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Objective: To investigate the relationship between of distinct domains of childhood disadvantage and cognitive performance among older adults within the context of a middle-income country., Methods: This study used baseline data (2015/2016) from the Brazilian Longitudinal Study of Aging (ELSI), a nationally representative cohort of 9412 adults aged 50 and over. Nine childhood exposure variables were grouped into three domains (family SES, childhood health, and cultural capital), for which scores were created. Survey-weighted Ordinary Least Squares (OLS) regressions estimated the association childhood disadvantage with cognitive performance as measured by immediate memory, late memory and semantic verbal fluency. Mediation analysis assessed whether adulthood socioeconomic status (SES) mediated this relationship of interest., Results: Important disparities in cognitive performance were observed, particularly in terms of age, education, income, occupational status. Before controlling for adulthood SES in the multivariable analysis, all domains of childhood disadvantage were found to be associated with lower cognitive performance across all three measures. After inclusion of adulthood SES variables, the observed associations only remained for semantic verbal fluency. Formal mediation analysis indicated that adulthood SES mediates 47.9% (95% CI: 34.3%-78.6%) of the association between later-life verbal fluency and poor childhood health, and 49.9% (95% CI: 43.6%-57.8%) of the association between later-life verbal fluency and low childhood cultural capital., Conclusions: We found that childhood disadvantage is associated with low performance in memory tests and semantic verbal fluency tests among older Brazilians. Adulthood SES fully mediated the association between all domains of childhood disadvantage and memory performance and only partially mediated its association with verbal fluency. Our findings support policy efforts to enhance early childhood development and improve adulthood SES, and guide additional research to better the mechanisms driving these relationships., Competing Interests: The authors declare that there is no conflict of interest., (© 2023 The Authors.)

Background: As the COVID-19 pandemic progresses, understanding its sustained impact on healthcare access and utilization represents a vital task for decision-makers and health systems. This study investigates how three aspects of health care utilization (i.e., consultations for COVID-19 related symptoms, cancelation of previously scheduled care and hospitalisation in the past 30 days) relate to individual and municipal factors in a nationally-representative sample of Brazilians aged 50 and over., Methods: Data were obtained for 6584 participants from the second wave of the Brazilian Longitudinal Study of Ageing (ELSI-Brazil in Portuguese) who were administered supplemental telephone interviews between September and October 2020. Descriptive statistics, bivariate analysis and multivariate analysis using survey-weighted Poisson regression were applied to evaluate all three outcomes of interest (consultation, care cancelation, and hospitalisation). Predicted probabilities were also calculated to understand the overall effect of relevant covariates., Results: Women were 76% less likely to seek care for COVID-19 symptoms (Odds Ratio [OR] = 0.24, 95% Confidence Interval [CI] = 0.10, 0.53) and 82% more likely to have healthcare cancelled due to the pandemic (OR = 1.82, 95% CI = 1.43, 2.33) than men. Those who live in municipalities with low coverage (<40%) of community-based primary care (the Family Health Strategy) were more likely (OR = 1.80, 95% CI = 1.00, 3.22) to be hospitalised for any reason in the past 30 days and more likely to experience healthcare cancelation (OR = 1.43, 95% CI = 1.01, 2.02). Living in the Southeast and Midwest regions was associated with 62% and 78%, respectively, lower odds of previously scheduled care being cancelled due to the pandemic, in comparison to the North region (OR = 0.38, 95% CI = 0.21, 0.67, and OR = 0.22, 95% CI = 0.14, 0.36). Living in the Southeast region was associated with over 7.61 higher odds of having sought care for COVID-19-related symptoms, relative to those living in the North (OR = 7.61, 95% CI = 2.16, 26.85)., Conclusion: Results highlight the uneven impact of the COVID-19 pandemic on health care utilization between males and females, and across Brazilian municipalities and regions., (© 2022 John Wiley & Sons Ltd.)

