Patients with multiple needs for healthcare and priority to the worse off

There is a growing body of literature which suggests that decisions about healthcare priority setting should take into account the extent to which patients are worse off. However, such decisions are often based on how badly off patients are with respect to the condition targeted by the treatment whose priority is under consideration (condition‐specific severity). In this paper I argue that giving priority to the worse off in terms of condition‐specific severity does not reflect the morally relevant sense of being worse off. I conclude that an account of giving priority to the worse off relevant for healthcare priority setting should take into account how badly off patients are when all of their conditions are considered (holistic severity).     

Incorporating evolutionary processes into conservation planning using species distribution data: a case study with the western Mediterranean herpetofauna

Aim To incorporate evolutionary processes into conservation planning using species distribution patterns and environmental gradients as surrogates for genetic diversity. Location Western Mediterranean Basin. Methods Distributions of 154 herpetological species were predicted using maximum entropy models, and groups of significantly co‐occurring species (biotic elements) were identified. Environmental gradients were characterized for the complete area and for the area covered by each biotic element, by performing a principal component analysis on the data matrix composed of nine environmental variables. The first two principal component analysis axes were classified into four categories each, and those categories were combined with each other resulting in an environmental classification with 16 categories. To identify priority conservation areas, biotic elements and environmental categories were used as surrogates for the neutral and adaptive components of genetic diversity, respectively. Priority areas for conservation were identified under three scenarios: (1) setting targets for species only; (2) setting targets for species and for each environmental category of the overall area; and (3) setting targets for each species and for each environmental category within each biotic element. Results Nine biotic elements were identified – four for the amphibians and five for the reptiles. Priority areas identified in the three scenarios were similar in terms of amount of area selected, but exhibited low spatial agreement. Main conclusions Prioritization exercises that integrate surrogates for evolutionary processes can deliver spatial priorities that are fairly different to those where only species representation is considered. While new methods are emerging to incorporate molecular data in conservation prioritization, it is unlikely to be enough data for enough taxa for this to be feasible in many regions. We develop an approach using surrogates for both the neutral and adaptive components of genetic diversity that may enhance biodiversity persistence and representation when molecular data are not available or geographically comprehensive.     

What is the Conservation Value of a Plant in a Botanic Garden? Using Indicators to Improve Management of Ex Situ Collections

Living botanic garden plant collections are a fundamental and underutilized worldwide resource for plant conservation. A common goal in managing a botanical living collection is to maintain the greatest biodiversity at the greatest economic and logistic efficiency. However to date there is no unified strategy for managing living plants within and among botanic gardens. We propose a strategy that combines three indicators of the management priority of a collection: information on species imperilment, genetic representation, and the operational costs associated to maintaining genetic representation. In combination or alone, these indicators can be used to assay effectiveness and efficiency of living collections, and to assign a numeric conservation value to an accession. We illustrate this approach using endangered palms that have been studied to varying degrees. Management decisions can be readily extended to other species based on our indicators. Thus, the conservation value of a species can be shared through existing databases with other botanic gardens and provide a list of recommendations toward a combined management strategy for living collections. Our approach is easily implemented and well suited for decision-making by gardens and organizations interested in plant conservation.     

Dimensions of rationing: who should do what?

Priority setting is a complex interaction of multiple decisions at various levels in the organisation and constrained by history. There is no self evident set of ethical principles or analytical tools to determine what decisions we should take at various levels, nor is there an obvious or easy way to resolve the clash of claims on resources. To make priority setting more "rational" we should concentrate on the processes and structure of decision making and the relation of macro and micro decisions. The debate should promote reasoned, informed, and open argument, draw on a variety of perspectives, and involve a plurality of interests. The aim must be to build up, over time, the capacity to engage in continuous, collective argument.     

Beyond accountability for reasonableness

This paper is a critique of Norman Daniels' and James Sabin's 'Accountability for Reasonableness' framework for making priority-setting decisions in health care in the face of widespread disagreement about values. Accountability for Reasonableness has been rapidly gaining worldwide acceptance, arguably to the point of becoming the dominant paradigm in the field of health policy. The framework attempts to set ground rules for a procedure that ensures that whatever decisions result will be fair, reasonable, and legitimate to the extent that even those who would be adversely affected will have reason to abide by them. I argue that the framework's four conditions are inadequate to this task. While we certainly require a fair and legitimate procedure for making priority setting decisions in health care despite a lack of consensus on relevant ethical and political issues, we must significantly revise the four conditions, and we cannot avoid facing our substantive disagreements head on if we hope to arrive at decisions that would (and should) be acceptable to everyone. I offer two suggestions. First, there is need for greater public involvement in all stages of deliberation. Second, we should give up on the idea that we can simplify the task of democratic deliberation by disallowing particular kinds or reasons and types of reasoning. Reasons of all kinds should be on the table, but then should be judged on their merits, such as consistency, plausibility and explanatory power, without any regard for their alleged sources of authority.     

