Comparative Effectiveness of Adalimumab vs Tofacitinib in Patients With Rheumatoid Arthritis in Australia

Importance

There is a need for observational studies to supplement evidence from clinical trials, and the target trial emulation (TTE) framework can help avoid biases that can be introduced when treatments are compared crudely using observational data by applying design principles for randomized clinical trials. Adalimumab (ADA) and tofacitinib (TOF) were shown to be equivalent in patients with rheumatoid arthritis (RA) in a randomized clinical trial, but to our knowledge, these drugs have not been compared head-to-head using routinely collected clinical data and the TTE framework.

Objective

To emulate a randomized clinical trial comparing ADA vs TOF in patients with RA who were new users of a biologic or targeted synthetic disease-modifying antirheumatic drug (b/tsDMARD).

Design, Setting, and Participants

This comparative effectiveness study emulating a randomized clinical trial of ADA vs TOF included Australian adults aged 18 years or older with RA in the Optimising Patient Outcomes in Australian Rheumatology (OPAL) data set. Patients were included if they initiated ADA or TOF between October 1, 2015, and April 1, 2021; were new b/tsDMARD users; and had at least 1 component of the disease activity score in 28 joints using C-reactive protein (DAS28-CRP) recorded at baseline or during follow-up.

Intervention

Treatment with either ADA (40 mg every 14 days) or TOF (10 mg daily).

Main Outcomes and Measures

The main outcome was the estimated average treatment effect, defined as the difference in mean DAS28-CRP among patients receiving TOF compared with those receiving ADA at 3 and 9 months after initiating treatment. Missing DAS28-CRP data were multiply imputed. Stable balancing weights were used to account for nonrandomized treatment assignment.

Results

A total of 842 patients were identified, including 569 treated with ADA (387 [68.0%] female; median age, 56 years [IQR, 47-66 years]) and 273 treated with TOF (201 [73.6%] female; median age, 59 years [IQR, 51-68 years]). After applying stable balancing weights, mean DAS28-CRP in the ADA group was 5.3 (95% CI, 5.2-5.4) at baseline, 2.6 (95% CI, 2.5-2.7) at 3 months, and 2.3 (95% CI, 2.2-2.4) at 9 months; in the TOF group, it was 5.3 (95% CI, 5.2-5.4) at baseline, 2.4 (95% CI, 2.2-2.5) at 3 months, and 2.3 (95% CI, 2.1-2.4) at 9 months. The estimated average treatment effect was -0.2 (95% CI, -0.4 to -0.03; P = .02) at 3 months and -0.03 (95% CI, -0.2 to 0.1; P = .60) at 9 months.

Conclusions and Relevance

In this study, there was a modest but statistically significant reduction in DAS28-CRP at 3 months for patients receiving TOF compared with those receiving ADA and no difference between treatment groups at 9 months. Three months of treatment with either drug led to clinically relevant average reductions in mean DAS28-CRP, consistent with remission.

Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

A novel electronic patient-reported outcome delivery system to implement health-related quality of life measures in routine clinical care: An analysis of 5 years of experience

Objective

To develop a simple and secure technological solution to incorporate electronic patient-reported outcomes (ePROs) into routine clinical care.

Methods

A novel ePRO questionnaire delivery system was developed by Software for Specialists (S4S) in partnership with OPAL Rheumatology Australia. Validated questionnaires were sent from the electronic medical record (EMR) (Audit4) of patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), lupus or giant cell arteritis (GCA) and delivered to the patient's email address or completed in the clinic waiting room using a smart device (in-practice). Completed questionnaires were encrypted and returned to the patient's Audit4. Deidentified clinical data was extracted and aggregated across all sites. Data collected between April 2016-Dec 2020 were analysed descriptively.

Results

Between April 2016 to Dec 2020, 221,352 Functional Assessment of Chronic Illness Therapy Fatigue (FACIT-F), Patient Health Questionnaire-2 (PHQ-2) and/or HealthCare Resource Utilization (HCRU) questionnaires were sent from 39 of 42 contributing clinics (93%). 85% of questionnaires were delivered via email and 15% in-practice. Overall, 85% of patients completed at least one questionnaire, and of all questionnaires sent, 73% were completed. Females were more likely to engage with the questionnaires than males (87% vs. 81%), and older patients were slightly more likely to complete all questionnaires delivered.

Conclusions

The novel Audit4 ePRO delivery system is an effective tool for incorporating PROs into routine clinical care. The data generated provides a unique opportunity to understand the full burden of disease for patients in the real-world setting and the impact of interventions.

Comparison of cone bioassay estimates at two laboratories with different Anopheles mosquitoes for quality assurance of pyrethroid insecticide-treated nets

Background

Quality assurance (QA) of insecticide-treated nets (ITNs) delivered to malaria-endemic countries is conducted by measuring physiochemical parameters, but not bioefficacy against malaria mosquitoes. This study explored utility of cone bioassays for pre-delivery QA of pyrethroid ITNs to test the assumption that cone bioassays are consistent across locations, mosquito strains, and laboratories.

Methods

Double-blinded bioassays were conducted on twenty unused pyrethroid ITNs of 4 brands (100 nets, 5 subsamples per net) that had been delivered for mass distribution in Papua New Guinea (PNG) having passed predelivery inspections. Cone bioassays were performed on the same net pieces following World Health Organization (WHO) guidelines at the PNG Institute of Medical Research (PNGIMR) using pyrethroid susceptible Anopheles farauti sensu stricto (s.s.) and at Ifakara Health Institute (IHI), Tanzania using pyrethroid susceptible Anopheles gambiae s.s. Additionally, WHO tunnel tests were conducted at IHI on ITNs that did not meet cone bioefficacy thresholds. Results from IHI and PNGIMR were compared using Spearman’s Rank correlation, Bland–Altman (BA) analysis and analysis of agreement. Literature review on the use of cone bioassays for unused pyrethroid ITNs testing was conducted.

Results

In cone bioassays, 13/20 nets (65%) at IHI and 8/20 (40%) at PNGIMR met WHO bioefficacy criteria. All nets met WHO bioefficacy criteria on combined cone/tunnel tests at IHI. Results from IHI and PNGIMR correlated on 60-min knockdown (KD60) (r_s = 0.6,p = 0.002,n = 20) and 24-h mortality (M24) (r_s = 0.9,p < 0.0001,n = 20) but BA showed systematic bias between the results. Of the 5 nets with discrepant result between IHI and PNGIMR, three had confidence intervals overlapping the 80% mortality threshold, with averages within 1–3% of the threshold. Including these as a pass, the agreement between the results to predict ITN failure was good with kappa = 0.79 (0.53–1.00) and 90% accuracy.