Objectives: To assess the cost-effectiveness of varenicline in comparison to currently funded smoking cessation strategies in Brazil., Methods: We modeled the lifetime direct costs and health-related quality of life of a hypothetical cohort of smokers with a single attempt to quit smoking using one of the following: (1) cognitive behavioral therapy (CBT) without any pharmacological intervention, (2) varenicline, (3) bupropion, (4) nicotine replacement therapy (NRT) with transdermal patch, (5) bupropion in combination with NRT transdermal patch, and (6) combined NRT (oral plus transdermal). All drug alternatives were considered with concomitant CBT. The analysis relied on a Markov model based on the Benefits of Smoking Cessation and Outcomes study and used different age and sex categories in the consideration of relative risks and incidence rates of the diseases included in the model. The analysis was conducted from the healthcare system perspective, and a 3% discounting rate for costs and outcomes was applied. Model parameter values were sourced from published literature. Probabilistic and deterministic sensitivity analyses assessed robustness., Results: Among the smoking cessation alternatives available in Brazil, varenicline and combined NRT were estimated to have higher effectiveness; varenicline, however, was dominated due to its higher average cost. In the base-case analysis, combined NRT had an incremental gain of 0.25 quality-adjusted life-years (QALYs) in comparison to the second-best option (bupropion in combination with NRT transdermal patch) and an incremental cost-effectiveness ratio of R$2173.47/QALY ($595.45/QALY)., Conclusions: Combination of oral and transdermal NRT (coupled with CBT) was the most effective smoking cessation option and was 100% cost-effective within a conservative willingness-to-pay threshold., (Copyright © 2021 International Society for Pharmacoeconomics and Outcomes Research, Inc. Published by Elsevier Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: Vaccine hesitancy may represent a barrier to effective COVID-19 immunisation campaigns. This study assesses individual, disease-specific and contextual factors associated with COVID-19 vaccine acceptance among a nationally representative sample of older Brazilian adults., Design: Cross-sectional analysis of data from household interviews and a supplementary telephone survey., Setting: Brazil and its five geographic regions., Participants: Data are derived from 6584 individuals aged 50 years and over who participated in the second wave of the Brazilian Longitudinal Study of Aging., Primary and Secondary Outcome Measures: Survey-weighted multinomial logistic regression assesses factors associated with intending, not intending or being uncertain about one's intention to vaccinate against COVID-19., Findings: Seventy-one per cent of study participants intend to receive a COVID-19 vaccine once available, while 17% (representative of nearly 9 million people) have no intention to vaccinate, and 12% are still undecided. Besides age, demographic and health-related factors related to COVID-19 severity and complications were not associated with intention to vaccinate. Those who most trusted social media or friends and family for COVID-19 information and those who did not trust any information source were 68% and 78% more likely to refuse vaccination, respectively, as compared with those who trusted official information sources. People who inconsistently used face masks when outside were 3.4 times more likely than consistent face mask users to intend to refuse vaccination. Higher municipal COVID-19 fatality rates were negatively associated with vaccine refusal., Conclusions: Most national COVID-19 immunisation strategies identify older individuals as among those prioritised for early vaccination, given their increased risk of more severe symptoms and complications of the disease. Because individual, disease-specific, and contextual factors were associated with vaccine acceptance, there is a clear need for multilevel and multichannel information and outreach campaigns to increase COVID-19 vaccine acceptance among vulnerable older populations., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: Missed opportunities for human papillomavirus (HPV) vaccination during pediatric health care visits are common., Objectives: To evaluate the effect of online communication training for clinicians on missed opportunities for HPV vaccination rates overall and at well-child care (WCC) visits and visits for acute or chronic illness (hereafter referred to as acute or chronic visits) and on adolescent HPV vaccination rates., Design, Setting, and Participants: From December 26, 2018, to July 30, 2019, a longitudinal cluster randomized clinical trial allocated practices to communication training vs standard of care in staggered 6-month periods. A total of 48 primary care pediatric practices in 19 states were recruited from the American Academy of Pediatrics Pediatric Research in Office Settings network. Participants were clinicians in intervention practices. Outcomes were evaluated for all 11- to 17-year-old adolescents attending 24 intervention practices (188 clinicians) and 24 control practices (177 clinicians). Analyses were as randomized and performed on an intent-to-treat basis, accounting for clustering by practice., Interventions: Three sequential online educational modules were developed to help participating clinicians communicate with parents about the HPV vaccine. Weekly text messages were sent to participating clinicians to reinforce learning. Statisticians were blinded to group assignment., Main Outcomes and Measures: Main outcomes were missed opportunities for HPV vaccination overall and for HPV vaccine initiation and subsequent doses at WCC and acute or chronic visits (visit-level outcome). Secondary outcomes were HPV vaccination rates (person-level outcome). Outcomes were compared during the intervention vs baseline., Results: Altogether, 122 of 188 clinicians in intervention practices participated; of these, 120, 119, and 116 clinicians completed training modules 1, 2, and 3, respectively. During the intervention period, 29 206 adolescents (14 664 girls [50.2%]; mean [SD] age, 14.2 [2.0] years) made 15 888 WCC and 28 123 acute or chronic visits to intervention practices; 33 914 adolescents (17 069 girls [50.3%]; mean [SD] age, 14.2 [2.0] years) made 17 910 WCC and 35 281 acute or chronic visits to control practices. Intervention practices reduced missed opportunities overall by 2.4 percentage points (-2.4%; 95% CI, -3.5% to -1.2%) more than controls. Intervention practices reduced missed opportunities for vaccine initiation during WCC visits by 6.8 percentage points (-6.8%; 95% CI, -9.7% to -3.9%) more than controls. The intervention had no effect on missed opportunities for subsequent doses of the HPV vaccine or at acute or chronic visits. Adolescents in intervention practices had a 3.4-percentage point (95% CI, 0.6%-6.2%) greater improvement in HPV vaccine initiation compared with adolescents in control practices., Conclusions and Relevance: This scalable, online communication training increased HPV vaccination, particularly HPV vaccine initiation at WCC visits. Results support dissemination of this intervention., Trial Registration: ClinicalTrials.gov Identifier: NCT03599557.