Species vulnerability to climate change: impacts on spatial conservation priorities and species representation

Climate change may shrink and/or shift plant species ranges thereby increasing their vulnerability and requiring targeted conservation to facilitate adaptation. We quantified the vulnerability to climate change of plant species based on exposure, sensitivity and adaptive capacity and assessed the effects of including these components in complementarity‐based spatial conservation prioritisation. We modelled the vulnerability of 584 native plant species under three climate change scenarios in an 11.9 million hectare fragmented agricultural region in southern Australia. We represented exposure as species' geographical range under each climate change scenario as quantified using species distribution models. We calculated sensitivity as a function of the impact of climate change on species' geographical ranges. Using a dispersal kernel, we quantified adaptive capacity as species' ability to migrate to new geographical ranges under each climate change scenario. Using Zonation, we assessed the impact of individual components of vulnerability (exposure, sensitivity and adaptive capacity) on spatial conservation priorities and levels of species representation in priority areas under each climate change scenario. The full vulnerability framework proved an effective basis for identifying spatial conservation priorities under climate change. Including different dimensions of vulnerability had significant implications for spatial conservation priorities. Incorporating adaptive capacity increased the level of representation of most species. However, prioritising sensitive species reduced the representation of other species. We conclude that whilst taking an integrated approach to mitigating species vulnerability to climate change can ensure sensitive species are well‐represented in a conservation network, this can come at the cost of reduced representation of other species. Conservation planning decisions aimed at reducing species vulnerability to climate change need to be made in full cognisance of the sensitivity of spatial conservation priorities to individual components of vulnerability, and the trade‐offs associated with focussing on sensitive species.     

Observing the observer (I): meta-bayesian models of learning and decision-making

In this paper, we present a generic approach that can be used to infer how subjects make optimal decisions under uncertainty. This approach induces a distinction between a subject's perceptual model, which underlies the representation of a hidden "state of affairs" and a response model, which predicts the ensuing behavioural (or neurophysiological) responses to those inputs. We start with the premise that subjects continuously update a probabilistic representation of the causes of their sensory inputs to optimise their behaviour. In addition, subjects have preferences or goals that guide decisions about actions given the above uncertain representation of these hidden causes or state of affairs. From a Bayesian decision theoretic perspective, uncertain representations are so-called "posterior" beliefs, which are influenced by subjective "prior" beliefs. Preferences and goals are encoded through a "loss" (or "utility") function, which measures the cost incurred by making any admissible decision for any given (hidden) state of affair. By assuming that subjects make optimal decisions on the basis of updated (posterior) beliefs and utility (loss) functions, one can evaluate the likelihood of observed behaviour. Critically, this enables one to "observe the observer", i.e. identify (context- or subject-dependent) prior beliefs and utility-functions using psychophysical or neurophysiological measures. In this paper, we describe the main theoretical components of this meta-Bayesian approach (i.e. a Bayesian treatment of Bayesian decision theoretic predictions). In a companion paper ('Observing the observer (II): deciding when to decide'), we describe a concrete implementation of it and demonstrate its utility by applying it to simulated and real reaction time data from an associative learning task.     

Representative Claims in Healthcare: Identifying the Variety in Patient Representation

In many countries patient involvement is high on the healthcare policy agenda, which includes patient representation in collective decision-making. Patient organizations are generally considered to be important representatives of patients. Other actors also claim to represent patients in decision-making, such as politicians, healthcare professionals, and client advisory councils. In this paper we take a broad view of patient representation, examining all the actors claiming to represent patients in the Dutch debate on the decentralization of care. We conclude that variety in forms of representation could help do justice to the variety of patient preferences. In addition we conclude that in order to ensure the democratic quality of patient representation, actors making representative claims have to reflect on how their claims relate to each other and how they can ensure authorization and accountability in the representative relationship with those they claim to represent.     