Conclusions

Based on these study findings, the WHO cone bioassay is a reproducible bioassay for ITNs with > 80% M24, and for all ITNs provided inherent stochastic variation and systematic bias are accounted for. The literature review confirms that WHO cone bioassay bioefficacy criteria have been previously achieved by all pyrethroid ITNs (unwashed), without the need for additional tunnel tests. The 80% M24 threshold remains the most reliable indicator of pyrethroid ITN quality using pyrethroid susceptible mosquitoes. In the absence of alternative tests, cone bioassays could be used as part of pre-delivery QA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-022-04217-3.

POS0691 EMULATING A TARGET TRIAL OF ADALIMUMAB VERSUS TOFACITINIB IN PATIENTS WITH RHEUMATOID ARTHRITIS: A COMPARATIVE EFFECTIVENESS ANALYSIS USING THE OPAL REAL-WORLD DATASET

Background

There is increasing recognition of the complementary role for real-world evidence (RWE) in health care and regulatory decision-making (1). However, careful analysis is required when drugs are compared using observational data to account for differences between treatment groups. Electronic medical records (EMR) are an important source of real-world data (RWD), but outcomes are often recorded incompletely.

We emulated a target trial of adalimumab (ADA) versus tofacitinib (TOF) in patients with rheumatoid arthritis (RA) using the OPAL dataset to illustrate the application of methodologies to address the challenges of non-random treatment assignment and incomplete data. The OPAL dataset is derived from EMR of 112 community-based rheumatologists around Australia, where practitioners have discretion to prescribe whichever b/tsDMARD they consider most clinically appropriate.

Objectives

To estimate the average treatment effect (ATE) of TOF compared to ADA at 3 and 9 months, defined as the difference in mean disease activity score (DAS28CRP), in patients with RA who are new users of a b/tsDMARD. This is equivalent to aiming to estimate the intention-to-treat effect in a randomised controlled trial.

Methods

OPAL patients diagnosed with RA were included if they initiated ADA or TOF between 1 October 2015 and 1 April 2021, were new b/tsDMARD users (no prior recorded b/tsDMARD, at least 6 months of prior csDMARD treatment), and had at least 1 component of DAS28CRP recorded at baseline or during follow-up. Data were also extracted on baseline characteristics. Baseline characteristics were DAS28CRP, patient demographics, regional location, disease duration, prescriber characteristics (including gender, experience), prior recorded comorbidities, and prior and concomitant treatment with csDMARDs and oral corticosteroids.

We used random forest multiple imputation to impute missing baseline and follow-up DAS28CRP components (2). Stable balancing weights (SBW) were then used to balance the treatment groups in terms of their baseline characteristics, including DAS28CRP (3). For each imputed dataset, the ATE at 3 months was estimated as the difference between the mean outcome in the two treatment groups after balancing (i.e. weighting) the sample, and then these estimates were averaged across the 10 imputed datasets. The ATE at 9 months was estimated similarly. The whole procedure was subsequently performed in 1000 bootstrap samples to estimate a 95% confidence interval (CI) for the ATEs using the percentile method (4).

Results

842 patients were identified including n=569 treated with ADA and n=273 treated with TOF. After applying the SBW, the maximum difference between the mean of each baseline characteristic in the ADA and TOF groups was less than 0.03% of the corresponding standard deviation in the whole sample, indicating reasonable balance was achieved in this complex dataset. After weighting, mean DAS28CRP reduced from 5.3 at baseline (both ADA and TOF groups) to 2.6 and 2.3 at 3 and 9 months for ADA, and 2.4 and 2.3 at 3 and 9 months for TOF.

The estimated ATE was -0.22 (95% CI -0.36, -0.03; p=0.02) at 3 months, indicating a modest but significant reduction in disease activity for patients on TOF. The estimated ATE was -0.03 (95% CI -0.19, 0.1; p=0.56) at 9 months, indicating no difference between groups.

Conclusion

DAS28CRP was significantly lower at 3 months for patients treated with TOF compared to ADA. However, 3 months of treatment with either drug led to substantive average reductions in mean DAS28CRP, consistent with remission. There was no difference between drugs at 9 months. Future work will estimate a per-protocol effect.

References

[1]Arlett et al. Clin Pharmacol Ther 2022;111(1):21–3.

[2]van Buuren and Groothuis-Oudshoorn J Stat Softw 201145(3):1–67

[3]Zubizarreta J Am Stat Assoc 2015;110(511):910–22

[4]Bartlett and Hughes Stat Methods Med Res 2020;29(12):3533–46

Acknowledgements

The authors acknowledge the members of OPAL Rheumatology Ltd and their patients for providing clinical data for this study, and Software4Specialists Pty Ltd for providing the Audit4 platform.

Disclosure of Interests

Claire Deakin: None declared, Bianca De Stavola: None declared, Geoff Littlejohn Consultant of: Abbvie, Janssen, Bristol Myers Squibb, Gilead, Eli Lilly, and MSD, Hedley Griffiths Consultant of: AbbVie and Eli Lilly, Sabina Ciciriello: None declared, Peter Youssef Speakers bureau: AbbVie, Novartis, Eli Lilly, David Mathers: None declared, Paul Bird Speakers bureau: Abbvie, Janssen, Bristol Myers Squibb, Pfizer, Novartis, Gilead, Eli Lilly, Consultant of: Abbvie, Janssen, Bristol Myers Squibb, Pfizer, Novartis, Gilead, Eli Lilly, Imaging consulting for Synarc and Boston Imaging Core Lab., Tegan Smith: None declared, Catherine OSullivan: None declared, Tim Freeman: None declared, Dana Segelov: None declared, David Hoffman: None declared, Shaun Seaman: None declared

Stratification of malaria incidence in Papua New Guinea (2011-2019): Contribution towards a sub-national control policy

