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Project AimTo retrospectively evaluate a clinical management algorithm for acute wheezers in a UK Pediatric Emergency Department (PED).Overview and RationaleAcute wheezing attacks are a leading cause of PED attendances and inpatient admissions. Prednisolone, a routine treatment, is intolerable in almost one-third of children, requiring repeated dosing, which may prolong length of stay (LOS). To address this problem, we: (1) developed an acute management algorithm (concise, single-sided flow-chart, instructing immediate management); (2) modified the OCS regime from prednisolone (1 mg/kg, 3-day course) to dexamethasone (600 then 300 mcg/kg); (3) and disseminated guidance regionally. Written information—handouts, e-mails, and posters—were followed-up with verbal reinforcement. We implemented the algorithm in 2017 and revised it further in 2018.EvaluationIn 2019, we retrospectively collected data on 100 acute wheeze attendances (those requiring OCS, aged 2–14), between October and December in 2016, 2017, and 2018 (n = 300), and assessed outcomes.ResultsOver a 48-month period, we reduced OCS intolerability by 67.2% and OCS drug costs by 85.8% (saving £41,470.14), while not significantly influencing the other outcomes.ConclusionsReduced intolerability and substantial cost savings can be achieved by implementing a structured acute pediatric wheeze algorithm and modifying the OCS to single-dose dexamethasone (300 mcg/kg).

Objective structured clinical exams (OSCEs) are a cornerstone of assessing the competence of trainee healthcare professionals, but have been criticised for (1) lacking authenticity, (2) variability in examiners' judgements which can challenge assessment equivalence and (3) for limited diagnosticity of trainees' focal strengths and weaknesses. In response, this study aims to investigate whether (1) sharing integrated-task OSCE stations across institutions can increase perceived authenticity, while (2) enhancing assessment equivalence by enabling comparison of the standard of examiners' judgements between institutions using a novel methodology (video-based score comparison and adjustment (VESCA)) and (3) exploring the potential to develop more diagnostic signals from data on students' performances.The study will use a complex intervention design, developing, implementing and sharing an integrated-task (research) OSCE across four UK medical schools. It will use VESCA to compare examiner scoring differences between groups of examiners and different sites, while studying how, why and for whom the shared OSCE and VESCA operate across participating schools. Quantitative analysis will use Many Facet Rasch Modelling to compare the influence of different examiners groups and sites on students' scores, while the operation of the two interventions (shared integrated task OSCEs; VESCA) will be studied through the theory-driven method of Realist evaluation. Further exploratory analyses will examine diagnostic performance signals within data.The study will be extra to usual course requirements and all participation will be voluntary. We will uphold principles of informed consent, the right to withdraw, confidentiality with pseudonymity and strict data security. The study has received ethical approval from Keele University Research Ethics Committee. Findings will be academically published and will contribute to good practice guidance on (1) the use of VESCA and (2) sharing and use of integrated-task OSCE stations.

IntroductionObjective structured clinical exams (OSCEs) are a cornerstone of assessing the competence of trainee healthcare professionals, but have been criticised for (1) lacking authenticity, (2) variability in examiners’ judgements which can challenge assessment equivalence and (3) for limited diagnosticity of trainees’ focal strengths and weaknesses. In response, this study aims to investigate whether (1) sharing integrated-task OSCE stations across institutions can increase perceived authenticity, while (2) enhancing assessment equivalence by enabling comparison of the standard of examiners’ judgements between institutions using a novel methodology (video-based score comparison and adjustment (VESCA)) and (3) exploring the potential to develop more diagnostic signals from data on students’ performances.Methods and analysisThe study will use a complex intervention design, developing, implementing and sharing an integrated-task (research) OSCE across four UK medical schools. It will use VESCA to compare examiner scoring differences between groups of examiners and different sites, while studying how, why and for whom the shared OSCE and VESCA operate across participating schools. Quantitative analysis will use Many Facet Rasch Modelling to compare the influence of different examiners groups and sites on students’ scores, while the operation of the two interventions (shared integrated task OSCEs; VESCA) will be studied through the theory-driven method of Realist evaluation. Further exploratory analyses will examine diagnostic performance signals within data.Ethics and disseminationThe study will be extra to usual course requirements and all participation will be voluntary. We will uphold principles of informed consent, the right to withdraw, confidentiality with pseudonymity and strict data security. The study has received ethical approval from Keele University Research Ethics Committee. Findings will be academically published and will contribute to good practice guidance on (1) the use of VESCA and (2) sharing and use of integrated-task OSCE stations.

