New Zealand

This paper explores how political-institutional factors influence the transition towards automated vehicles (AVs) in New Zealand (NZ). Using the lens of ‘mobilities paradigm’ and analysing policy documents along with interviews data from government officials, the findings reveal the complexity of governing AVs transition due to fragmented responsibility, contested visions, and high interdependency across government agencies. The findings suggest that strong political leadership coupled with infrastructure investments and building regulators’ capability are important catalysts of change towards AVs transition in NZ. The paper concludes that the complex governance environment, and the central government action and inaction to set priority for the AVs agenda, may hinder or facilitate a smooth transition towards AVs in NZ. This paper contributes to the mobilities paradigm by enriching our understanding of the political-institutional challenges associated with the emergence of AVs and offers illuminating policy guidance to better inform decision-making around governing the future transition towards AVs.

Health care prioritization process for the elderly in rural Tanzania under decentralized system: Prospects and challenges.

Beginning the early 1990s, many countries globally adopted the third-generation health sector reforms with a focus of strengthening the primary health care system through community participation. On the contrary, three decades later, primary health care systems in many Low- and Middle-Income countries (LMICs) including Tanzania have remained weak. Specifically, priority setting for the vulnerable groups including the elderly have been weak. We aimed to analyse the prospects and challenges of the priority setting process for the elderly health care services following the 1990s health sector reforms in Tanzania. We conducted an exploratory case study on priority setting process for the elderly healthcare services in Igunga and Nzega Tanzania. We carried out 24 Key Informant Interviews (KIIs) with the positions of District medical officers, social welfare, Medical Officers in-charge (MOI), planning officers and health system information focal person. Additionally, we carried out two focus group discussions (FGDs), one from each district with six participants from each group. Participants for the FGDs were MOI, health secretary, representative members of Health Facility Governing Committee (HFGC) and Council Health Management Team (CHMT). Data were analyzed using the qualitative content analysis. Two categories emerged from the analysis of the transcripts. These were the prospects and challenges in priority setting for the elderly population under the decentralized health sector in rural Tanzania. The prospects included; the capacity of the LGAs on priority setting; existence of strategies used by LGAs; availability of teamwork spirit and the existence of guidelines for priority setting at LGAs. The challenges included difficulties of elderly identification, insufficient resources to implement the planned activities at the LGAs, unintegrated digitalized government health information tools or programs at the LGAs, interference of LGAs by the Central Government and low interest of stakeholders on elderly health care. This study highlights the prospects and challenges facing priority setting for elderly care at the centralized health system in rural Tanzania. From the results the process is well organized but faces some challenges which if not addressed jeopardized and has potential to continue affecting the priority setting. Addressing the challenges highlighted requires joint efforts from both the elderly population in the community, healthcare providers and decision makers across all levels of the health system. This study serves as an eye-opener and calls for a bigger study to get a comprehensive picture of priority setting of the elderly health care in Tanzania.

Identifying neonatal transport research priorities: a modified Delphi consensus

ObjectivesWith increasing advances in neonatal transport, a focused research strategy is required to increase the evidence base towards providing optimal care. We aimed to identify the most important neonatal transport...

Etiology of hospital mortality in children living in low- and middle-income countries: a systematic review and meta-analysis.

In 2019, 80% of the 7.4 million global child deaths occurred in low- and middle-income countries (LMICs). Global and regional estimates of cause of hospital death and admission in LMIC children are needed to guide global and local priority setting and resource allocation but are currently lacking. The study objective was to estimate global and regional prevalence for common causes of pediatric hospital mortality and admission in LMICs. We performed a systematic review and meta-analysis to identify LMIC observational studies published January 1, 2005-February 26, 2021. Eligible studies included: a general pediatric admission population, a cause of admission or death, and total admissions. We excluded studies with data before 2,000 or without a full text. Two authors independently screened and extracted data. We performed methodological assessment using domains adapted from the Quality in Prognosis Studies tool. Data were pooled using random-effects models where possible. We reported prevalence as a proportion of cause of death or admission per 1,000 admissions with 95% confidence intervals (95% CI). Our search identified 29,637 texts. After duplicate removal and screening, we analyzed 253 studies representing 21.8 million pediatric hospitalizations in 59 LMICs. All-cause pediatric hospital mortality was 4.1% [95% CI 3.4%-4.7%]. The most common causes of mortality (deaths/1,000 admissions) were infectious [12 (95% CI 9-14)]; respiratory [9 (95% CI 5-13)]; and gastrointestinal [9 (95% CI 6-11)]. Common causes of admission (cases/1,000 admissions) were respiratory [255 (95% CI 231-280)]; infectious [214 (95% CI 193-234)]; and gastrointestinal [166 (95% CI 143-190)]. We observed regional variation in estimates. Pediatric hospital mortality remains high in LMICs. Global child health efforts must include measures to reduce hospital mortality including basic emergency and critical care services tailored to the local disease burden. Resources are urgently needed to promote equity in child health research, support researchers, and collect high-quality data in LMICs to further guide priority setting and resource allocation.

Emerging Role of Environmental Epitranscriptomics and RNA Modifications in Parkinson's Disease.