Malaria risk in Papua New Guinea (PNG) is highly heterogeneous, between and within geographical regions, which is operationally challenging for control. To enhance targeting of malaria interventions in PNG, we investigated risk factors and stratified malaria incidence at the level of health facility catchment areas. Catchment areas and populations of 808 health facilities were delineated using a travel-time accessibility approach and linked to reported malaria cases (2011-2019). Zonal statistics tools were used to calculate average altitude and air temperature in catchment areas before they were spatially joined with incidence rates. In addition, empirical Bayesian kriging (EBK) was employed to interpolate incidence risk strata across PNG. Malaria annual incidence rates are, on average, 186.3 per 1000 population in catchment areas up to 600 m, dropped to 98.8 at (800-1400) m, and to 24.1 cases above 1400 m altitude. In areas above the two altitudinal thresholds 600m and 1400m, the average annual temperature drops below 22°C and 17°C, respectively. EBK models show very low- to low-risk strata (<100 cases per 1000) in the Highlands, National Capital District and Bougainville. In contrast, patches of high-risk (>200 per 1000) strata are modelled mainly in Momase and Islands Regions. Besides, strata with moderate risk (100-200) predominate throughout the coastal areas. While 35.7% of the PNG population (estimated 3.33 million in 2019) lives in places at high or moderate risk of malaria, 52.2% (estimated 4.88 million) resides in very low-risk areas. In five provinces, relatively large proportions of populations (> 50%) inhabit high-risk areas: New Ireland, East and West New Britain, Sandaun and Milne Bay. Incidence maps show a contrast in malaria risk between coastal and inland areas influenced by altitude. However, the risk is highly variable in low-lying areas. Malaria interventions should be guided by sub-national risk levels in PNG.

Insights into the potential of rheological measurements in development of dry powder inhalation formulations

Study of flow is a key to development of dry powder inhalation formulations. Various static (bulk) and dynamic rheological measurements are used to study different aspects of powder flow and packing. Among rheological measurements, the permeability and the fluidization energy are, conceptually, most relevant to dispersion of dry powder inhalation formulations. The aim of the current study was to test the robustness and the range of applications of the two measurements, among other rheological measurements. To this end, we prepared and studied a series of ternary, carrier-based dry powder inhalation formulations. The formulations were mixtures of coarse-fine excipient (α-lactose monohydrate) blends, with different fine excipient concentrations (0.0-15.0 % w/w), and a spray-dried drug (fluticasone propionate) material. The excipient blends were characterized in terms of morphology, size, crystallinity and rheological properties. The formulations were evaluated in vitro using a low resistance inhalation device, the Cyclohaler®, and a high resistance inhalation device, the Handihaler®. The study design aimed to complement literature data. Bulk rheological measurements, specifically the bulk density, the compressibility, and the permeability, exhibited satisfactory precision and could demonstrate changes in powder composition and structure. They hold a potential for use as critical material attributes to aid monitoring and optimization of carrier-based dry powder inhalation formulations in quality-by-design systems. On the other hand, dynamic rheological measurements, specifically the basic flowability energy, the specific energy, and the fluidization energy, generally exhibited high variability, which obscured interpretation of the measurements and implied heterogeneous powder structures. The fluidization energy could, nevertheless, convey structural changes taking place during powder fluidization.

At the limits of "capability": The sexual and reproductive health of women migrant workers in Malaysia

Despite the centrality of sexual and reproductive health (SRH) to UN Sustainable Development Goals (SDGs), women migrant workers in Malaysia face an environment inimical to their SRH needs. Drawing on qualitative case study material, we present the first empirical application of the capability approach (CA) to explore the reproductive health needs of women migrant workers in a developing country, offering an original analysis of the capability for SRH of these women. Specifically, we explore the resources available to them; their opportunities and freedoms ("capabilities"); and factors that mediate transformation of resources into capability sets ("conversion factors"). While SRH information and health care are notionally available, women migrant workers face multiple challenges in converting resources into functionings, constraining the achievement of capability for SRH. Challenges include language barriers, personal beliefs, power relations between workers and employers and the consequences of current migration policy. We consider the scale of the challenges facing these women in securing SRH rights, the difficulties of operationalising the CA within such a setting, and the implications of our findings for the adequacy of the CA in supporting marginalised populations.

POS1461-HPR THE DEVELOPMENT OF A NOVEL EPRO DELIVERY SYSTEM TO MEASURE PATIENT QUALITY OF LIFE IN ROUTINE CLINICAL CARE: AN ANALYSIS OF 5 YEARS OF EXPERIENCE

Background:

Registry studies and clinical trials are increasingly incorporating patient reported outcomes (PROs) to measure the full burden of disease and better measure the efficacy and value of medicines; however, the burden of paper-based surveys, time constraints, and privacy concerns impede the widespread use of PROs in routine clinical care.

Objectives:

To develop a simple and secure technological solution to incorporate validated PROs into routine clinical care for patients with rheumatic diseases, and to assess the patient response to functional assessment of chronic illness therapy fatigue (FACIT-F), patient health questionnaire-2 (PHQ-2), and healthcare resource utilization (HCRU) questionnaires delivered using this ePRO method.

Methods:

A novel ePRO questionnaire delivery system was developed by Software4Specialists in partnership with OPAL Rheumatology. Validated PRO questionnaires were sent from the patient’s electronic medical record (Audit4, Software4Specialists) and delivered to the patient’s email address at time intervals specified by the rheumatologist (defaults to quarterly) or completed in the clinic waiting room prior to the consultation using a tablet or the patient’s smart phone (in-practice). Completed questionnaires were encrypted and returned directly to the patient’s Audit4 electronic medical record held on the clinician’s server for review at the next clinical consultation. The link to the PRO questionnaire expired within 28 days if the questionnaire was not completed, and the questionnaires were automatically cancelled if 2 consecutive links expired. This technology was made available to up to 111 rheumatologists located in 42 clinics in 6 states/territories in Australia, and the use of this technology to furnish the clinical consultation was voluntary for clinicians and patients. Deidentified clinical data was extracted from the servers of participating rheumatologists and aggregated across all sites.1 Data collected between April 2016-Dec 2020 was analysed descriptively.

Results:

Between April 2016-Dec 2020, 99,505 FACIT-F, PHQ-2 and HCRU questionnaires have been delivered to 5,784 patients from 39 of 42 contributing clinics (93%). 85% of questionnaires were delivered via email and 15% in-practice. Overall, 85% of patients completed at least one questionnaire, and of all questionnaires sent, 73% were completed. These rates have remained consistent over time. The completion rates were higher when questionnaires were delivered to patients in-practice compared to email (96% vs 69%). Females were more likely to engage with the questionnaires than males (87% vs 81%), and older patients were slightly more likely to complete all questionnaires delivered. 69% of questionnaires sent via email were completed on the day they were delivered and 94% were completed within 7 days. The median (IQR) number of questionnaires completed per patient was 3 (1,7) and the median (IQR) time since the first questionnaire was completed was 13 months (5,26).