Representation of Ecosystem Services by Terrestrial Protected Areas: Chile as a Case Study

Protected areas are increasingly considered to play a key role in the global maintenance of ecosystem processes and the ecosystem services they provide. It is thus vital to assess the extent to which existing protected area systems represent those services. Here, for the first time, we document the effectiveness of the current Chilean protected area system and its planned extensions in representing both ecosystem services (plant productivity, carbon storage and agricultural production) and biodiversity. Additionally, we evaluate the effectiveness of protected areas based on their respective management objectives. Our results show that existing protected areas in Chile do not contain an unusually high proportion of carbon storage (14.9%), agricultural production (0.2%) or biodiversity (11.8%), and also represent a low level of plant productivity (Normalized Difference Vegetation Index of 0.38). Proposed additional priority sites enhance the representation of ecosystem services and biodiversity, but not sufficiently to attain levels of representation higher than would be expected for their area of coverage. Moreover, when the species groups were assessed separately, amphibians was the only one well represented. Suggested priority sites for biodiversity conservation, without formal protection yet, was the only protected area category that over-represents carbon storage, agricultural production and biodiversity. The low representation of ecosystem services and species’ distribution ranges by the current protected area system is because these protected areas are heavily biased toward southern Chile, and contain large extents of ice and bare rock. The designation and management of proposed priority sites needs to be addressed in order to increase the representation of ecosystem services within the Chilean protected area system.     

Exclusion of agricultural lands in spatial conservation prioritization strategies: consequences for biodiversity and ecosystem service representation

Agroecosystems have traditionally been considered incompatible with biological conservation goals, and often been excluded from spatial conservation prioritization strategies. The consequences for the representativeness of identified priority areas have been little explored. Here, we evaluate these for biodiversity and carbon storage representation when agricultural land areas are excluded from a spatial prioritization strategy for South America. Comparing different prioritization approaches, we also assess how the spatial overlap of priority areas changes. The exclusion of agricultural lands was detrimental to biodiversity representation, indicating that priority areas for agricultural production overlap with areas of relatively high occurrence of species. By contrast, exclusion of agricultural lands benefits representation of carbon storage within priority areas, as lands of high value for agriculture and carbon storage overlap little. When agricultural lands were included and equally weighted with biodiversity and carbon storage, a balanced representation resulted. Our findings suggest that with appropriate management, South American agroecosystems can significantly contribute to biodiversity conservation.     

Hung out to dry: choice of priority ecoregions for conserving threatened neotropical anurans depends on life-history traits

Background

In the Neotropics, nearly 35% of amphibian species are threatened by habitat loss, habitat fragmentation, and habitat split; anuran species with different developmental modes respond to habitat disturbance in different ways. This entails broad-scale strategies for conserving biodiversity and advocates for the identification of high conservation-value regions that are significant in a global or continental context and that could underpin more detailed conservation assessments towards such areas.

Methodology/Principal Findings

We identified key ecoregion sets for anuran conservation using an algorithm that favors complementarity (beta-diversity) among ecoregions. Using the WWF''s Wildfinder database, which encompasses 700 threatened anuran species in 119 Neotropical ecoregions, we separated species into those with aquatic larvae (AL) or terrestrial development (TD), as this life-history trait affects their response to habitat disturbance. The conservation target of 100% of species representation was attained with a set of 66 ecoregions. Among these, 30 were classified as priority both for species with AL and TD, 26 were priority exclusively for species with AL, and 10 for species with TD only. Priority ecoregions for both developmental modes are concentrated in the Andes and in Mesoamerica. Ecoregions important for conserving species with AL are widely distributed across the Neotropics. When anuran life histories were ignored, species with AL were always underrepresented in priority sets.

Conclusions/Significance

The inclusion of anuran developmental modes in prioritization analyses resulted in more comprehensive coverage of priority ecoregions–especially those essential for species that require an aquatic habitat for their reproduction–when compared to usual analyses that do not consider this life-history trait. This is the first appraisal of the most important regions for conservation of threatened Neotropical anurans. It is also a first endeavor including anuran life-history traits in priority area-selection for conservation, with a clear gain in comprehensiveness of the selection process.     

Setting priorities: is there a role for citizens' juries?