Despite unprecedented progress in developing COVID-19 vaccines, global vaccination levels needed to reach herd immunity remain a distant target, while new variants keep emerging. Obtaining near universal vaccine uptake relies on understanding and addressing vaccine resistance. Simple questions about vaccine acceptance however ignore that the vaccines being offered vary across countries and even population subgroups, and differ in terms of efficacy and side effects. By using advanced discrete choice models estimated on stated choice data collected in 18 countries/territories across six continents, we show a substantial influence of vaccine characteristics. Uptake increases if more efficacious vaccines (95% vs 60%) are offered (mean across study areas=3.9%, range of 0.6%-8.1%) or if vaccines offer at least 12 months of protection (mean across study areas=2.4%, range of 0.2%-5.8%), while an increase in severe side effects (from 0.001% to 0.01%) leads to reduced uptake (mean=-1.3%, range of -0.2% to -3.9%). Additionally, a large share of individuals (mean=55.2%, range of 28%-75.8%) would delay vaccination by 3 months to obtain a more efficacious (95% vs 60%) vaccine, where this increases further if the low efficacy vaccine has a higher risk (0.01% instead of 0.001%) of severe side effects (mean=65.9%, range of 41.4%-86.5%). Our work highlights that careful consideration of which vaccines to offer can be beneficial. In support of this, we provide an interactive tool to predict uptake in a country as a function of the vaccines being deployed, and also depending on the levels of infectiousness and severity of circulating variants of COVID-19. We acknowledge financial support as follows: CN Chinese National Natural Science Foundation (72071017), the joint project of the National Natural Science Foundation of China and the Joint Programming Initiative Urban Europe (NSFC – JPI UE) (‘U- PASS’, 71961137005). CL Instituto Sistemas Complejos de Ingeniería (ISCI), through grant ANID PIA/BASAL AFB180003. ES FEDER/Ministry of Science, Innovation and Universities through grant PID2020-113650RB-I00; Basque Government through grant IT1359-19 (UPV/EHU Econometrics Research Group); BERC 2018–2021 programme; MICINN María de Maeztu excellence accreditation (MDM- 2017-0714). FR FR French National Research Agency Grants ANR-17-EURE-0020 and the Excellence Initiative of Aix-Marseille University - A*MIDEX. KR Creative-Pioneering Researchers Program through Seoul Na- tional University. NA Ndatara Surveys. NZ Waikato Management School. UK European Research Council through the consolidator grant 615596-DECISIONS; internal funding through the Choice Modelling Centre (CMC). We would also like to express our thanks to technical support from Aix-Marseille University, and thank Sofia Hern ́andez Benavides (CL), Simon Dec Pedersen (DK) and Robbie Maris (NZ) for help in data preparation and analysis.

Background & local problem: Acute wheezing attacks are a leading cause of Pediatric Emergency Department (PED) attendances and inpatient admissions and are a considerable burden on the healthcare providers. Almost one-third of children vomit prednisolone in the PED, requiring anti-emetics and repeat dosing. Aim: This quality improvement (QI) intervention aimed to improve oral corticosteroid (OCS) tolerability, reduce emergency department length of stay (LOS), and reduce OCS drug costs for acute wheeze attendances in a PED, while not adversely affecting admissions, re-attendance, or mortality rates. QI Interventions: Included (1) a departmental protocol and (2) modification of the OCS type and dosage from prednisolone (3-day course of 1 mg/kg) to dexamethasone (600 mcg/kg, then single dose 300 mcg/kg). Methods: The study team reviewed the evidence and implemented the interventions. To assess the scale of improvement, we retrospectively collected data on attendance records for patients aged 2-14 years with acute wheeze requiring OCS. We collected data on 100 children who attended the PED between October and December for each year (2016, 2017, and 2018). We then assessed OCS tolerability, LOS, OCS drug costs, and, admission, re-attendance, and mortality rates. Results: Over a 48-month period, we increased OCS tolerability by 67.2% and achieved an 85.8% reduction in OCS drug costs (saving £41,553.14). There was no change in the LOS, admission, re-attendance, and mortality rates. Conclusions: Improved tolerability and substantial cost savings can be achieved by implementing a structured acute pediatric wheeze protocol and modifying the OCS to single-dose dexamethasone (300 mcg/kg).