Conclusion:

The novel Audit4 ePRO delivery system is an effective tool for incorporating PROs into routine clinical care to capture data directly from the patient on the impact of their condition on their quality of life. The data generated provides a unique opportunity to understand the full burden of disease for patients in the real-world setting and the impact of interventions.

References:

[1]Littlejohn GO, Tymms KE, Smith T, Griffiths HT. Using big data from real-world Australian rheumatology encounters to enhance clinical care and research. Clin Exp Rheum 2020:38(5): 874 -880.

Acknowledgements:

The authors acknowledge the members of OPAL Rheumatology Ltd and their patients for providing clinical data for this study, and Software4Specialists Pty Ltd for providing the Audit4 platform.

Disclosure of Interests:

Kathleen Tymms: None declared, Tegan Smith: None declared, Claire Deakin: None declared, Tim Freeman: None declared, David Hoffman: None declared, Dana Segelov: None declared, Hedley Griffiths Consultant of: AbbVie, Gilead, Novartis and Lilly., Sabina Ciciriello: None declared, Peter Youssef: None declared, David Mathers: None declared, Catherine OSullivan: None declared, Geoff Littlejohn Consultant of: Over the last 5 years Geoffrey Littlejohn has received educational grants and consulting fees from AbbVie, Bristol Myers Squibb, Eli Lilly, Gilead, Novartis, Pfizer, Janssen, Sandoz, Sanofi and Seqirus

A comparison of the characteristics, motivations, preferences and expectations of men donating sperm online or through a sperm bank

STUDY QUESTION

How do the demographic characteristics, motivations, experiences and expectations of unregulated sperm donors (men donating sperm online through a connection website) compare to sperm donors in the regulated sector (men donating through a registered UK sperm bank)?

SUMMARY ANSWER

Online donors were more likely to be older, married and have children of their own than sperm bank donors, were more varied in their preferences and expectations of sperm donation, and had more concerns about being a sperm donor.

WHAT IS KNOWN ALREADY

While studies have examined motivations and experiences of both regulated sperm bank, and unregulated online sperm donors, no study has directly compared these two groups of donors.

STUDY DESIGN, SIZE, DURATION

An email was sent to the 576 men who were registered sperm donors at the London Sperm Bank, the UK’s largest sperm bank regulated by the Human Fertilisation and Embryology Authority (HFEA), who had commenced donation between January 2010 and December 2016, and had consented to be contacted for research. The online survey, which contained multiple choice and open-ended questions, was completed by 168 men over a 7-week period. The responses were compared to those of sperm donors registered on Pride Angel, a large UK-based connection website for donors and recipients of sperm: our research team had already collected these data. In total, 5299 sperm donors were on Pride Angel at time of data capture and 400 men had completed a similar survey. The responses of 70 actual online sperm donors (i.e. those whose sperm had been used to conceive at least one child) were used for comparison with the sperm bank donors.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The survey obtained data on the sperm donors’ demographic characteristics, motivations, experiences and expectations of sperm donation. Data from sperm bank donors were compared to online donors to examine differences between the two groups. The study compared online and clinic donors who had all been accepted as sperm donors: online donors who had been ‘vetted’ by recipients and sperm bank donors who had passed the rigorous screening criteria set by the clinic.

MAIN RESULTS AND THE ROLE OF CHANCE

A response rate of 29% was obtained from the sperm bank donors. Online donors were significantly older than sperm bank donors (mean ± SD: 38.7 ± 8.4 versus 32.9 ± 6.8 years, respectively) and were more likely to have their own children (p < 0.001 for both characteristics). Both groups rated the motivation ‘I want to help others’ as very important. Online donors rated ‘I don’t want to have children myself’, ‘to have children/procreate’ and ‘to enable others to enjoy parenting as I have myself’ as more important than sperm bank donors, whereas sperm bank donors rated financial payment as more important than online donors, as well as confirmation of own fertility. Most (93.9%) online donors had donated their sperm elsewhere, through other connection sites, fertility clinics, sperm banks or friends and family, compared to only 2.4% of sperm bank donors (p < 0.001). There was a significant difference in how donors viewed their relationship to the child, with online donors much less likely than sperm bank donors to see their relationship as a ‘genetic relationship only’. Online donors had more concerns about being a donor (p < 0.001), for example, being concerned about ‘legal uncertainty and child financial support’ and ‘future contact and uncertainty about relationship with donor-conceived child’.

LIMITATIONS, REASONS FOR CAUTION

Findings may not be representative of all sperm donors as only one online connection site and one HFEA registered sperm bank were used for recruitment.

WIDER IMPLICATIONS OF THE FINDINGS

Despite concern regarding shortages of sperm donors in licensed clinics and unease regarding the growing popularity of unregulated connection websites, this is the first study to directly compare online and sperm bank donors. It highlights the importance of considering ways to incorporate unregulated online sperm donors into the regulated sector. With many online donors well aware of the legal risks they undertake when donating in the unregulated online market, this would both increase the number of sperm donors available at clinics but also provide legal protection and support for donors.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by the Wellcome Trust Grants 104 385/Z/14/Z and 097857/Z/11/Z. The authors have no conflicts of interest.

Gaining political will for actions to achieve health equity: lessons from Australia for advocates

Background

There has been an accumulation of evidence on the importance of action on the social determinants of health to reduce global and national health equity. Yet there has been little effective systematic action by governments. This is commonly attributed to the absence of political will. Despite its importance, however, little research has examined how political will might be created or prevented.

Methods

This paper reports on the results of eight case studies of the extent to which Australian public policy is likely to contribute to reducing health inequities. 192 participants were interviewed including public servants, politicians and their staff, non-government organisation workers and community members. The transcripts were interrogated with the assistance of NVivo software to determine lessons about the creation or destruction of political will. The case studies were of: national primary health care policy, crucial determinants of health (work conditions, internet access, urban planning, social welfare, trade) and an automotive plant closure.

Results

We found the following factors to be important in determining the extent of political will for health equity, whether: path dependency was present; the issue would impact on staying in or winning government; political philosophies stressed collectivism or individualism; there were negative or positive social constructions of groups affected by the policies; economic and/or biomedical framings were dominant; elites (especially business interests) lobbied against the policies; and there was effective civil society and policy advocacy in favour of the policies.

