Multi-Criteria Decision Analysis (MCDA) as the basis for the development, implementation and evaluation of interactive patient decision aids

BACKGROUND: In the context of the progressive movement towards patientcentred care, patient-specific decision support is an important focus of interest. Many diagnostic and treatment patient decision aids (PDAs) are now available to help patients make informed choice decisions. An increasing number of these are software-based, with some available online. Multi-Criteria Decision Analysis (MCDA) is a potentially useful technique on which to base a software-assisted PDA, especially when the decision is complex - as is the case in choosing the best treatment for non-small cell lung cancer – but it has so far been relatively little exploited in this area. The use of any from a number of existing MCDA-based software applications in the development and delivery of a MCDA-based interactive PDA can be an effective way of achieving “best-practice” or normative standards of decision making, such as 1) a well-constructed set of decision criteria or 2) logically consistent patient preferences. However, it also involves the use of resources such as the time and cognitive effort involved in decision-making. The comparative evaluation of alternative MCDA-based software applications in developing and delivering a PDA therefore involves trade-offs between decision effectiveness and decision resource criteria moving from the normative to the prescriptive. MCDA is an ideal tool for this meta-evaluation task as well as for the adoption decision itself. AIM: To analyse, as proof of concept, the use of MCDA for the development, implementation and evaluation of interactive PDAs in routine clinical practice. OBJECTIVES: 1. To assess the use with clinicians in the Spanish NHS of two alternative MCDA software applications which implement dissimilar MCDA techniques in the development of a PDA in routine clinical practice; 2. To assess the use with clinicians in the Spanish NHS of the same two alternative MCDA software applications in the implementation of a PDA in an environment replicating actual clinical consultations; 3. To build a meta-multi-criteria decision model based on the Decision Resources Decision Effectiveness Analysis (DRDEA) framework and assess the use of this model by clinicians in the Spanish NHS to make the choice between the two MCDA applications as the basis for a PDA. METHODS: 1) Two dissimilar MCDA software applications served as a basis for the development of a lung cancer clinical management PDA in close collaboration with two different groups of three clinicians from two different Spanish NHS hospitals (H1 and H2): 1) Expert Choice, which implements the Analytic Hierarchy Process (AHP) MCDA approach; 2) Annalisa in Elicia (ALEL), which implements the Simple Attribute Weighting (SAW) MCDA approach. The process of codevelopment of the PDA in hospitals H1 and H2 was documented; 2) Expert Choice was used to implement (i.e. deliver) the lung cancer clinical management PDA in three hypothetical consultations in hospital H1. In each consultation, one of the three clinicians involved in the development of the tool, with support by this researcher, guided a proxy patient (a non-clinical member of hospital staff) through the PDA. The same process was repeated with the MCDA software ALEL in hospital H2. The process of delivery of the PDA in hospitals H1 and H2 was documented; 3) This researcher built a meta-multi-criteria decision model based on the DRDEA framework to help clinicians choose between different MCDA software applications as the basis of a PDA. The MCDA approach used for this meta-model was Multi- Attribute Value Theory (MAVT). The model was implemented, using the software HiView 3, with three clinicians from hospital H3 for the choice between Expert Choice and ALEL as the basis of a lung cancer clinical management PDA. RESULTS: The thesis makes a three-fold contribution to research in patient-centred decision support. First, it presents two new MCDA software-based approaches to clinical decision support, based on joint work with clinicians in the Spanish NHS, for developing an interactive PDA for the clinical management of non-small cell lung cancer. Second, it describes the use of these decision support tools in the delivery of 5 an interactive PDA for the clinical management of non-small cell lung cancer in a hospital environment via simulated consultations between actual clinicians, with support from this researcher, and proxy lung cancer patients. Third, it presents and applies a new MCDA-based methodology for evaluating the use of alternative MCDA software applications in the development and delivery of interactive PDAs

The 'Dream Team' for sexual, reproductive, maternal, newborn and adolescent health: An adjusted service target model to estimate the ideal mix of health care professionals to cover population need

© 2017 The Author(s). Background: A competent, enabled and efficiently deployed health workforce is crucial to the achievement of the health-related sustainable development goals (SDGs). Methods for workforce planning have tended to focus on 'one size fits all' benchmarks, but because populations vary in terms of their demography (e.g. fertility rates) and epidemiology (e.g. HIV prevalence), the level of need for sexual, reproductive, maternal, newborn and adolescent health (SRMNAH) workers also varies, as does the ideal composition of the workforce. In this paper, we aim to provide proof of concept for a new method of workforce planning which takes into account these variations, and allocates tasks to SRMNAH workers according to their competencies, so countries can assess not only the needed size of the SRMNAH workforce, but also its ideal composition (the 'Dream Team'). Methods: An adjusted service target model was developed, to estimate (i) the amount of health worker time needed to deliver essential SRMNAH care, and (ii) how many workers from different cadres would be required to meet this need if tasks were allocated according to competencies. The model was applied to six low- and middle-income countries, which varied in terms of current levels of need for health workers, geographical location and stage of economic development: Azerbaijan, Malawi, Myanmar, Peru, Uzbekistan and Zambia. Results: Countries with high rates of fertility and/or HIV need more SRMNAH workers (e.g. Malawi and Zambia each need 44 per 10,000 women of reproductive age, compared with 20-27 in the other four countries). All six countries need between 1.7 and 1.9 midwives per 175 births, i.e. more than the established 1 per 175 births benchmark. Conclusions: There is a need to move beyond universal benchmarks for SRMNAH workforce planning, by taking into account demography and epidemiology. The number and range of workers needed varies according to context. Allocation of tasks according to health worker competencies represents an efficient way to allocate resources and maximise quality of care, and therefore will be useful for countries working towards SDG targets. Midwives/nurse-midwives who are educated according to established global standards can meet 90% or more of the need, if they are part of a wider team operating within an enabled environment

