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PubMed2001

Maximising health gain within available resources in the New Zealand public health system.

OBJECTIVE: to obtain intervention-condition-specific investment and disinvestment recommendations which optimise the potential for health gain from existing respiratory diseases resource expenditure; and to trial a health economics technique for this purpose, assessing its usefulness as a means of prioritising health services resource allocation. DESIGN: a programme budgeting and marginal analysis (PBMA) exercise drawing upon the expertise of an advisory group of clinicians, managers and consumer advocates, supported by health authority staff. SETTING: the Southern and Midland health regions in New Zealand which have populations of one million and seven hundred thousand respectively. HEALTH SYSTEM CONTEXT: publicly funded secondary care sector in which regional health authority (RHA) purchasers contract for services with health care providers. METHODS: available evidence on the marginal costs and benefits of services for respiratory diseases was examined by an advisory group who produced investment and disinvestment recommendations by consensus using agreed prioritisation criteria. RESULTS: A list of specific investment and disinvestment proposals. Implementation plans for a number of investments formed part of the business plans for both RHAs in 1997/1998. No disinvestments were planned. CONCLUSIONS: prioritisation methods like PBMA, which are explicit and rational, can produce defensible evidence-based recommendations with the additional benefit of the credibility and support of an expert advisory group. The process encourages co-operative working and may itself have enduring benefits. However, preparation and conduct of such exercises is resource intensive and requires careful planning. This exercise has provided valuable lessons for the conduct of future prioritisation work.

Delivery of Health Care↗

PubMed1996

Comparison of doctors', nurses', politicians' and public attitudes to health care priorities.

OBJECTIVES: The aim of this study was to investigate differences in attitudes concerning prioritisation in health care held by doctors, nurses, local politicians and the general public. METHODS: Four groups were established: a population sample of 2000 subjects, aged 18-70 years; a random sample of 1500 doctors of working age; a random sample of 1000 nurses of working age; and a sample of 2200 politicians involved in health and social care administration, mostly at the municipal level (altogether 6700 subjects). The main questionnaire contained, among other things, a list of 12 statements concerning ethical decisions regarding prioritisation in health care. Respondents were asked to indicate their level of agreement with each statement. RESULTS: Most respondents in all the groups felt able to express an opinion on the statements. Despite considerable professional and cultural differences between groups, the views were generally similar. On the whole, respondents supported liberal policies in which the community took responsibility for subsidising health care. When differences between groups occurred, it was usually the doctors who held discordant views. Doctors were less inclined to consider a patient's economic status as a determinant of priority for treatment than the other three groups. Both doctors and nurses were less punitive towards patients with self-induced diseases. And doctors and politicians were more likely to feel further cuts in health care expenditure were possible than was true for nurses and the public. CONCLUSIONS: While considerable uniformity of opinion exists on ethical issues of prioritisation between the principal interested parties, the views of doctors differ substantially on some matters. If prioritisation was left entirely to doctors, health care provision would not reflect the views of other groups in some important ways.

Attitude of Health Personnel↗

PubMed2005

Testing and implementing signal impact analysis in a regulatory setting: results of a pilot study.

BACKGROUND AND AIM: Statistical signal detection methods such as proportional reporting ratios (PRRs) detect many drug safety signals when applied to databases of spontaneous suspected adverse drug reactions (ADRs). Impact analysis is a tool that was developed as an aid to prioritisation of such signals. This paper describes a pilot project whereby impact analysis was simultaneously introduced into practice in a regulatory setting and tested in comparison with the existing approach. METHODS: Impact analysis was run on signals detected during a 26-week period from the UK Adverse Drug Reactions On-line Information Tracking (ADROIT) database of spontaneous ADRs that met minimum criteria (PRR>or=3.0, chi2>or=4.0 and >or=3 reported cases) and related to established drugs (i.e. those that have been available for at least 2 years and no longer carry the 'black triangle' symbol). The current method of signal prioritisation (i.e. the collective judgement at a weekly meeting) was initially performed without knowledge of the findings of impact analysis. Subsequently, the meeting was presented with the findings and, where appropriate, given the opportunity to reconsider the judgement made. The categories arising from the two methods were compared and the ultimate action recorded. Inter-observer variation between scientists performing impact analysis was also assessed. RESULTS: Eighty-six separate signals were analysed by impact analysis, of which 5% were categorised as high priority (A), 14% as requiring further information (B), 31% as low priority (C) and 50% as no action required (D). In general, the new method tended to give a higher level of priority to signals than the existing approach. Overall, there was 59% agreement between the impact analysis and the collective judgement at the meetings (kappa statistic=0.30). There was slightly greater agreement between impact analysis and the final action taken (kappa statistic=0.39), indicating that the findings of an impact analysis had an influence on the outcome. Assessment of inter-observer variation demonstrated that the method is repeatable (kappa statistic for overall category=0.77). Almost 70% of those who participated in the pilot study believed that impact analysis represented an improvement in how signals were prioritised. CONCLUSIONS: Impact analysis is a repeatable method of signal prioritisation that tended to give a higher level of priority to signals than the standard approach and which had an influence on the ultimate outcome.