Conclusions

Building on our insights from our case studies of action for political will, we conclude with a series of questions to guide the work of public health activists and policy advocates working to support existing and to create new political will in multiple contexts.

Key messages

The creation of political will is vital to the adoption of policies supportive of health equity. Analysis of 8 policy case studies points to how advocacy can most effectively create political will.

The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications

BACKGROUND

The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications.

METHODS

ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery.

RESULTS

The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784.

CONCLUSIONS

This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance.

CLINICAL TRIAL REGISTRATION

NCT03044899.

Mathematical modelling of the impact of expanding levels of malaria control interventions on Plasmodium vivax

Plasmodium vivax poses unique challenges for malaria control and elimination, notably the potential for relapses to maintain transmission in the face of drug-based treatment and vector control strategies. We developed an individual-based mathematical model of P. vivax transmission calibrated to epidemiological data from Papua New Guinea (PNG). In many settings in PNG, increasing bed net coverage is predicted to reduce transmission to less than 0.1% prevalence by light microscopy, however there is substantial risk of rebounds in transmission if interventions are removed prematurely. In several high transmission settings, model simulations predict that combinations of existing interventions are not sufficient to interrupt P. vivax transmission. This analysis highlights the potential options for the future of P. vivax control: maintaining existing public health gains by keeping transmission suppressed through indefinite distribution of interventions; or continued development of strategies based on existing and new interventions to push for further reduction and towards elimination.

Low density, good flowability cyclodextrin-raffinose binary carrier for dry powder inhaler: anti-hygroscopicity and aerosolization performance enhancement

BACKGROUND

The hygroscopicity of raffinose carrier for dry powder inhaler (DPI) was the main obstacle for its further application. Hygroscopicity-induced agglomeration would cause deterioration of aerosolization performance of raffinose, undermining the delivery efficiency.

METHODS

Cyclodextrin-raffinose binary carriers (CRBCs) were produced by spray-drying so as to surmount the above issue. Physicochemical attributes and formation mechanism of CRBCs were explored in detail. The flow property of CRBCs was examined by FT4 Powder Rheometer. Hygroscopicity of CRBCs was elucidated by dynamic vapor sorption study. Aerosolization performance was evaluated by in vitro deposition profile and in vivo pharmacokinetic profile of CRBC based DPI formulations.

RESULTS

The optimal formulation of CRBC (R₄) was proven to possess anti-hygroscopicity and aerosolization performance enhancement properties. Concisely, the moisture uptake of R₄ was c.a. 5% which was far lower than spray-dried raffinose (R₀, c.a. 65%). R₄ exhibited a high fine particle fraction value of 70.56 ± 0.61% and it was 3.75-fold against R₀. The pulmonary and plasmatic bioavailability of R₄ were significantly higher than R₀ (p < 0.05).

CONCLUSION

CRBC with anti-hygroscopicity and aerosolization performance enhancement properties was a promising approach for pulmonary drug delivery, which could provide new possibilities to the application of hygroscopic carriers for DPI.

Overseeing oversight: governance of quality and safety by hospital boards in the English NHS

OBJECTIVES

To contribute towards an understanding of hospital board composition and to explore board oversight of patient safety and health care quality in the English NHS.

METHODS

We reviewed the theory related to hospital board governance and undertook two national surveys about board management in NHS acute and specialist hospital trusts in England. The first survey was issued to 150 trusts in 2011/2012 and was completed online via a dedicated web tool. A total 145 replies were received (97% response rate). The second online survey was undertaken in 2012/2013 and targeted individual board members, using a previously validated standard instrument on board members' attitudes and competencies (the Board Self-Assessment Questionnaire). A total of 334 responses were received from 165 executive and 169 non-executive board members, providing at least one response from 95 of the 144 NHS trusts then in existence (66% response rate).

RESULTS

Over 90% of the English NHS trust boards had 10-15 members. We found no significant difference in board size between trusts of different types (e.g. Foundation Trusts versus non-Foundation Trusts and Teaching Hospital Trusts versus non-Teaching Hospital Trusts). Clinical representation on boards was limited: around 62% had three or fewer members with clinical backgrounds. For about two-thirds of the trusts (63%), board members with a clinical background comprised less than 30% of the members. Boards were using a wide range and mix of quantitative performance metrics and soft intelligence (e.g. walk-arounds, patient stories) to monitor their organisations with regard to patient safety. The Board Self-Assessment Questionnaire data showed generally high or very high levels of agreement with desirable statements of practice in each of its six dimensions. Aggregate levels of agreement within each dimension ranged from 73% (for the dimension addressing interpersonal issues) to 85% (on the political).

CONCLUSIONS

English NHS boards largely hold a wide range of attitudes and behaviours that might be expected to benefit patient safety and quality. However, there is significant scope for improvement as regards formal training for board members on quality and safety, routine morbidity reporting at boards and attention to the interpersonal dynamics within boards. Directors with clinical backgrounds remain a minority on most boards despite policies to increase their representation. A better understanding of board composition, actions and attitudes should help refine policy recommendations around boards.

Online sperm donation: a survey of the demographic characteristics, motivations, preferences and experiences of sperm donors on a connection website

STUDY QUESTION

What are the demographic characteristics, motivations, preferences and experiences of heterosexual, gay and bisexual sperm donors on a connection website (i.e. a website that facilitates direct contact between donors and recipients of gametes)?

SUMMARY ANSWER

This demographically diverse group of men was donating for altruistic reasons and perceived the website as providing greater choice over donation arrangements: approximately one third favoured anonymous donation, most of whom were heterosexual, whilst gay and bisexual donors were more likely to be in contact with children conceived with their sperm.

WHAT IS KNOWN ALREADY

Despite substantially more sperm donors being registered on connection websites than with clinics, there has been very little research on this population. Current understanding of the impact of sexual orientation on donors' attitudes is also limited.

STUDY DESIGN, SIZE, DURATION

An online survey was conducted over 7 weeks with 383 men registered as sperm donors with Pride Angel, a large UK-based connection website for donors and recipients of sperm.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The survey obtained data on participants' demographic characteristics and their motivations, preferences and experiences regarding online sperm donation, including attitudes towards contact with offspring. Differences according to participants' sexual orientation were examined.

