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Abstract Purpose Lung cancer is the leading cause of cancer deaths in Canada, and because early cancers are often asymptomatic screening aims to prevent mortality by detecting cancer earlier when treatment is more likely to be curative. These reviews will inform updated recommendations by the Canadian Task Force on Preventive Health Care on screening for lung cancer. Methods We will update the review on the benefits and harms of screening with CT conducted for the task force in 2015 and perform de novo reviews on the comparative effects between (i) trial-based selection criteria and use of risk prediction models and (ii) trial-based nodule classification and different nodule classification systems and on patients’ values and preferences. We will search Medline, Embase, and Cochrane Central (for questions on benefits and harms from 2015; comparative effects from 2012) and Medline, Scopus, and EconLit (for values and preferences from 2012) via peer-reviewed search strategies, clinical trial registries, and the reference lists of included studies and reviews. Two reviewers will screen all citations (including those in the previous review) and base inclusion decisions on consensus or arbitration by another reviewer. For benefits (i.e., all-cause and cancer-specific mortality and health-related quality of life) and harms (i.e., overdiagnosis, false positives, incidental findings, psychosocial harms from screening, and major complications and mortality from invasive procedures as a result of screening), we will include studies of adults in whom lung cancer is not suspected. We will include randomized controlled trials comparing CT screening with no screening or alternative screening modalities (e.g., chest radiography) or strategies (e.g., CT using different screening intervals, classification systems, and/or patient selection via risk models or biomarkers); non-randomized studies, including modeling studies, will be included for the comparative effects between trial-based and other selection criteria or nodule classification methods. For harms (except overdiagnosis) we will also include non-randomized and uncontrolled studies. For values and preferences, the study design may be any quantitative design that either directly or indirectly measures outcome preferences on outcomes pertaining to lung cancer screening. We will only include studies conducted in Very High Human Development Countries and having full texts in English or French. Data will be extracted by one reviewer with verification by another, with the exception of result data on mortality and cancer incidence (for calculating overdiagnosis) where duplicate extraction will occur. If two or more studies report on the same comparison and it is deemed suitable, we will pool continuous data using a mean difference or standardized mean difference, as applicable, and binary data using relative risks and a DerSimonian and Laird model unless events are rare (

Abstract Background Cancer is the second leading cause of death worldwide. Alongside other interventions, access to certain medicines may decrease cancer‐associated mortality. Listing medicines on national essential medicines lists may improve health outcomes. We examine the association between cancer mortality amenable to care and the listing of cancer medicines on national essential medicines lists (NEMLs) of 124 countries. Methods In this cross‐sectional study, we determined the number of medicines used to treat eight cancers on NEMLs and used multiple linear regression to analyze the association between cancer health outcome scores and the number of medicines on NEMLs while controlling for GDP. A sensitivity analysis was also conducted using selected medicines. Findings The number of cancer medicines on NEMLs was not associated with cancer health outcome scores when GDP was controlled for non‐melanoma skin (p = 0.224), uterine (p = 0.221), breast (p = 0.145), Hodgkin's lymphoma (p = 0.697), colon (p = 0.299), leukemia (p = 0.103), cervical (p = 0.834), and testicular cancers (p = 0.178). Interpretation There was a weak association between listing medicines for eight cancers in NEMLs and amenable mortality. Further studies are required to explore association between cancer health outcomes and other factors such as actual availability of medicines listed, access to surgeries, accurate diagnosis, radiotherapy, and early detection.