With the growing interest in the topic of attribute non-attendance, there is now widespread use of latent class (LC) structures aimed at capturing such behaviour, across a number of different fields. Specifically, these studies rely on a confirmatory LC model, using two separate values for each coefficient, one of which is fixed to zero while the other is estimated, and then use the obtained class probabilities as an indication of the degree of attribute non-attendance. In the present paper, we argue that this approach is in fact misguided, and that the results are likely to be affected by confounding with regular taste heterogeneity. We contrast the confirmatory model with an exploratory LC structure in which the values in both classes are estimated. We also put forward a combined latent class mixed logit model (LC-MMNL) which allows jointly for attribute non-attendance and for continuous taste heterogeneity. Across three separate case studies, the exploratory LC model clearly rejects the confirmatory LC approach and suggests that rates of non-attendance may be much lower than what is suggested by the standard model, or even zero. The combined LC-MMNL model similarly produces significant improvements in model fit, along with substantial reductions in the implied rate of attribute non-attendance, in some cases even eliminating the phenomena across the sample population. Our results thus call for a reappraisal of the large body of recent work that has implied high rates of attribute non-attendance for some attributes. Finally, we also highlight a number of general issues with attribute non-attendance, in particular relating to the computation of willingness to pay measures.

There has long been substantial interest in understanding consumer food choices, where a key complexity in this context is the potentially large amount of heterogeneity in tastes across individual consumers, as well as the role of underlying attitudes towards food and cooking. The present paper underlines that both tastes and attitudes are unobserved, and makes the case for a latent variable treatment of these components. Using empirical data collected in Northern Ireland as part of a wider study to elicit intra-household trade-offs between home-cooked meal options, we show how these latent sensitivities and attitudes drive both the choice behaviour as well as the answers to supplementary questions. We find significant heterogeneity across respondents in these underlying factors and show how incorporating them in our models leads to important insights into preferences.

With many real world decisions being made in conjunction with other decision makers, or single agent decisions having an influence on other members of the decision maker’s immediate entourage, there is strong interest in studying the relative weight assigned to different agents in such contexts. In the present paper, we focus on the case of one member of a two person household being asked to make choices affecting the travel time and salary of both members. We highlight the presence of significant heterogeneity across individuals not just in their underlying sensitivities, but also in the relative weight they assign to their partner, and show how this weight varies across attributes. This is in contrast to existing work which uses weights assigned to individual agents at the level of the overall utility rather than for individual attributes. We also show clear evidence of a risk of confounding between heterogeneity in marginal sensitivities and heterogeneity in the weights assigned to each member. We show how this can lead to misleading model results, and argue that this may also explain past results showing bargaining or weight parameters outside the usual [0,1] range in more traditional joint decision making contexts. In terms of substantive results, we find that male respondents place more weight on their partner’s travel time, while female respondents place more weight on their partner’s salary.

Seldom have studies taken account of changes in lifestyle habits in the elderly, or investigated their impact on disease-free life expectancy (LE) and LE with cardiovascular disease (CVD). Using data on subjects aged 50+ years from three European cohorts (RCPH, ESTHER and Tromsø), we used multi-state Markov models to calculate the independent and joint effects of smoking, physical activity, obesity and alcohol consumption on LE with and without CVD. Men and women aged 50 years who have a favourable lifestyle (overweight but not obese, light/moderate drinker, non-smoker and participates in vigorous physical activity) lived between 7.4 (in Tromsø men) and 15.7 (in ESTHER women) years longer than those with an unfavourable lifestyle (overweight but not obese, light/moderate drinker, smoker and does not participate in physical activity). The greater part of the extra life years was in terms of “disease-free” years, though a healthy lifestyle was also associated with extra years lived after a CVD event. There are sizeable benefits to LE without CVD and also for survival after CVD onset when people favour a lifestyle characterized by salutary behaviours. Remaining a non-smoker yielded the greatest extra years in overall LE, when compared to the effects of routinely taking physical activity, being overweight but not obese, and drinking in moderation. The majority of the overall LE benefit is in disease free years. Therefore, it is important for policy makers and the public to know that prevention through maintaining a favourable lifestyle is “never too late”. Electronic supplementary material The online version of this article (doi:10.1007/s10654-015-0112-8) contains supplementary material, which is available to authorized users.