Objectives: Little is known about sleeping pills consumption among older adults in low- and middle-income countries. This study investigated the prevalence and factors associated with sleeping pills use among Brazilians aged 50 and over., Methods: A cross-sectional study was conducted using baseline data from the Brazilian Longitudinal Study of Aging (ELSI-Brazil), a nationally representative study of persons aged 50 years and older (n = 9412). Univariate and bivariate analyses were used to describe the sample. Robust Poisson regression was employed to estimate prevalence ratios and predict probabilities., Key Findings: Prevalence of sleeping pills use among older Brazilians was estimated at 16.8%, with considerable disparities related to gender (22.3% among women and 10.3% among men), race/skin colour (19.7% among whites and 11.9% among blacks) and geographic region (ranging from 5.9% in the North to 20.5% in the South). The multivariate analysis showed associations between sleeping pills consumption and sociodemographic factors (age, gender, race/skin colour, geographic region and income), health status/behaviour characteristics (poor self-rated health status, number of chronic conditions and alcohol consumption) and variables related to healthcare utilisation (number of visits, usual source of care, care coordination, doctor's awareness of all medication, difficulty in managing own medication and number of medicines)., Conclusions: Our work found that sleeping pills consumption is disproportionately prevalent among women, is associated with worse health status and increases with more medical office visits and use of additional medicines. Moreover, the large inexplicable variations in care deserve special attention from policy-makers and clinicians., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Royal Pharmaceutical Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: To assess the association between childhood hunger experiences and the prevalence of chronic diseases later in life., Methods: A cross-sectional study was conducted using baseline data from the Brazilian Longitudinal Study of Aging (ELSI-Brazil), a nationally representative study of persons aged 50 years and older (n = 9 412). Univariate and bivariate analyses were used to describe the sample, and multivariate logistic regressions to examine the association between childhood hunger and hypertension, diabetes, arthritis and osteoporosis. Adjusted odds ratios and predicted probabilities were calculated., Results: 24.7% of Brazilians aged 50 and over experienced hunger during childhood. This harmful exposure was significantly more common among non-white people, individuals with lower educational attainment, lower household income and heavy manual laborers. Regional variation was also observed, as the prevalence of individuals reporting childhood hunger was higher in the North and Northeast regions. The multivariate analysis revealed that older adults who reported having experienced hunger during childhood had 20% higher odds of developing diabetes in adulthood (aOR = 1.20, 95% CI: 1.02 - 1.41) and 38% higher odds of developing osteoporosis (aOR = 1.38, 95% CI: 1.15 - 1.64) than adults who did not experience hunger during childhood, after controlling for covariates., Conclusions: The study showed an association between childhood hunger and two chronic diseases in later life: diabetes and osteoporosis. This work restates that investing in childhood conditions is a cost-effective way to have a healthy society and provides evidence on relationships that deserve further investigation to elucidate underlying mechanisms.