Objective/design Lacking diversity in pharmaceutical leadership positions could contribute to inequities in medicine access. The objective of this cross-sectional study was to determine the gender and racial identities of individuals who hold leadership positions in the Canadian pharmaceutical sector.Participants We compiled a list of all Canadian governmental bodies, pharmaceutical companies and insurance providers. We identified individuals who were part of the leadership team, including executives and members of the board of directors.Primary outcome measures The main outcomes of the study were the racialisation and gender of the individuals in leadership positions. The gender and racialisation of an individual were determined by reviewing their name, pronouns and institutional profile through internet searches. Two members of the research team performed the assessment and a third reviewer resolved disagreements.Results We identified 957 individuals holding leadership positions within the pharmaceutical sector, including 280 drug evaluation committee members, 12 governmental executive officers, 273 insurance company executive and board members and 392 executive and board members. Reviewers identified a total of 375 (39.2% of 957) women holding leadership roles, with most of these positions being held by governmental leaders (52.4% of 292) and a minority by insurance (37.0% of 273) and pharmaceutical (30.9% of 392) leaders. There were a total of 157 (16.4% of 957) racialised leaders, with most of these positions being held by governmental (18.5% of 292) and pharmaceutical (18.1% of 392) leaders, and a minority in insurance companies (11.7% of 273). Across the pharmaceutical sector, there were a total of 48 (5.0% of 957) racialised women and 327 (34.2% of 957) white women.Conclusions Leaders within the Canadian pharmaceutical sector are mostly white men, and racialised women hold few leadership roles. Public policy should recognise that these institutions are mostly led by white men and reasons for this disparity could be explored.

Abstract Background The prevalence of overweight (15%) and obesity (6%) in children under 5 years of age in Canada are high, and young children with overweight and obesity are at increased risk of the development of chronic disease(s) in adulthood. Prior research has demonstrated very few published trials on effective obesity prevention interventions in young children at risk of obesity, within primary healthcare settings. The aim of this study is to determine if 18–48-month-old children at risk for obesity, who are randomized to receive the Parents Together program (i.e., intervention group), have reduced body mass index z-score (zBMI), compared to those not receiving the intervention, at a 12-month follow-up. Secondary clinical outcomes between the intervention and control groups will be compared at 12 months. Methods A pragmatic, parallel group, 1:1, superiority, randomized control trial (RCT) through the TARGetKids! Practice Based Research Network will be conducted. Young children (ages 18–48 months) who are at increased risk for childhood obesity will be invited to participate. Parents who are enrolled in the intervention group will participate in eight weekly group sessions and 4–5 coaching visits, facilitated by a trained public health nurse. Children and parents who are enrolled in the control group will receive the usual health care. The primary outcome will be compared between intervention arms using an analysis of covariance (ANCOVA). Feasibility and acceptability will be assessed by parent focus groups and interviews, and fidelity to the intervention will be measured using nurse-completed checklists. A cost-effectiveness analysis (CEA) will be conducted. Discussion This study will aim to reflect the social, cultural, and geographic diversity of children in primary care in Toronto, Ontario, represented by an innovative collaboration among applied child health researchers, community health researchers, and primary care providers (i.e., pediatricians and family physicians in three different models of primary care). Clinical and implementation outcomes will be used to inform future research to test this intervention in a larger number, and diverse practices across diverse geographic settings in Ontario. Trial registration ClinicalTrials.gov NCT03219697. Registered on June 27, 2017.

Objectives Out-of-pocket medication costs can contribute to financial insecurity and many Canadians have trouble affording medicines. This study aimed to determine if the effect of eliminating out-of-pocket medication costs on individual’s financial security varied by gender, racialisation, income and location.Design In this post hoc subgroup analysis of the CLEAN Meds trial, a binary logistic regression model was fitted and a qualitative inductive thematic analysis of comments related to participant’s ability to make ends meet was carried out.Setting Primary care patients in Ontario, Canada.Participants Adult patients (786) who reported not being able to afford medicines during the previous 12 months.Intervention Free access to a comprehensive list of essential medicines for 24 months.Primary outcome measure Ability to make ends meet or afford basic necessities.Results There were no significant differences in the effect of free medicine distribution by gender (OR for male 0.82; 95% CI 0.51 to 1.33, p=0.76), age (older than 65 years OR 1.28; 95 % CI 0.62 to 2.64, p=0.73), racialisation (OR 0.85; 95 % CI 0.51 to 1.45, p=0.66), household income level (above US$30 000 per year OR 1.08; 95 % CI 0.64 to 1.80, p=0.99) or location (urban OR 0.47; 95 % CI 0.23 to 0.96, p=0.10). The main theme in the qualitative analysis was insufficient income, and there were three related themes: out-of-pocket medication expenses, cost-related non-adherence and the importance of medication coverage. In the intervention group, additional themes identified included improved health, functioning and access to basic needs.Conclusions Providing free essential medications improved financial security across subgroups in a trial population who all had trouble affording medicines. Free access to medicines could improve health directly by improving medicine adherence and indirectly by making other necessities more accessible to people who have an insufficient income.Trial registration number NCT02744963.