MAIN RESULTS AND THE ROLE OF CHANCE

Most participants (80.4%, 308) were heterosexual, 10.5% (40) were gay and 9.1% (35) were bisexual; ages ranged from 18 to 69 years (median = 36, mean = 37.3, SD = 9.7). A greater proportion of gay and bisexual men desired open-identity donation (P < 0.005) and contact with offspring (P <0.005) than heterosexual men. Approximately one third (28.7%, 110) had donated sperm; 18.3% (70) had conceived at least one child, of whom a minority (25.7%, 18) were currently in contact with the child, comprising significantly more gay and bisexual than heterosexual men (P = 0.001). Heterosexual men were most likely to state a preference for natural insemination, although the large majority (94.3%, 66) of donors who had conceived children had used artificial insemination.

LIMITATIONS, REASONS FOR CAUTION

Findings may not be representative of all sperm donors using connection websites because members of only one website participated and participants were, by necessity, a self-selected sample.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first comprehensive study of donors who connect with recipients via the internet, including a substantial number who have donated and conceived children. The findings indicate that sexual orientation may influence men's donation preferences and raise policy issues concerning donor recruitment and the incorporation of online sperm donation into clinical practice.

STUDY FUNDING/COMPETING INTERESTS

This study was supported by the Wellcome Trust (097857/Z/11/Z). E.T. is the co-founder of Pride Angel; the remaining authors have no conflicts of interest.

Measuring progress in clinical governance: assessing the reliability and validity of the Clinical Governance Climate Questionnaire

Despite a lack of conceptual clarity, the importance of cultural change to clinical governance is widely accepted. While generic measures of organizational performance, culture and climate are available, their relationship to clinical governance is unclear. Consequently, there is currently no valid and reliable measure of clinical governance climate. This study aimed to address the deficiency by reducing a pool of clinical governance climate indicators developed via previous qualitative research, describing a latent factor structure and assessing the internal consistency and external validity of the factor model. The resultant instrument, the Clinical Governance Climate Questionnaire (CGCQ), attained high internal consistency and external (discriminant and construct) validity in a study population of healthcare Trust staff. It consists of 60 items distributed across six sub-scales of clinical governance: planned and integrated quality improvement; proactive risk management; absence of unjust blame and punishment; working with colleagues; training and development; and organizational learning. The measure enables those charged with leading the clinical governance agenda in UK healthcare organizations to assess the progress of organizational development initiatives, highlighting areas requiring particular attention. They might also be of interest to those concerned about the negative unintended consequences of performance management.

Enacting corporate governance of healthcare safety and quality: a dramaturgy of hospital boards in England

The governance of patient safety is a challenging concern for all health systems. Yet, while the role of executive boards receives increased scrutiny, the area remains theoretically and methodologically underdeveloped. Specifically, we lack a detailed understanding of the performative aspects at play: what board members say and do to discharge their accountabilities for patient safety. This article draws on qualitative data from overt non-participant observation of four NHS hospital Foundation Trust boards in England. Applying a dramaturgical framework to explore scripting, setting, staging and performance, we found important differences between case study sites in the performative dimensions of processing and interpretation of infection control data. We detail the practices associated with these differences--the legitimation of current performance, the querying of data classification, and the naming and shaming of executives--to consider their implications.

Effective board governance of safe care: a (theoretically underpinned) cross-sectioned examination of the breadth and depth of relationships through national quantitative surveys and in-depth qualitative case studies

Background

Recent high-profile reports into serious failings in the quality of hospital care in the NHS raise concerns over the ability of trust boards to discharge their duties effectively.

Objectives

Our study aimed to generate theoretically grounded empirical evidence on the associations between board governance, patient safety processes and patient-centred outcomes. The specific aims were as follows: (1) to identify the types of governance activities undertaken by hospital trust boards in the English NHS with regard to ensuring safe care in their organisation; (2) in foundation trusts, to explore the role of boards and boards of governors with regards to the oversight of patient safety in their organisation; (3) to assess the association between particular hospital trust board oversight activities and patient safety processes and clinical outcomes; (4) to identify the facilitators and barriers to developing effective hospital trust board governance of safe care; and (5) to assess the impact of external commissioning arrangements and incentives on hospital trust board oversight of patient safety.

Methods

The study comprised three distinct but interlocking strands: (1) a narrative systematic review in order to describe, interpret and synthesise key findings and debates concerning board oversight of patient safety; (2) in-depth mixed-methods case studies in four organisations to assess the impact of hospital board governance and external incentives on patient safety processes and outcomes; and (3) two national surveys exploring board management in NHS acute and specialist hospital trusts in England, and relating board characteristics to whole-organisation outcomes.

Results

A very high proportion of trust boards reported the kinds of desirable characteristics and board-related processes that research says may be associated with higher performance. Our analysis of the symbolic aspects of board activities highlights the role and differences in local processes of organising the governance of patient safety. Most boards do allocate a considerable amount of time to discussing patient safety and quality-related issues and were using a wide range of hard performance metrics and soft intelligence to monitor its organisation with regard to patient safety. Although the board of governors is generally perceived to be well-meaning, they were also considered to be being largely ineffective in helping to promote and deliver safer care for their organisations. We did not find any statistically significant relationship between board attributes (self-reported) and processes and any patient safety outcome measures. However, we did find a significant relationship between two dimensions of the Board Self-Assessment Questionnaire and two specific-and-related national staff survey organisational ‘process’ measures: (1) staff feeling safe to raise concerns about errors, near-misses and incidents and (2) staff feeling confident that their organisation would address their concerns, if raised. We also found that contracting and external financial incentives appeared to play only a relatively minor role in incentivising quality and safety improvement.

Conclusions

Our research is the first large-scale mixed-methods study of hospital board activity and behaviour related to the oversight of patient safety in the English NHS and the key findings should be used to influence the design of future governance arrangements as well as the training and support of board. Our finding that board governance/competencies appear to be linked to staff feeling safe to raise concerns about patient safety issues, and also their confidence that their organisation would address their concern, is worthy of further and more sustained exploration, particularly in the context of the current focus on improving whistleblowing policies in the NHS.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Absence or presence? Complexities in the donor narratives of single mothers using sperm donation

STUDY QUESTION

How do single mothers who have conceived a child via anonymous or identity-release sperm donation represent the donor?

SUMMARY ANSWER

While the majority of mothers described their anonymous and identity-release donors as symbolically significant to their families, others were more likely to emphasize that their lack of information limited their thoughts about him.

WHAT IS KNOWN ALREADY

There is limited understanding of the factors that impact upon how single mothers represent the donor, and whether or not they are determined by specific donor programmes (anonymous or identity-release).