Health workforce metrics pre- and post-2015: A stimulus to public policy and planning

© 2017 The Author(s). Background: Evidence-based health workforce policies are essential to ensure the provision of high-quality health services and to support the attainment of universal health coverage (UHC). This paper describes the main characteristics of available health workforce data for 74 of the 75 countries identified under the 'Countdown to 2015' initiative as accounting for more than 95% of the world's maternal, newborn and child deaths. It also discusses best practices in the development of health workforce metrics post-2015. Methods: Using available health workforce data from the Global Health Workforce Statistics database from the Global Health Observatory, we generated descriptive statistics to explore the current status, recent trends in the number of skilled health professionals (SHPs: physicians, nurses, midwives) per 10 000 population, and future requirements to achieve adequate levels of health care in the 74 countries. A rapid literature review was conducted to obtain an overview of the types of methods and the types of data sources used in human resources for health (HRH) studies. Results: There are large intercountry and interregional differences in the density of SHPs to progress towards UHC in Countdown countries: a median of 10.2 per 10 000 population with range 1.6 to 142 per 10 000. Substantial efforts have been made in some countries to increase the availability of SHPs as shown by a positive average exponential growth rate (AEGR) in SHPs in 51% of Countdown countries for which there are data. Many of these countries will require large investments to achieve levels of workforce availability commensurate with UHC and the health-related sustainable development goals (SDGs). The availability, quality and comparability of global health workforce metrics remain limited. Most published workforce studies are descriptive, but more sophisticated needs-based workforce planning methods are being developed. Conclusions: There is a need for high-quality, comprehensive, interoperable sources of HRH data to support all policies towards UHC and the health-related SDGs. The recent WHO-led initiative of supporting countries in the development of National Health Workforce Accounts is a very promising move towards purposive health workforce metrics post-2015. Such data will allow more countries to apply the latest methods for health workforce planning

Ecotypic differentiation and phenotypic plasticity combine to enhance the invasiveness of the most widespread daisy in Chile, Leontodon saxatilis

Dispersal and reproductive traits of successful plant invaders are expected to undergo strong selection during biological invasions. Numerous Asteraceae are invasive and display dimorphic fruits within a single flower head, resulting in differential dispersal pathways - wind-dispersed fruits vs. nondispersing fruits. We explored ecotypic differentiation and phenotypic plasticity of seed output and fruit dimorphisms in exotic Chilean and native Spanish populations of Leontodon saxatilis subsp. rothii. We collected flower heads from populations in Spain and Chile along a rainfall gradient. Seeds from all populations were planted in reciprocal transplant trials in Spain and Chile to explore their performance in the native and invasive range. We scored plant biomass, reproductive investment and fruit dimorphism. We observed strong plasticity, where plants grown in the invasive range had much greater biomass, flower head size and seed output, with a higher proportion of wind-dispersed fruits, than those grown in the native range. We also observed a significant ecotype effect, where the exotic populations displayed higher proportions of wind-dispersed fruits than native populations. Together, these patterns reflect a combination of phenotypic plasticity and ecotypic differentiation, indicating that Leontodon saxatilis has probably increased propagule pressure and dispersal distances in its invasive range to enhance its invasiveness

Identification and validation of common molecular targets of hydroxytyrosol

Hydroxytyrosol (HT) is involved in healthful activities and is beneficial to lipid metabolism. Many investigations focused on finding tissue-specific targets of HT through the use of different omics approaches such as transcriptomics and proteomics. However, it is not clear which (if any) of the potential molecular targets of HT reported in different studies are concurrently affected in various tissues. Following the bioinformatic analyses of publicly available data from a selection of in vivo studies involving HT-supplementation, we selected differentially expressed lipid metabolism-related genes and proteins common to more than one study, for validation in rodent liver samples from the entire selection. Four miRNAs (miR-802-5p, miR-423-3p, miR-30a-5p, and miR-146b-5p) responded to HT supplementation. Of note, miR-802-5p was commonly regulated in the liver and intestine. Our premise was that, in an organ crucial for lipid metabolism such as the liver, consistent modulation should be found for a specific target of HT even if different doses and duration of HT supplementation were used in vivo. Even though our results show inconsistency regarding differentially expressed lipid metabolism-related genes and proteins across studies, we found Fgf21 and Rora as potential novel targets of HT. Omics approaches should be fine-tuned to better exploit the available databases