Abstract Background Essential medicines lists (EMLs) are intended to reflect the priority health care needs of populations. We hypothesized that biologic disease-modifying antirheumatic drugs (DMARDs) are underrepresented relative to conventional DMARDs in existing national EMLs. We aimed to survey the extent to which biologic DMARDs are included in EMLs, to determine country characteristics contributing to their inclusion or absence, and to contrast this with conventional DMARD therapies. Methods We searched 138 national EMLs for 10 conventional and 14 biologic DMARDs used in the treatment of childhood rheumatologic diseases. Via regression modelling, we determined country characteristics accounting for differences in medicine inclusion between national EMLs. Results Eleven countries (7.97%) included all 10 conventional DMARDs, 115 (83.33%) ≥5, and all countries listed at least one. Gross domestic product (GDP) per capita was associated with the total number of conventional DMARDs included (β11.02 [95% CI 0.39, 1.66]; P = 0.00279). Among biologic DMARDs, 3 countries (2.2%) listed ≥10, 15 (10.9%) listed ≥5, and 47 (34.1%) listed at least one. Ninety-one (65.9%) of countries listed no biologic DMARDs. European region (β1 1.30 [95% CI 0.08, 2.52]; P = 0.0367), life expectancy (β1–0.70 [95% CI -1.22, − 0.18]; P = 0.0085), health expenditure per capita (β1 1.83 [95% CI 1.24, 2.42]; P

Background: Tuberculosis (TB) remains a major cause of morbidity and mortality globally despite effective treatments. Along with high-quality health services, essential medicines are a key tool in curbing TB related mortality. Examining relationships between listing TB medicines on national essential medicines lists (NEMLs) and population health outcomes related to amenable mortality is one way to assess TB care. Methods: In this cross-sectional study of 137 countries, we used linear regression to examine the relationship between the number of TB medicines listed on NEMLs and TB related mortality while controlling for country income, region and TB burden. Results: Most countries listed essential TB medicines to treat latent, drug-sensitive and disseminated TB but few listed enough for multi-drug resistant TB (MDR-TB) therapy. The total number of TB medicines listed ranged from 1 to 29 (median: 19, interquartile range: 15 to 22). Over 75% of the variation in health outcomes were explained by the number of TB medicines listed, gross domestic product (GDP) per capita, region and high-burden MDR-TB status. The number of TB medicines listed was not associated with TB mortality. Conclusion: Most countries list essential TB treatments and the variation in TB outcomes is explained by other factors such as GDP.

Abstract Background National essential medicines lists are used to guide medicine reimbursement and public sector medicine procurement for many countries therefore medicine listings may impact health outcomes. Methods Countries’ national essential medicines lists were scored on whether they listed proven medicines for ischemic heart disease, cerebrovascular disease and hypertensive heart disease. In this cross sectional study linear regression was used to measure the association between countries’ medicine coverage scores and healthcare access and quality scores. Results There was an association between healthcare access and quality scores and health expenditure for ischemic heart disease (p ≤ 0.001), cerebrovascular disease (p ≤ 0.001) and hypertensive heart disease (p ≤ 0.001). However, there was no association between medicine coverage scores and healthcare access and quality scores for ischemic heart disease (p = 0.252), cerebrovascular disease (p = 0.194) and hypertensive heart disease (p = 0.209) when country characteristics were accounted for. Conclusions Listing more medicines on national essential medicines lists may only be one factor in reducing mortality from cardiovascular disease and improving healthcare access and quality scores.