STUDY DESIGN, SIZE, DURATION

Qualitative interviews were conducted with 46 women who had treatment at a UK licensed fertility clinic during the years 2003–2009. Twenty mothers (43%) had used an anonymous donor, and 26 (57%) had used an identity-release donor.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Among the 46 mothers interviewed, all had at least one child conceived via donor insemination who was between the ages of 4 and 9 years. Mothers were heterosexual and were currently without a live-in and/or long-term partner. Interview data were analysed qualitatively according to the principles of thematic analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

Findings indicated marked diversity in single mothers' representations of the donor. Most (n = 27) mothers talked about the donor as symbolically significant to family life and were likely to describe the donor as (i) a gift-giver, (ii) a gene-giver and (iii) a potential partner. Others (n = 16) talked about the donor as (i) unknown, (ii) part of a process and (iii) out of sight and out of mind. There were mothers with anonymous and identity-release donors in each group. Several mothers explained that their feelings about the donor had changed over time.

LIMITATIONS, REASONS FOR CAUTION

All mothers conceived at a licensed fertility clinic in the UK. Findings are limited to individuals willing and able to take part in research on donor conception.

WIDER IMPLICATIONS OF THE FINDINGS

The study offers greater insight into the factors influencing the donor narratives produced in single-mother families. It has implications for the counselling and treatment of single women seeking fertility treatment with donor gametes in both anonymous and identity-release programmes. Given that the number of clinics offering identity-release programmes worldwide seems to be increasing, the finding that single women may have varying preferences with regard to donor type, and varying interest levels with regard to donor information, is important. It is recommended that clinicians and other fertility clinic staff guard against making assumptions about such preferences and any thoughts and feelings about the donor or donor information on the basis of marital status.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the Wellcome Trust [097857/Z/11/Z]. The authors have no conflicts of interest to declare.

The Application of Modern Powder Characterisation Methods in Product and Process Development of Solid Dosage Forms

The pharmaceutical industry still produces the vast majority of their products, from powdered ingredients, in the form of solid doses. Despite their ubiquity, powders are difficult materials to characterise and understand, as evidenced by the frequent problems encountered during manufacture. The reason for this is their complex rheological behaviour coupled with numerous environmental variations, such as humidity. Equally, the range of processes used to manipulate powders subject them to extremes of stress from high compaction loads seen in compactors to the dispersed state seen in fluidised bed dryers. Thus, it is evident that ensuring that the powders characteristics are compatible with the way they are to be processed is a clear prerequisite for today's Quality by Design driven manufacturing. Modern, computer controlled instrumental techniques, including the dynamic, bulk and shear property measurements have enabled direct measurements of a powders response to aeration, consolidation and flow rate - all at low stresses - as well as quantifying shear and bulk properties (such as density, compressibility and permeability). In order to demonstrate how fully characterising a powder can be used in the design, operation and troubleshooting of processes, this paper will present examples of common pharmaceutical unit operations and the different powder characteristics that most influence the performance of each.

Hospital board oversight of quality and safety: a stakeholder analysis exploring the role of trust and intelligence

BACKGROUND

Hospital boards, those executive members charged with developing appropriate organisational strategies and cultures, have an important role to play in safeguarding the care provided by their organisation. However, recent concerns have been raised over boards' ability to enact their duty to ensure the quality and safety of care. This paper offers critical reflection on the relationship between hospital board oversight and patient safety. In doing so it highlights new perspectives and suggestions for developing this area of study.

METHODS

The article draws on 10 interviews with key informants and policy actors who form part of the 'issue network' interested in the promotion of patient safety in the English National Health Service.

RESULTS

The interviews surfaced a series of narratives regarding hospital board oversight of patient safety. These elaborated on the role of trust and intelligence in highlighting the potential dangers and limitations of approaches to hospital board oversight which have been narrowly focused on a risk-based view of organisational performance. In response, a need to engage with the development of trust based organisational relationships is identified, in which effective board oversight is built on 'trust' characterised by styles of leadership and behaviours that are attentive to the needs and concerns of both staff and patients. Effective board oversight also requires the gathering and triangulating of 'intelligence' generated from both national and local information sources.

CONCLUSIONS

We call for a re-imagination of hospital board oversight in the light of these different perspectives and articulate an emerging research agenda in this area.

'Friendly allies in raising a child': a survey of men and women seeking elective co-parenting arrangements via an online connection website

STUDY QUESTION

What are the characteristics, motivations and expectations of men and women who search for a co-parent online?

SUMMARY ANSWER

Male and female prospective co-parents differed in terms of their motivations, choice of co-parent and expectations of co-parenting, while differences according to sexual orientation were less marked.

WHAT IS KNOWN ALREADY

Very few studies have addressed the experiences of elective co-parents, i.e. men and women who are not in a relationship with each other creating and raising a child together. No study has examined the motivations and experiences of those who seek co-parents online.

STUDY DESIGN, SIZE AND DURATION

An online survey was completed by 102 participants (61 men, 41 women) who were members of Pride Angel, an online connection website that facilitates contact between people looking for someone with whom to have a child. The survey was live for 7 weeks.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Details of the survey were emailed to all members of Pride Angel. The survey obtained data on participants' demographic characteristics, motivations, choice of co-parent and expectations of co-parenting. Data were analysed to examine differences by gender and by sexual orientation within each gender.

MAIN RESULTS AND THE ROLE OF CHANCE

Approximately one-third of men and one half of women seeking co-parenting arrangements were heterosexual. The majority (69, 68%) of participants were single, although significantly more gay and bisexual men (15, 36%) and lesbian and bisexual women (11, 55%) had a partner compared with heterosexual men (4, 20%) and heterosexual women (2, 12%), respectively. Overall, the most important motivation for seeking co-parenting arrangements was in order for both biological parents to be involved in the child's upbringing. Co-parents were looking for someone with a good medical history. Most female co-parents expected the child to live with them, whereas male co-parents either wished the child to reside with the mother or to live equally in both households. A higher proportion of gay and bisexual men than heterosexual men wanted daily contact with the child.

LIMITATIONS, REASONS FOR CAUTION

Although this study presents data from the largest sample of elective co-parents to date, the main limitations were the low response rate and that only members of one website were approached. The findings may not be representative of all potential elective co-parents.