Background: Healthcare spending has grown over the last decades in all developed countries. Making hard choices for investments in a rational, evidence-informed, systematic, transparent and legitimate manner constitutes an important objective. Yet, most scientific work in this area has focused on developing/improving prescriptive approaches for decision making and presenting case studies. The present work aimed to describe existing practices of priority setting and resource allocation (PSRA) within the context of publicly funded health care systems of high-income countries and inform areas for further improvement and research., Methods: An online qualitative survey, developed from a theoretical framework, was administered with decision-makers and academics from 18 countries. 450 individuals were invited and 58 participated (13% of response rate)., Results: We found evidence that resource allocation is still largely carried out based on historical patterns and through ad hoc decisions, despite the widely held understanding that decisions should be based on multiple explicit criteria. Health technology assessment (HTA) was the tool most commonly indicated by respondents as a formal priority setting strategy. Several approaches were reported to have been used, with special emphasis on Program Budgeting and Marginal Analysis (PBMA), but limited evidence exists on their evaluation and routine use. Disinvestment frameworks are still very rare. There is increasing convergence on the use of multiple types of evidence to judge the value of investment options., Conclusions: Efforts to establish formal and explicit processes and rationales for decision-making in priority setting and resource allocation have been still rare outside the HTA realm. Our work indicates the need of development/improvement of decision-making frameworks in PSRA that: 1) have well-defined steps; 2) are based on multiple criteria; 3) are capable of assessing the opportunity costs involved; 4) focus on achieving higher value and not just on adoption; 5) engage involved stakeholders and the general public; 6) make good use and appraisal of all evidence available; and 6) emphasize transparency, legitimacy, and fairness.

Background: Due to growing expenditures, health systems have been pushed to improve decision-making practices on resource allocation. This study aimed to identify which practices of priority setting and resource allocation (PSRA) have been used in healthcare systems of high-income countries., Methods: A scoping literature review (2007-2019) was conducted to map empirical PSRA activities. A two-stage screening process was utilized to identify existing approaches and cluster similar frameworks. That was complemented with a gray literature and horizontal scanning. A narrative synthesis was carried out to make sense of the existing literature and current state of PSRA practices in healthcare., Results: One thousand five hundred eighty five references were found in the peer-reviewed literature and 25 papers were selected for full-review. We identified three major types of decision-making framework in PSRA: 1) Program Budgeting and Marginal Analysis (PBMA); 2) Health Technology Assessment (HTA); and 3) Multiple-criteria value assessment. Our narrative synthesis indicates these formal frameworks of priority setting and resource allocation have been mostly implemented in episodic exercises with poor follow-up and evaluation. There seems to be growing interest for explicit robust rationales and ample stakeholder involvement, but that has not been the norm in the process of allocating resources within healthcare systems of high-income countries., Conclusions: No single dominate framework for PSRA appeared as the preferred approach across jurisdictions, but common elements exist both in terms of process and structure. Decision-makers worldwide can draw on our work in designing and implementing PSRA processes in their contexts.

Background: Polypharmacy has become an increasingly public health issue as population age and novel drugs are developed. Yet, evidence on low- and middle-income countries (LMIC) is still scarce., Objective: This work aims to estimate the prevalence of polypharmacy among Brazilians aged 50 and over, and investigate associated factors., Methods: A cross-sectional study was conducted using data from the baseline assessment of the Brazilian Longitudinal Study of Aging (ELSI-Brazil), a nationally representative study of persons aged 50 years and older (n=9,412). Univariate and bivariate analyses described the sample. Robust Poisson regression was used to estimate prevalence ratios and predict probabilities of polypharmacy., Results: Prevalence of polypharmacy was estimated at 13.5% among older adults in Brazil. Important disparities were observed in regard to gender (16.1% among women and 10.5% among men), race (16.0% among whites and 10.1% among blacks) and geographic region (ranging from 5.1% in the North to 18.7% in the South). The multivariate analysis showed that polypharmacy is associated with various sociodemographic/individual factors (age, gender, race, education, region, health status, body mass index) as well as with several variables of healthcare access/utilization (number of visits, same physician, provider's knowledge of patient's medications, gate-keeper, and difficulty managing own medication). Overall, the more utilization of health services, the higher the probability of polypharmacy, after adjusting for all other model covariates., Conclusions: Polypharmacy prevalence is relatively low in Brazil, compared to European countries. After controlling for variables of healthcare need and demographic characteristics, there is still substantial residual variance in polypharmacy prevalence. Policies to identify inappropriate prescribing and reduce regional discrepancies are necessary., Competing Interests: CONFLICT OF INTEREST The authors declare no conflict of interest., (Copyright: © Pharmacy Practice and the Authors.)