Objectives. To compare national essential medicines lists (NEMLs) from countries in the Region of the Americas and to identify potential opportunities for improving those lists. Methods. In June of 2017, NEMLs from 31 countries in the Americas were abstracted from documents included in a World Health Organization (WHO) repository. The lists from the Americas were compared to each other and to NEMLs from outside of the Americas, as well as with the WHO Model List of Essential Medicines, 20th edition (“WHO Model List”) and the list of the Pan American Health Organization (PAHO) Regional Revolving Fund for Strategic Public Health Supplies (“Strategic Fund”). Results. The number of differences between the NEMLs from the Americas and the WHO Model List were similar within those countries (median: 295; interquartile range (IQR): 265 to 347). The NEMLs from the Americas were generally similar to each other. While the NEMLs from the Americas coincided well with the Strategic Fund list, some medicines were not included on any of those NEMLs. All the NEMLs in the Americas included some medicines that were withdrawn due to adverse effects by a national regulatory body (median: 8 withdrawn medicines per NEML; IQR: 4 to 12). Conclusions. The NEMLs in the Americas were fairly similar to each other and to the WHO Model List and the Strategic Fund list. However, some areas of treatment and some specific medicines were identified that the countries should reassess when revising their NEMLs.

Objective Essential medicines lists have been created and used globally in countries that range from low-income to high-income status. The aim of this paper is to compare the essential medicines list of high-income countries with each other, the WHO’s Model List of Essential Medicines and the lists of countries of other income statuses.Design High-income countries were defined by World Bank classification. High-income essential medicines lists were assessed for medicine inclusion and were compared with the subset of high-income countries, the WHO’s Model List and 137 national essential medicines lists. Medicine lists were obtained from the Global Essential Medicines database. Countries were subdivided by income status, and the groups’ most common medicines were compared. Select medicines and medicine classes were assessed for inclusion among high-income country lists.Results The 21 high-income countries identified were most like each other when compared with other lists. They were more like upper middle-income countries and least like low-income countries. There was significant variability in the number of medicines on each list. Less than half (48%) of high-income countries included a newer diabetes medicines in their list. Most countries (71%) included naloxone while every country including at least one opioid medicine. More than half of the lists (52%) included a medicine that has been globally withdrawn or banned.Conclusion Essential medicines lists of high-income countries are similar to each other, but significant variations in essential medicine list composition and specifically the number of medications included were noted. Effective medicines were left off several countries’ lists, and globally recalled medicines were included on over half the lists. Comparing the essential medicines lists of countries within the same income status category can provide a useful subset of lists for policymakers and essential medicine list creators to use when creating or maintaining their lists.

BackgroundAdherence to medicines is low for a variety of reasons, including the cost borne by patients. Some jurisdictions publicly fund medicines for the general population, but many jurisdictions do not, and such policies are contentious. To our knowledge, no trials studying free access to a wide range of medicines have been conducted.Methods and findingsWe randomly assigned 786 primary care patients who reported not taking medicines due to cost between June 1, 2016 and April 28, 2017 to either free distribution of essential medicines (n = 395) or to usual medicine access (n = 391). The trial was conducted in Ontario, Canada, where hospital care and physician services are publicly funded for the general population but medicines are not. The trial population was mostly female (56%), younger than 65 years (83%), white (66%), and had a low income from wages as the primary source (56%). The primary outcome was medicine adherence after 2 years. Secondary outcomes included control of diabetes, blood pressure, and low-density lipoprotein (LDL) cholesterol in patients taking relevant treatments and healthcare costs over 2 years. Adherence to all appropriate prescribed medicines was 38.7% in the free distribution group and 28.6% in the usual access group after 2 years (absolute difference 10.1%; 95% confidence interval (CI) 3.3 to 16.9, p = 0.004). There were no statistically significant differences in control of diabetes (hemoglobin A1c 0.27; 95% CI -0.25 to 0.79, p = 0.302), systolic blood pressure (-3.9; 95% CI -9.9 to 2.2, p = 0.210), or LDL cholesterol (0.26; 95% CI -0.08 to 0.60, p = 0.130) based on available data. Total healthcare costs over 2 years were lower with free distribution (difference in median CAN$1,117; 95% CI CAN$445 to CAN$1,778, p = 0.006). In the free distribution group, 51 participants experienced a serious adverse event, while 68 participants in the usual access group experienced a serious adverse event (p = 0.091). Participants were not blinded, and some outcomes depended on participant reports.ConclusionsIn this study, we observed that free distribution of essential medicines to patients with cost-related nonadherence substantially increased adherence, did not affect surrogate health outcomes, and reduced total healthcare costs over 2 years.Trial registrationClinicalTrials.gov NCT02744963.