Citizens'' juries are an attempt to meaningfully involve members of the public in decisions which affect them in their own communities. The Institute for Public Policy Research and Cambridge and Huntingdon Health Authority have recently piloted the first jury in the United Kingdom. Sixteen jurors sat for four days, hearing evidence from a number of expert witnesses. The jurors were asked to consider how priorities for health care should be set, according to what criteria, and to what extent the public should be involved in this process. This pilot was also an attempt to assess the process itself, and our initial evaluation indicates that, given enough time and information, the public is willing and able to contribute to the debate about priority setting in health care.     

Patients' responsibilities in medical ethics

Patients have not been entirely ignored in medical ethics. There has been a shift from the general presumption that 'doctor knows best' to a heightened respect for patient autonomy. Medical ethics remains one–sided, however. It tends (incorrectly) to interpret patient autonomy as mere participation in decisions, rather than a willingness to take the consequences. In this respect, medical ethics remains largely paternalistic, requiring doctors to protect patients from the consequences of their decisions. This is reflected in a one–sided account of duties in medical ethics. Duties fall mainly on doctors and only exceptionally on patients. Medical ethics may exempt patients from obligations because they are the weaker or more vulnerable party in the doctor–patient relationship. We argue that vulnerability does not exclude obligation. We also look at others ways in which patient responsibilities flow from general ethics: for instance, from responsibilities to others and to the self, from duties of citizens, and from the responsibilities of those who solicit advice. Finally, we argue that certain duties of patients counterbalance an otherwise unfair captivity of doctors as helpers.     

A straightforward conceptual approach for evaluating spatial conservation priorities under climate change

Despite wide evidence of a quickly changing world, systematic conservation planning analyses are usually static assuming that the biodiversity being preserved in sites do not change through time. Here we generated a comprehensive ensemble forecasting experiment for 444 amphibian species inhabiting the Atlantic Forest Biodiversity Hotspot. Models were based on four methods for modeling ecological niches, and three future climate simulations. Combinations of these models were used to estimate species occurrences. We used species occurrences to optimize the current and future representation of amphibians with different conservation targets based on their geographic range size. We compared spatial priority outcomes (variance of site selection frequency scores) under dynamic conditions, using a bi-dimensional plot in which the relative importance of each site in achieving conservation targets was assessed both for current time and to 2050. Projections for 2050 show that species richness pattern will remain approximately constant, whereas high turnover rates are forecasted. Selection frequency of several locations varied widely, with recurrent sites located at the north and southeast of the biome. As for 2050, spatial priorities concentrate in the northern part of the biome. Thirty-three sites have high priority for conservation as they play an important role now and will still stand as priority locations in 2050. We present a conceptual model for dynamic spatial conservation prioritization that helps to identify priority sites under climate change. We also call attention to sites in which risk of investment is high, and to those that may become interesting options in the future.     

Conservation planning in a subdivided world

The identification of priority areas for conservation tends to take place over two fundamentally different spatial extents. First, there are analyses conducted at global or large biogeographic extents. Second, there are those conducted within geopolitical units. In this paper we show, using data for North American mammals, that spatial extent can have a profound effect both on the number and locations of the priority areas identified to attain a particular conservation goal. For example, applying the same selection target to obtaining just a single representation of each species, the numbers of areas required increased by approximately an order of magnitude between treating North America as a single unit and treating the provinces separately. Although this scenario is undoubtedly extremely simplistic, such large differences are maintained with greater occurrence targets. Balancing the benefits and disadvantages of conservation planning at different spatial extents is not straightforward. However, a multi-scale approach that exploits the respective benefits and downplays the disadvantages when focussing on smaller or larger extents would seem valuable.     

Synergistic effects of climate and land-use change on representation of African bats in priority conservation areas

Bats are considered important bioindicators and deliver key ecosystem services to humans. However, it is not clear how the individual and combined effects of climate change and land-use change will affect their conservation in the future. We used a spatial conservation prioritization framework to determine future shifts in the priority areas for the conservation of 169 bat species under projected climate and land-use change scenarios across Africa. Specifically, we modelled species distribution models under four different climate change scenarios at the 2050 horizon. We used land-use change scenarios within the spatial conservation prioritization framework to assess habitat quality in areas where bats may shift their distributions. Overall, bats’ representation within already existing protected areas in Africa was low (∼5% of their suitable habitat in protected areas which cover ∼7% of Africa). Accounting for future land-use change resulted in the largest shift in spatial priority areas for conservation actions, and species representation within priority areas for conservation actions decreased by ∼9%. A large proportion of spatial conservation priorities will shift from forested areas with little disturbance under present conditions to agricultural areas in the future. Planning land use to reduce impacts on bats in priority areas outside protected areas where bats will be shifting their ranges in the future is crucial to enhance their conservation and maintain the important ecosystem services they provide to humans.     