The fiscal regime implemented in Brazil with the constitutional amendment 95 (EC-95) of December 2016 froze primary expenditures for 20 years, including healthcare spending. Previous studies have estimated strong negative effects of this policy on the health of Brazilians. Although there has been a constant pressure to repeal EC-95, this policy is unlikely to be changed in the near future. Thus, there is also a need to take actions within its own terms in order to mitigate its harmful consequences on population health. Shedding light on the existing evidence about the impact of austerity on health, the present work discusses how decision-makers can use a formal framework of decision making in priority setting and resource allocation to tackle the amplified budgetary strain. Drawing on principles of Program Budgeting and Marginal Analysis (PBMA), efficiency can be improved by shifting spending from low-value to higher-value areas, avoiding the "across-the-board cut" caused by non-differential consideration of expenditures in a context of mismatched growth of demand and supply of healthcare. By evaluating opportunity costs of investment and disinvestment proposals on the basis of multiple criteria and marginal analysis, the Brazilian public healthcare system could obtain gains in value, achieving better performance and attenuating the relative decline in spending on health brought by an austerity scenario.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused over half a million deaths worldwide. Brazil has been particularly impacted, registering more than 1.3 million infections and 57,000 deaths by late June 2020. Aggregate numbers of cases are essential in modeling the epidemic and planning responses; however, more detailed analysis of risk factors associated with SARS-CoV-2 infection are needed. Our study provides an initial examination of characteristics associated with receiving a doctor's diagnosis of COVID-19 among a nationally representative sample of Brazilians aged 50 and over. Data are derived from the second wave of the Brazilian Longitudinal Study of Aging (ELSI-Brazil) and a telephone follow-up survey to ELSI-Brazil participants, known as the ELSI-COVID-19 initiative. The telephone survey was conducted between 26 May and 8 June 2020. Results show that about 2.4% (n = 70) of the sample reported being told by a doctor they had COVID-19, however, only about half of these individuals (n = 37) reported receiving a diagnostic confirmation from viral testing (RT-PCR). Demographic factors (aged 50-60 years), socioeconomic factors (lower household income), health-related factors (obesity, three or more chronic conditions), and geography (living in the Northern region of the country) were positively associated with reporting a COVID-19 diagnosis. Despite the descriptive and preliminary nature of these findings, results reported here suggest the need for more targeted approaches to enhance personal protection and provide greater viral testing options, especially for older, sicker and more vulnerable adults in Brazil.

The continent of the Americas has the greatest number of people infected and deaths associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the world. Brazil occupies the 2nd position in numbers of infected cases and deaths, preceded only by the United States. Older adults and those with pre-existing chronic illnesses are more vulnerable to the consequences of the virus. The SARS-CoV-2 epidemic has serious consequences for health services. Therefore, an assessment of the pandemic's effect on the older Brazilian population is urgently needed. The study examines the prevalence of COVID-19 related symptoms, care-seeking, and cancellation of surgery or other scheduled medical care among a nationally representative sample of Brazilians aged 50 and over derived from the Brazilian Longitudinal Study of Aging (ELSI-Brazil) and a telephone follow-up survey (the ELSI-COVID-19 initiative) between late May and early June 2020. About 10.4% of older adults reported any fever, dry cough or difficulty breathing in the 30 days prior to the interview, with the highest prevalence in the North region (50%). Among individuals with symptoms, only 33.6% sought care. Individuals living in the South or Southeast regions were significantly less likely to seek care for COVID-19 related symptoms. Nearly one in six participants had to cancel scheduled surgery or other medical care; this proportion was higher among women, those with more education, and people with multiple chronic conditions. This paper is among the first to investigate the effect of COVID-19 on health care use in Brazil among older adults. Results highlight the need to adapt health care delivery (such as through telemedicine) to ensure the continuity of care as well as the urgent need for wide dissemination of information to guide the population on disease prevention measures and how to obtain healthcare when needed.