Abstract Background Measuring body mass index (BMI) has been proposed as a method of screening for preventive primary care and population surveillance of childhood obesity. However, the accuracy of routinely collected measurements has been questioned. The purpose of this study was to assess the reliability of height, length and weight measurements collected during well-child visits in primary care relative to trained research personnel. Methods A cross-sectional study of measurement reliability was conducted in community pediatric and family medicine primary care practices. Each participating child, ages 0 to 18 years, was measured four consecutive times; twice by a primary care team member (e.g. nurses, practice personnel) and twice by a trained research assistant. Inter- and intra-observer reliability was calculated using the technical error of measurement (TEM), relative TEM (%TEM), and a coefficient of reliability (R). Results Six trained research assistants and 16 primary care team members performed measurements in three practices. All %TEM values for intra-observer reliability of length, height, and weight were classified as ‘acceptable’ ( 99% for both intra- and inter-observer reliability. Length measurements in children

Introduction Opioids are deemed essential medicines by the World Health Organization (WHO). However, many countries have inadequate access to them. Whether including opioids in national essential medicines lists (EMLs) influences national opioid consumption has not been evaluated.Methods We conducted a cross-sectional study to determine whether the listing of opioids in national EMLs was associated with consumption. We quantified the numbers and types of all opioids included in 137 national EMLs, for comparison with opioids in the WHO’s Model List of Essential Medicines. Using the International Narcotics Control Board (INCB) consumption statistics for 2015–2017, we assessed the relation between annual mean opioid consumption (mg/person) and the numbers of opioids included in EMLs, controlling for region, population, healthcare expenditure, life expectancy, gross domestic product, human development and corruption.Results Five opioids were included in the 20th edition of the WHO’s Model List of Essential Medicines: codeine, fentanyl, loperamide, methadone and morphine. On average, countries’ lists included significantly (p

Background: In Canada, pharmacists accessing electronic health records (EHR) and mailing medications to patients are relatively uncommon. We evaluated a pharmacy model implemented in a clinical trial that combined allowing the pharmacist access to patients’ EHR and mailing medications to participants. Methods: We conducted thematic analysis of comments made by participants and prescribers, and chart stimulated recalls with the pharmacist involved with the novel pharmacy model implemented in a clinical trial. Results: Major themes from participant’s comments related to the ease of obtaining information about medications from the pharmacy and satisfaction with the delivery. Prescribers felt that this model facilitated collaboration with the pharmacist and welcomed suggestions regarding therapeutic medication changes. Major themes from the pharmacist’s chart stimulated recalls were that access to participants’ EHRs allowed for improved drug therapy management and participant experience, and this pharmacy model increased participant’s access to pharmacy services. Discussion: According to the pharmacist and prescribers, this pharmacy model facilitated their collaboration in prescribing appropriate medications and participants were generally satisfied with the delivery of medications. Conclusion: Participants and prescribers were generally supportive of a pharmacy model that combined allowing the pharmacist access to participants’ EHR and medication mailing. This allowed the pharmacist more opportunities for drug therapy management and collaboration with prescribers. It also improved the participant’s access to pharmacy services, although those services were not always fully utilized.

BACKGROUND:Starting in the late 1990s, the pharmaceutical industry sought to increase prescribing of opioids for chronic non-cancer pain. Influencing the content of clinical practice guidelines may have been one strategy industry employed. In this study we assessed potential risk of bias from financial conflicts of interest with the pharmaceutical industry in guidelines for opioid prescribing for chronic non-cancer pain published between 2007 and 2013, the peak of opioid prescribing. METHODS:We used the Guideline Panel Review (GPR) to appraise the guidelines included in the 2014 systematic review and critical appraisal by Nuckols et al. These were English language opioid prescribing guidelines for adults with chronic non-cancer pain published between July 2007 and July 2013, the peak of opioid prescribing. The GPR assigns red flags to items known to introduce potential bias from financial conflicts of interest. We operationalized the GPR by creating specific definitions for each red flag. Two reviewers independently evaluated each guideline. Disagreements were resolved with discussion. We also compared our score to the critical appraisal scores for overall quality from the study by Nuckols et al. RESULTS:We appraised 13 guidelines, which received 43 red flags in total. Guidelines had 3.3 red flags on average (out of a possible seven) with range from one to six. Four guidelines had missing information, so red flags may be higher than reported. The guidelines with the highest and second highest scores for overall quality in the 2014 critical appraisal by Nuckols et al. had five and three red flags, respectively. CONCLUSION:Our findings reveal that the guidelines for opioid prescribing chronic non-cancer pain from 2007 to 2013 were at risk of bias because of pervasive conflicts of interest with the pharmaceutical industry and a paucity of mechanisms to address bias. Even highly-rated guidelines examined in a 2014 systematic review and critical appraisal had many red flags.