Vive la variance: a functional oviposition theory for insect herbivores

We developed state-dependent life-history theory to explain the variance in clutch size decisions made by insect herbivores under a variety of ecological scenarios. An important aspect of our theory is explicit representation of the distribution of host quality and frequency of occurrence. Examination of the theory suggests that clutch size decisions can be highly non-linear with respect to host quality and variability. We then use our theory to explore the potential for bet-hedging strategies to evolve as a function of unpredictable catastrophic events that decimate entire clutches. Our analysis suggests that the benefits to employing such a strategy will frequently be outweighed by costs brought on by delayed oviposition.     

Analysis of patient reported outcomes included in the registrational clinical trials of nivolumab for advanced non-small cell lung cancer

In the era of value-based oncology care, stakeholders are increasingly using patient reported outcomes (PROs) to guide clinical and regulatory decisions. PROs are also included in health technology assessments to guide patient access, drug reimbursement and pricing. We reviewed PROs collected in the United States Food and Drug Administration approved indications of nivolumab in advanced NSCLC. We analyzed the PRO data reported in the CheckMate 9LA (NCT03215706), CheckMate 227 (NCT02477826), CheckMate 057 (NCT01673867), and CheckMate 017 (NCT01642004) registrational clinical trials, and concluded that nivolumab alleviated symptom burden and improved health status of patients in this setting. However, inability of the included PRO instruments to measure immune-related adverse events, differences in the timing of PRO evaluation between treatment groups, incomplete patient participation at all time points, limited patient participation in the later time points, and interpretation of the longitudinal data are key challenges that impede accurate analysis and validation of PROs.     

Habitat suitability models to make conservation decisions based on areas of high species richness and endemism

Biodiversity positively relates with the provisioning of ecosystem services and preserving areas with elevated diversity of highly-functional species could help to ensure human well-being. Most studies addressed to make these decisions use maps relying on species occurrences, where sites containing several species are proposed as priority conservation areas. These maps, however, may underestimate species richness because of the incompleteness of occurrence data. To improve this methodology, we propose using habitat suitability models to estimate the potential distribution of species from occurrence data, and later shaping richness maps by overlapping these predicted distribution ranges. We tested this proposal with Mexican oaks because they provide several ecosystem services and habitat suitability models of species were calibrated with MaxEnt. We used linear regressions to compare the outputs of these predictive maps with those of maps based on species occurrences only and, for both mapping methods, we assessed how much surface of sites with elevated richness and endemism of oaks is currently included within nature reserves. Both mapping methods indicated that oak species are concentrated in mountain regions of Mexico, but predictive maps based on habitat suitability models indicated higher oak richness and endemism that maps based on species occurrences only. Our results also indicated that nature reserves cover a small fraction of areas harboring elevated richness and endemism of oaks. These results suggest that estimating richness across extensive geographic regions using habitat suitability models quickly provides accurate information to make conservation decisions for highly-functional species groups.     

Inpatient to Outpatient Transfer of Diabetes Care: Planning for an Effective Hospital Discharge

ObjectiveTo review data on diabetes discharge planning, provide a definition of an effective diabetes discharge, and summarize one institution’s diabetes discharge planning processes in a teaching hospital.MethodsWe performed a MEDLINE search of the English-language literature published between January 1998 and December 2007 for articles related to the inpatient to outpatient transition of diabetes care. Regulatory guidelines about discharge planning were reviewed. We also analyzed our institution’s procedures regarding hospital discharge.ResultsWe define an effective diabetes discharge as one where the patient has received the necessary skills training and been provided with a clear and understandable postdischarge plan for diabetes care that has been clearly documented and is accessible by the patient’s outpatient health care team. Diabetes is one of the most common conditions managed in the hospital, yet how to transition a patient with diabetes to the outpatient setting is understudied, and the outcome of patients with diabetes after discharge is unknown. Strategies that can be used to ensure an effective diabetes discharge are early identification of patients in need of education, implementation of a clinical pathway, and clear instructions about medications and follow-up appointments at the time of discharge.ConclusionsEffective transfer of care from the inpatient to the outpatient setting remains a priority in the United States. Studies are needed to better define how best to ensure that patients with diabetes are successfully transitioned to ambulatory care. (Endocr Pract. 2009;15:263-269)