Measurements of Flavour Dependent Fragmentation Functions in Z^0 -> qq(bar) Events

Fragmentation functions for charged particles in Z -> qq(bar) events have been measured for bottom (b), charm (c) and light (uds) quarks as well as for all flavours together. The results are based on data recorded between 1990 and 1995 using the OPAL detector at LEP. Event samples with different flavour compositions were formed using reconstructed D* mesons and secondary vertices. The \xi_p = ln(1/x_E) distributions and the position of their maxima \xi_max are also presented separately for uds, c and b quark events. The fragmentation function for b quarks is significantly softer than for uds quarks.Comment: 29 pages, LaTeX, 5 eps figures (and colour figs) included, submitted to Eur. Phys. J.

Bose-Einstein Correlations of Three Charged Pions in Hadronic Z^0 Decays

Bose-Einstein Correlations (BEC) of three identical charged pions were studied in 4 x 10^6 hadronic Z^0 decays recorded with the OPAL detector at LEP. The genuine three-pion correlations, corrected for the Coulomb effect, were separated from the known two-pion correlations by a new subtraction procedure. A significant genuine three-pion BEC enhancement near threshold was observed having an emitter source radius of r_3 = 0.580 +/- 0.004 (stat.) +/- 0.029 (syst.) fm and a strength of \lambda_3 = 0.504 +/- 0.010 (stat.) +/- 0.041 (syst.). The Coulomb correction was found to increase the \lambda_3 value by \~9% and to reduce r_3 by ~6%. The measured \lambda_3 corresponds to a value of 0.707 +/- 0.014 (stat.) +/- 0.078 (syst.) when one takes into account the three-pion sample purity. A relation between the two-pion and the three-pion source parameters is discussed.Comment: 19 pages, LaTeX, 5 eps figures included, accepted by Eur. Phys. J.

Measurement of the cross-section and charge asymmetry of WW bosons produced in proton-proton collisions at s=8\sqrt{s}=8 TeV with the ATLAS detector

This paper presents measurements of the $W^+ \rightarrow \mu^+\nu$ and $W^- \rightarrow \mu^-\nu$ cross-sections and the associated charge asymmetry as a function of the absolute pseudorapidity of the decay muon. The data were collected in proton--proton collisions at a centre-of-mass energy of 8 TeV with the ATLAS experiment at the LHC and correspond to a total integrated luminosity of 20.2~\mbox{fb^{-1}}. The precision of the cross-section measurements varies between 0.8% to 1.5% as a function of the pseudorapidity, excluding the 1.9% uncertainty on the integrated luminosity. The charge asymmetry is measured with an uncertainty between 0.002 and 0.003. The results are compared with predictions based on next-to-next-to-leading-order calculations with various parton distribution functions and have the sensitivity to discriminate between them.Comment: 38 pages in total, author list starting page 22, 5 figures, 4 tables, submitted to EPJC. All figures including auxiliary figures are available at https://atlas.web.cern.ch/Atlas/GROUPS/PHYSICS/PAPERS/STDM-2017-13

Search for chargino-neutralino production with mass splittings near the electroweak scale in three-lepton final states in √s=13 TeV pp collisions with the ATLAS detector

A search for supersymmetry through the pair production of electroweakinos with mass splittings near the electroweak scale and decaying via on-shell W and Z bosons is presented for a three-lepton final state. The analyzed proton-proton collision data taken at a center-of-mass energy of √s=13  TeV were collected between 2015 and 2018 by the ATLAS experiment at the Large Hadron Collider, corresponding to an integrated luminosity of 139  fb−1. A search, emulating the recursive jigsaw reconstruction technique with easily reproducible laboratory-frame variables, is performed. The two excesses observed in the 2015–2016 data recursive jigsaw analysis in the low-mass three-lepton phase space are reproduced. Results with the full data set are in agreement with the Standard Model expectations. They are interpreted to set exclusion limits at the 95% confidence level on simplified models of chargino-neutralino pair production for masses up to 345 GeV

A Measurement of Rb using a Double Tagging Method

The fraction of Z to bbbar events in hadronic Z decays has been measured by the OPAL experiment using the data collected at LEP between 1992 and 1995. The Z to bbbar decays were tagged using displaced secondary vertices, and high momentum electrons and muons. Systematic uncertainties were reduced by measuring the b-tagging efficiency using a double tagging technique. Efficiency correlations between opposite hemispheres of an event are small, and are well understood through comparisons between real and simulated data samples. A value of Rb = 0.2178 +- 0.0011 +- 0.0013 was obtained, where the first error is statistical and the second systematic. The uncertainty on Rc, the fraction of Z to ccbar events in hadronic Z decays, is not included in the errors. The dependence on Rc is Delta(Rb)/Rb = -0.056*Delta(Rc)/Rc where Delta(Rc) is the deviation of Rc from the value 0.172 predicted by the Standard Model. The result for Rb agrees with the value of 0.2155 +- 0.0003 predicted by the Standard Model.Comment: 42 pages, LaTeX, 14 eps figures included, submitted to European Physical Journal