BackgroundEssential medicines lists and related policies are intended to meet the priority health needs of populations and their implementation is associated with more appropriate use of medicines. The World Health Organization (WHO) recommends that countries carefully select the medicines to be included in their national essential medicines lists. Lists that are used to prioritize access to important treatments should not include medicines that have been withdrawn elsewhere because of an unfavourable benefit-to-harm balance; however, countries still list and use medicines that have been withdrawn worldwide. The objective of this study was to determine whether the national essential medicines lists of 137 countries include medicines that have been withdrawn in other countries.Methods and findingsWe performed an audit of national essential medicines lists for medicines that had been withdrawn. Medicines withdrawn from worldwide markets between 1953 and 2014 were identified using a systematic review of published literature and regulatory documents. The reviewers used sources including the WHO's database of drugs, PubMed, and the websites of regulatory agencies to obtain information regarding adverse effects associated with the medicines, the year of first withdrawal, markets of withdrawal, and the level of evidence supporting each withdrawal. We recorded the number of countries with a withdrawn medicine included in their national medicines list, the number of withdrawn medicines included in each nation's list, and the number of national essential medicines including each withdrawn medicine. 97 medicines were withdrawn in at least one country but still included in one more national essential medicines list. Of 137 countries with a national essential medicines list, 136 lists included at least one withdrawn medicine, with 54% of the lists containing 5 or fewer withdrawn medicines, and 27% including 10 or more withdrawn medicines. 11 medicines were withdrawn worldwide but still included on at least one national essential medicines list. Countries with longer essential medicines lists had more withdrawn medicines included in their lists.ConclusionsThis study found that withdrawn medicines are included in all but one national essential medicines list, representing a need for more stringent processes for selecting and removing medicines on these lists. Countries may wish to apply special scrutiny to medicines withdrawn in other nations when selecting medicines to include on their lists.

BackgroundNon-communicable diseases (NCDs) are the leading cause of death worldwide. Inadequate and inequitable access to essential NCD medicines is a major concern, particularly in low- and middle-income countries. National Essential Medicines Lists (EMLs) are important policy tools that indicate which medicines are prioritized as essential within a country's health system. This study sought to analyze a wide range of national essential medicines lists (EMLs) for their inclusion of priority non communicable disease (NCD) interventions recommended by the World Health Organization (WHO).MethodsThree lists of WHO endorsed priority NCD interventions were included. A database with 137 national EMLs and the WHO EML was created from the WHO Repository and these EMLs were compared for listing of priority NCD interventions.ResultsAcross 137 countries with national EMLs, the median percentage of 20 Best Buys interventions listed was 90% (IQR 80-95) and 31 Package of essential noncommunicable disease interventions (PEN) interventions listed was 94% (IQR 90-97), of 9 HEARTS interventions was 100% (IQR 89-100), and of the 43 unique interventions across the three priority lists was 88% (IQR 84-93). Less than 80% of the 43 interventions were listed by 22 (16%) countries and less than half of the interventions were listed by 2 countries: Angola (35%) and Cambodia (23%). Interventions listed on the fewest number of national EMLs were: influenza vaccine, HPV vaccine, hepatitis B vaccine, cervical cancer chemotherapy, codeine, promethazine, senna, and oxygen.ConclusionMost NCD interventions have been prioritized in national policy in most cases. The majority of priority medicines for NCDs described within key WHO NCD technical packages are listed on nearly all national EMLs across 137 countries of all income levels. Most NCD interventions have been prioritized in national policy in most cases, but in some countries and for select interventions such as the HPV vaccine, prioritization may be reviewed.