WIDER IMPLICATIONS OF THE FINDINGS

This study provides important insights into the new phenomenon of elective co-parenting. With the increasing use of assisted reproductive technologies and the diversification of family forms, a growing number of people are seeking co-parenting arrangements to have children. While up until now, elective co-parenting has been principally associated with the gay and lesbian community, this study shows that, with the rise of co-parenting websites, increasing numbers of heterosexual men and women are seeking these types of parenting arrangements. This study generates the first findings on the expectations and motivations of those who seek co-parents online and examines whether these differ according to gender and sexual orientation. Future studies are needed to assess the impact of this new form of parenting on all involved, particularly the children.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by the Wellcome Trust (097857/Z/11/Z). Erika Tranfield is the co-founder of the website Pride Angel, the remaining authors have no conflicts of interest to declare.

Hospital board oversight of quality and patient safety: a narrative review and synthesis of recent empirical research

CONTEXT

Recurring problems with patient safety have led to a growing interest in helping hospitals' governing bodies provide more effective oversight of the quality and safety of their services. National directives and initiatives emphasize the importance of action by boards, but the empirical basis for informing effective hospital board oversight has yet to receive full and careful review.

METHODS

This article presents a narrative review of empirical research to inform the debate about hospital boards' oversight of quality and patient safety. A systematic and comprehensive search identified 122 papers for detailed review. Much of the empirical work appeared in the last ten years, is from the United States, and employs cross-sectional survey methods.

FINDINGS

Recent empirical studies linking board composition and processes with patient outcomes have found clear differences between high- and low-performing hospitals, highlighting the importance of strong and committed leadership that prioritizes quality and safety and sets clear and measurable goals for improvement. Effective oversight is also associated with well-informed and skilled board members. External factors (such as regulatory regimes and the publication of performance data) might also have a role in influencing boards, but detailed empirical work on these is scant.

CONCLUSIONS

Health policy debates recognize the important role of hospital boards in overseeing patient quality and safety, and a growing body of empirical research has sought to elucidate that role. This review finds a number of areas of guidance that have some empirical support, but it also exposes the relatively inchoate nature of the field. Greater theoretical and methodological development is required if we are to secure more evidence-informed governance systems and practices that can contribute to safer care.

Comparing the content of leadership theories and managers' shared perceptions of effective leadership: A Q-method study of trainee managers in the English NHS

Health service managers face potential conflicts between corporate and professional agendas, a tension sharpened for trainees by their junior status and relative inexperience. While academic leadership theory forms an integral part of contemporary management development programmes, relatively little is known of trainees' patterned subjectivities in relation to leadership theories. The objective of this study was to explore such subjectivities within a cohort of trainees on the National Health Service Graduate Management Training Scheme (NHS GMTS), a ‘fast-track’ programme which prepares graduate entrants for director-level health service management posts. A Q-method design was used and four shared subjectivities were identified: leadership as collaborative social process (‘relational’); leadership as integrity (‘moral’); leadership as effective support of subordinates (‘team’); and leadership as construction of a credible leadership persona (‘identity’). While the factors broadly map onto competencies indicated within the NHS Leadership Qualities Framework which underpin assessments of performance for this student group, it is important not to overstate the governance effect of the assessment regime. Rather, factors reflect tensions between required competencies, namely the mobilisation of diverse interest groups, the ethical base of decisions and the identity work required to convince others of leadership status. Indeed, factor 2 (‘moral’) effectively defines leadership as the embodiment of public service ethos.

Structures and processes for priority-setting by health-care funders: a national survey of primary care trusts in England

Although explicit priority-setting is advocated in the health services literature and supported by the policies of many governments, relatively little is known about the extent and ways in which this is carried out at local decision-making levels. Our objective was to undertake a survey of local resource allocaters in the English National Health Services in order to map and explore current priority-setting activity. A national survey was sent to Directors of Commissioning in English Primary Care Trusts (PCTs). The survey was designed to provide a picture of the types of priority-setting activities and techniques that are in place and offer some assessment of their perceived effectiveness. There is variation in the scale, aims and methods of priority-setting functions across PCTs. A perceived strength of priority-setting processes is in relation to the use of particular tools and/or development of formal processes that are felt to increase transparency. Perceived weaknesses tended to lie in the inability to sufficiently engage with a range of stakeholders. Although a number of formal priority-setting processes have been developed, there are a series of remaining challenges such as ensuring priority-setting goes beyond the margins and is embedded in budget management, and the development of disinvestment as well as investment strategies. Furthermore, if we are genuinely interested in a more explicit approach to priority-setting, then fostering a more inclusive and transparent process will be required.

Priority-setting and rationing in healthcare: evidence from the English experience

In a context of ever increasing demand, the recent economic downturn has placed further pressure on decision-makers to effectively target healthcare resources. Over recent years there has been a push to develop more explicit evidence-based priority-setting processes, which aim to be transparent and inclusive in their approach and a number of analytical tools and sources of evidence have been developed and utilised at national and local levels. This paper reports findings from a qualitative research study which investigated local priority-setting activity across five English Primary Care Trusts, between March and November 2012. Findings demonstrate the dual aims of local decision-making processes: to improve the overall effectiveness of priority-setting (i.e. reaching 'correct' resource allocation decisions); and to increase the acceptability of priority-setting processes for those involved in both decision-making and implementation. Respondents considered priority-setting processes to be compartmentalised and peripheral to resource planning and allocation. Further progress was required with regard to disinvestment and service redesign with respondents noting difficulty in implementing decisions. While local priority-setters had begun to develop more explicit processes, public awareness and input remained limited. The leadership behaviours required to navigate the political complexities of working within and across organisations with differing incentives systems and cultures remained similarly underdeveloped.

Content validity of the Rodeo-SCAT

The purpose of this study was to establish the content validity of the Rodeo SCAT for the sport of rodeo and bull riding. The study design was comprised of expert consensus and content validation. A modified Ebel procedure was employed to content validate the rodeo SCAT. Content validation using this method includes experts agreeing on the importance of each item that comprises the rodeo SCAT. This 3-stage process involved: 1) face validation by a local committee: 2) initial expert consensus measurement via distance; and 3) a face-to-face discussion for items that did not originally achieve 80% consensus of the group. Experts were chosen from the Canadian Professional Rodeo Sport Medicine Team (Canada) and the Justin Sports Medicine Team (USA). 27 out of a total possible 68 items achieved 80% consensus in the second stage. In the third stage, 4 of the 68 items were removed with consensus from the expert group. All remaining items achieved 80% consensus for inclusion. In summary, the rodeo SCAT is content valid and thus, appropriate for use in the sport of rodeo context or environment.