Objective: To assess the association between availability of paid sick leave among parents and children's use of several distinct types of nonurgent health services and emergency care., Methods: Using pooled 2013 to 2017 data from the National Health Interview Survey (NHIS), we created dyadic units of observation linking adults with their children (n = 21 235). Descriptive statistics, logistic regressions for binary outcomes, and regular and zero-inflated negative binomial regressions for count outcomes assessed the relationship between parental coverage by paid sick leave benefits and 12 dependent variables related to health care utilization. Regression analyses controlled for a set of child, parent, and family covariates., Results: Overall, 58.3% of individuals in our sample reported having paid sick leave in their current or latest job. There are substantial disparities in availability of paid sick leave in terms of parent sex, race, education, and income. Controlling for covariates, the odds of children with at least one parent with access to paid sick leave having any visit to a medical office in the past 12 months are 27% higher than for children whose parents do not have this benefit. Similar positive associations were observed for general doctor visit (OR = 1.18, 95%CI: 1.05-1.32), mental health professional visit (OR = 1.19, 95%CI: 1.01-1.42), and receipt of flu vaccination (OR = 1.21, 95%CI: 1.11-1.33). There was no statistically significant association with emergency room use, once covariates were controlled., Conclusions: Availability of paid sick leave among parents is associated with increased children's utilization of nonemergency health services and primary care., (© 2020 John Wiley & Sons, Ltd.)

Over the last two decades, economic evaluation of health technologies has developed enormously, affirming its importance within the pursuit of efficiency in the management of health care systems. One concern that has been raised with health technology assessment (HTA) has been its operationalization within the realm of decision making. Here, we suggest a mechanism by which HTA can be understood as an input into a broader framework for priority setting and resource allocation. When HTA is seen in this light, topics that at times have had some lack of clarity, such as public engagement and disinvestment, simply become steps in the overall decision-making process.

Background: Implementing adequate strategies to assess the value of health services plays a central role in the effort to deal with the financial pressures faced by health care systems worldwide. This study aimed to understand which approaches to value assessment have been used in developed countries., Methods: We conducted a rapid review and a gray literature search to identify value assessment frameworks. A two-stage screening process was utilized to identify existing approaches and cluster similar frameworks. In addition, we developed an interpretive classification system to make sense of existing approaches., Results: One thousand one hundred seventy-six references were identified and 38 papers were selected for full-review. Among these 38 articles, 22 distinct approaches to assess value of health care interventions were identified and classified according to four points: 1) use of single or multiple considerations to base value estimates; 2) use of disease-specific or generic criteria; 3) reliance on process-based or outcomes-based consideration; and 4) type of input and evidence considered., Conclusions: The contextual nature of value assessment in health care becomes evident with the diversity of existing approaches. Despite the predominance of cases relying on the Incremental cost-effectiveness ratio as the measure of value, this approach has not been sufficient to meet the needs of decision-makers. The use of multiple criteria has become more and more important, as well as the consideration of patient-reported measures. Considerations of costs are not always explicit and consistent.

International comparative studies constitute a highly valuable contribution to public policy research. Analysing different policy designs offers not only a mean of knowing the phenomenon itself but also gives us insightful clues on how to improve existing practices. Although much of the work carried out in this realm relies on quantitative appraisal of the data contained in international databases or collected from institutional websites, countless topics may simply not be studied using this type of methodological design due to, for instance, the lack of reliable databases, sparse or diffuse sources of information, etc. Here then we discuss the use of the qualitative descriptive approach as a methodological tool to obtain data on how policies are structured. We propose the use of online qualitative surveys with key stakeholders from each relevant national context in order to retrieve the fundamental pieces of information on how a certain public policy is addressed there. Starting from Sandelowski's seminal paper on qualitative descriptive studies, we conduct a theoretical reflection on the current methodological proposition. We argue that a researcher engaged in this endeavour acts like a composite-sketch artist collecting pieces of information from witnesses in order to draw a valid depiction of reality. Furthermore, we discuss the most relevant aspects involving sampling, data collection and data analysis in this context. Overall, this methodological design has a great potential for allowing researchers to expand the international analysis of public policies to topics hitherto little appraised from this perspective., (© 2018 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Background: Active management of existing health technologies (e.g., devices, diagnostic, and/or medical procedures) to ensure the delivery of high value care is increasingly recognized around the world. A number of initiatives have raised awareness of technologies that may be overused, mis-used, or potentially harmful by compiling them into lists of low value care. However, despite the growing number of lists, changes to local healthcare practices remain challenging for many systems. The objective of this study was to develop and implement a process, leveraging existing initiatives and data assets, to produce a list of prioritized low value technologies for health technology reassessment (HTR)., Methods: An expert advisory committee comprised of clinical experts and health system decision-makers was convened to determine key process requirements. Once developed, the process was piloted to assess feasibility in the Canadian province of British Columbia (BC)., Results: The expert advisory committee identified five required attributes for the process: data-driven, routine and replicable, actionable, stakeholder collaboration, and high return on investment. Guided by these attributes, a 5-step process was developed. First, over 1300 published low value technologies (i.e., from the National Institute for Health and Care Excellence [NICE] "do not do" recommendations, low value technologies in the Australian Medical Benefits Schedule, and Choosing Wisely "Top 5" lists) were identified. Using appropriate coding systems for BC's administrative health data (e.g., International Classification of Diseases [ICD]), the low value technologies were queried to examine frequencies and costs of technology use. This information was used to rank potential candidates for reassessment based on high annual budgetary impact. Lastly, clinical experts reviewed the ranked technologies prior to broad dissemination and stakeholder action. Pilot testing of the process in BC resulted in the prioritization of 9 initial candidate technologies for reassessment., Conclusions: This is the first account of a systematic approach to move a collective body of low value technology recommendations into action in a healthcare setting. This work demonstrates the feasibility and strength of using administrative data to identify and prioritize low value technologies for HTR at a population-level.