BackgroundFree provision of tangible goods that may improve health is one approach to addressing discrepancies in health outcomes related to income, yet it is unclear whether providing goods for free improves health. We systematically reviewed the literature that reported the association between the free provision of tangible goods and health outcomes.MethodsA search was performed for relevant literature in all languages from 1995-May 2017. Eligible studies were observational and experimental which had at least one tangible item provided for free and had at least one quantitative measure of health. Studies were excluded if the intervention was primarily a service and the free good was relatively unimportant; if the good was a medication; or if the data in a study was duplicated in another study. Covidence screening software was used to manage articles for two levels of screening. Data was extracted using an adaption of the Cochrane data collection template. Health outcomes, those that affect the quality or duration of life, are the outcomes of interest. The study was registered with PROSPERO (CRD42017069463).FindingsThe initial search identified 3370 articles and 59 were included in the final set with a range of 20 to 252 246 participants. The risk of bias assessment revealed that overall, the studies were of medium to high quality. Among the studies included in this review, 80 health outcomes were statistically significant favouring the intervention, 19 health outcomes were statistically significant favouring the control, 141 health outcomes were not significant and significance was unknown for 28 health outcomes.InterpretationThe results of this systematic review provide evidence that free goods can improve health outcomes in certain circumstances, although there were important gaps and limitations in the existing literature.

ObjectiveTo develop key performance indicators that evaluate the effectiveness of a prescription medication system.MethodsA modified RAND/UCLA appropriateness method was used to develop key performance indicators (KPIs) for a prescription medication system. A broad list of potential KPIs was compiled. A multidisciplinary group composed of 21 experts rated the potential KPIs. A face-to-face meeting was held following the first rating exercise to discuss each potential KPI individually. The expert panel undertook a final rating of KPIs. The final set of KPIs were those indicators where at least 80 percent of experts rated the indicator highly i.e. rating of ≥ 7 on a scale from 1 to 9.Results292 KPIs were identified from the published literature. After removing duplicates and combining similar indicators 71 KPIs were included. The final ranking resulted in six indicators being ranked 7 or higher by 80% of the respondents and an additional seven indicators being ranked 7 or higher by ≥70 but ≤80% of respondents. The six selected indicators include four specific disease areas, measure structural and process aspects of health service delivery, and assessed three of the domains of healthcare quality: efficiency, effectiveness, and safety.ConclusionsThese indicators are recommended as a starting point to assess the current performance of prescription medication systems. Consideration should be given to developing indicators in additional disease areas as well as indicators that measure the domains of timeliness and patient-centeredness. Future work should focus on the feasibility of measuring these indicators.

BACKGROUND:High quality primary care is fundamental to achieving health for all. Research priority setting is a key facilitator of improving how research activity responds to concrete needs. There has never before been an attempt to identify international primary care research priorities, in order to guide resource allocation and to enhance global primary care. This study aimed to identify a list of top 10 primary care research priorities, as identified by members of the public, health professionals working in primary care, researchers, and policymakers. METHODS:We adapted the James Lind Alliance Priority Setting Partnership process, to conduct multiple rounds of stakeholder recruitment and prioritization. The study included an online survey conducted in three languages, followed by an in-person priority setting exercise involving primary care stakeholders from 13 countries. FINDINGS:Participants identified a list of top 10 international primary care research priorities. These were focused on diverse topics such as enhancing use of information and communication technology, and improving integration of indigenous communities' knowledge in the design of primary care services. The main limitations of the study related to challenges in engaging an adequate diversity and number of appropriate stakeholders, particularly members of the public, in aggregating the diverse set of responses into coherent categories representative of the participants' perspectives and in adequately representing the diversity of submitted responses while ensuring research priorities on the final list are sufficiently actionable to guide resource allocation. CONCLUSIONS:The top 10 identified research priorities have the potential to guide research resource allocation, supporting funding agencies and initiatives to promote global primary care research and practice.