Environmental risk factors and gene-environment interactions play a critical role in Parkinson's disease (PD). However, the relatively large contribution of environmental risk factors in the overwhelming majority of PD cases has been widely neglected in the field. A "PD prevention agenda" proposed in this journal laid out a set of research priorities focused on preventing PD through modification of environmental risk factors. This agenda includes a call for preclinical studies to employ new high-throughput methods for analyzing transcriptomics and epigenomics to provide a deeper understanding of the effects of exposures linked to PD. Here, we focus on epitranscriptomics as a novel area of research with the potential to add to our understanding of the interplay between genes and environmental exposures in PD. Both epigenetics and epitranscriptomics have been recognized as potential mediators of the complex relationship between genes, environment, and disease. Multiple studies have identified epigenetic alterations, such as DNA methylation, associated with PD and PD-related exposures in human studies and preclinical models. In addition, recent technological advancements have made it possible to study epitranscriptomic RNA modifications, such as RNA N6-methyladenosine (m6A), and a handful of recent studies have begun to explore epitranscriptomics in PD-relevant exposure models. Continued exploration of epitranscriptomic mechanisms in environmentally relevant PD models offers the opportunity to identify biomarkers, pre-degenerative changes that precede symptom onset, and potential mitigation strategies for disease prevention and treatment.

A Systematic Review of Cost-Effectiveness of Treating Out of Hospital Cardiac Arrest: Implications for Resource-limited Health Systems.

Out-of-hospital cardiac arrest (OHCA) is a prevalent condition with high mortality and poor outcomes even in settings where extensive emergency care resources are available. Interventions to address OHCA have had limited success, with survival rates below 10% in national samples of high-income countries. In resource-limited settings, where scarcity requires careful priority setting, more data is needed to determine the optimal allocation of resources. To establish the cost-effectiveness of OHCA care and assess the affordability of interventions across income settings. The authors conducted a systematic review of economic evaluations on interventions to address OHCA. Included studies were (1) economic evaluations (beyond a simple costing exercise); and (2) assessed an intervention in the chain of survival for OHCA. Article quality was assessed using the CHEERs checklist and data summarised. Findings were reported by major themes identified by the reviewers. Based upon the results of the cost-effectiveness analyses we then conduct an analysis for the progressive realization of the OHCA chain of survival from the perspective of decision-makers facing resource constraints. 468 unique articles were screened, and 46 articles were included for final data abstraction. Studies predominantly used a healthcare sector perspective, modeled for all patients experiencing non-traumatic cardiac OHCA, were based in the US, and presented results in US Dollars. No studies reported results or used model inputs from low-income settings. Progressive realization of the chain of survival could likely begin with investments in TOR protocols, professional prehospital defibrillator use, and CPR training followed by distribution of AEDs in high-density public locations. Finally, other interventions such as indiscriminate defibrillator placement or adrenaline use, would be the lowest priority for early investment. Our review found no high-quality evidence on the cost-effectiveness of treating OHCA in low-resource settings. Existing evidence can be utilized to develop a roadmap for the development of a cost-effective approach to OHCA care, however further economic evaluations using context-specific data are crucial to accurately inform prioritization of scarce resources within emergency care in these settings.

Is a larger patient benefit always better in healthcare priority setting?

When considering the introduction of a new intervention in a budget constrained healthcare system, priority setting based on fair principles is fundamental. In many jurisdictions, a multi-criteria approach with several different considerations is employed, including severity and cost-effectiveness. Such multi-criteria approaches raise questions about how to balance different considerations against each other, and how to understand the logical or normative relations between them. For example, some jurisdictions make explicit reference to a large patient benefit as such a consideration. However, since patient benefit is part of a cost-effectiveness assessment it is not clear how to balance considerations of greater patient benefit against considerations of severity and cost-effectiveness. The aim of this paper is to explore the role of a large patient benefit as an independent criterion for priority setting in a healthcare system also considering severity and cost-effectiveness. By taking the opportunity cost of new interventions (i.e., the health forgone in patients already receiving treatment) into account, we argue that patient benefit has a complex relationship to priority setting. More specifically, it cannot be reasonably concluded that large patient benefits should be given priority if severity, cost-effectiveness, and opportunity costs are held constant. Since we cannot find general support for taking patient benefit into account as an independent criterion from any of the most discussed theories about distributive justice: utilitarianism, prioritarianism, telic egalitarianism and sufficientarianism, it is reasonable to avoid doing so. Hence, given the complexity of the role of patient benefit, we conclude that in priority practice, a large patient benefit should not be considered as an independent criterion, on top of considerations of severity and cost-effectiveness.

Priority setting and migration health policies for European countries.

The 2030 Sustainable Development Goals (SDG) agenda has committed to 'ensuring that no one is left behind'. Applying the right to health of non-citizens and international migrants is challenging in today's highly polarized political discourse on migration governance and integration. We explore the role of a priority setting approach to help support better, fairer and more transparent policy making in migration health. A priority setting approach must also incorporate migration health for more efficient and fair allocation of scarce resources. Explicitly recognizing the trade-offs as part of strategic planning, would circumvent ad hoc decision-making during crises, not well-suited for fairness. Discussions surrounding decisions about expanding services to migrants or subgroups of migrants, which services and to whom should be transparent and fair. We conclude that a priority setting approach can help better inform policy making by being more closely aligned with the practical challenges policy makers face towards the progressive realization of migration health.

Strength in family medicine research: New CFPC efforts identify opportunities and set priorities.

Strength in family medicine research: New CFPC efforts identify opportunities and set priorities.