In dealing with scarcity of resources within healthcare systems, decision-makers inevitably have to make choices about which services to fund. Setting priorities represents a challenging task that requires systematic, explicit and transparent methodologies with focus on economic efficiency. In addition, the engagement of the general public in the process of decision-making has been regarded as one of the most important aspects of the management of publicly-funded health systems in liberal democracies. In the current essay, we aim to discuss the problematics of public engagement in the process of resource allocation and priority-setting within the context of publiclyfunded health systems. Our central argument is that although there may be a conflict between democratic mechanisms of citizen participation and economic efficiency, in the extra-welfarist sense, expected for/from the system, the solution for this tension does not seem to rely on more or novel authoritative technocratic approaches, but rather on the deepening and betterment of democratic participation., (© 2018 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Rules and principles for guiding decision-making in the health care sector have been debated for decades. Here, we present a critical appraisal of the two most important paradigms in this respect: welfarism and extra-welfarism. While the former deals with the maximization of the overall sum of individual utilities as its primary outcome, the latter has been focusing on the maximization of the overall health status. We argue that welfarism has three main problems: (1) its central idea of overall sum of individual utilities does not capture societal values decisively relevant in the context of health; (2) the use of the Potential Pareto Improvement brings an unresolvable separation between efficiency and equity; and (3) individual utility may not be a good measure in the health sector, given that individuals might value things that diminish their overall health. In turn, the extra-welfarist approach is criticized regarding four main limitations: (1) the advocated expansion of the evaluative space, moving from utility to health, may have represented in reality a narrowing of it; (2) it operates using non-explicit considerations of equity; (3) it still holds the issue of "inability to desire" of unprivileged people being considered the best judges of weighing the criteria used to building the health measures; and (4) there is controversial empirical evidence about society members' values that support its assumptions. Overall, both paradigms show significant weaknesses, but the debate has still been within the realm of welfare economics, and even the new approaches to resource allocation in health care systems appear to be unable to escape from these boundaries.

A method based on liquid-liquid extraction followed by high-performance liquid chromatography (HPLC) with positive ion electrospray ionization tandem mass spectrometry (ESI-MS/MS) detection was developed for the simultaneous determination of lopinavir (LPV) and ritonavir (RTV) in human blood, semen and saliva samples. The acquisition was performed in multiple reaction monitoring (MRM) mode, monitoring the transitions: m/z 629 > 447.1 for LPV, 721.18 > 268.02 for RTV and m/z 747.22 > 322.03 for the internal standard (IS). The limit of quantification was 1 ng/mL for both analytes in all matrices. The method was linear in the studied range (1-2000 ng/mL for LPV and 1-200 ng/mL for RTV), with r2 > 0.99 for each drug, and the run time was 4.5 min. The intra-assay precisions (%) were in the ranges of 0.1-14.2 (LPV) and 0.4-12.7 (RTV), the inter-assay precisions were in the ranges of 2.8-15.3 (LPV) and 1.1-12.8 (RTV) and the intra-and inter-assay recoveries were >85% for both drugs. The extraction efficiencies were 73.5-118.4% for LPV and 74.4-126.2% for RTV. The analytical method was applied to measure LPV and RTV concentrations in blood plasma (total and unbound fraction), saliva and semen of six HIV+ individuals under stable treatment with Kaletra soft gel capsules. The results were consistent with previously published data.