Adverse Drug Reaction Reporting Systems↗

PubMed2004

A pilot study on the use of decision theory and value of information analysis as part of the NHS Health Technology Assessment programme.

OBJECTIVES: To demonstrate the benefits of using appropriate decision-analytic methods and value of information analysis (DA-VOI). Also to establish the feasibility and implications of applying these methods to inform the prioritisation process of the NHS Health Technology Assessment (HTA) programme, and possibly extending their use therein. DATA SOURCES: Three research topics that were considered by the HTA panels in the September 2002 and February 2003 prioritisation rounds. REVIEW METHODS: A brief and non-technical overview of DA-VOI methods was circulated to the panels and Prioritisation Strategy Group (PSG). For each case study the results were presented to the panels and the PSG in the form of brief case-study reports. Feedback on the DA-VOI analysis and its presentation was obtained in the form of completed questionnaires from panel members, and reports from panel senior lecturers and PSG members. RESULTS: Although none of the research topics identified met all of the original selection criteria for inclusion as case studies in the pilot, it was possible to construct appropriate decision-analytic models and conduct probabilistic analysis for each topic. In each case, the tasks were completed within the time-frame required by the existing HTA research prioritisation process. The brief case-study reports provided a description of the decision problem, a summary of the current evidence base and a characterisation of decision uncertainty in the form of cost-effectiveness acceptability curves. Estimates of value of information for the decision problem were presented for relevant patient groups and clinical settings, as well as the value of information associated with particular model inputs. The implications for the value of research in each of the areas were presented in general terms. Details were also provided on what the analysis suggested regarding the design of any future research in terms of features such as the relevant patient groups and comparators, and whether experimental design was likely to be required. CONCLUSIONS: The pilot study showed that, even with very short timelines, it is possible to undertake DA-VOI that can feed into the priority-setting process that has been developed for the HTA programme. There are however a number of areas that need to be established at the beginning of the process, such as clarification of the nature of the decision problem for which additional research is being considered, explicitness about which existing data should be used and how data that exhibit particular weaknesses should be down-weighted in the analysis. Other areas, including optimum application of researcher time, integrating the vignette (a summary of the clinical problem and existing evidence) and the use of DA-VOI, training, use of sensitivity analyses, and deployment of clinical expertise, are also considered in terms of the potential implementation of DA-VOI within the HTA programme. Recommendations for further research include how literature searching should focus on those variables to which the model's results are most sensitive and with the highest expected value of perfect information; methods of evidence synthesis (multiple parameter synthesis) to consider the evidence surrounding multiple comparators and networks of evidence; and ways in which the value of sample information can be used by the NHS HTA programme and other research funders to decide on the most efficient design of new evaluative research. There is also a need for an analytical framework to be developed that can jointly address the question of whether additional resources would better be devoted to additional research or interventions to change clinical practice.

Biomedical Technology↗

PubMed1998

Priorities in the development of alternative methodologies in the pharmaceutical industry.

Promotion of animal welfare is an underlying and laudable goal for toxicologists and there is good reason to adopt practical, focused, investigative approaches towards this aim. Pharmaceutical regulatory toxicology can be subdivided into the areas of systemic (target organ), reproductive, genetic and topical toxicology, as well as immunotoxicology and oncology. These areas can be assessed for prioritisation as to where adoption of measures to promote any or all of the 3 Rs (reduction, replacement, refinement) would lead to the most tangible benefit for animals. These measures can range, for example, from replacement of animal experimentation with alternative in vitro techniques, to adoption of regulatory protocols that reduce the number of animals required. This paper is confined to consideration of in vitro technology in terms of reducing/replacing laboratory animal use, and a suggested list of criteria for prioritisation is potential for:- Regulatory acceptability Reducing development cost Reducing animal numbers Promoting welfare aspects Elucidating toxic mechanisms Usefulness in compound selection Advancing the science of toxicology Clear messages emerge from such an analysis which could influence prioritisation of the application of in vitro toxicology from the standpoints of animal welfare, feasibility and resources.

Animal Testing Alternatives↗

PubMed2026

Shared genetic architecture and therapeutic targets across paediatric immune-mediated diseases.

OBJECTIVES: Paediatric-onset immune-mediated inflammatory diseases (IMIDs), including juvenile idiopathic arthritis and related rheumatic diseases, remain genetically undercharacterised. We aimed to define shared and category-specific genetic architecture across paediatric IMIDs, compare signals with adult IMIDs, and identify therapeutic opportunities. METHODS: We analysed 24 paediatric IMIDs classified as autoimmune, polygenic-autoinflammatory, mixed-pattern, or allergic. Genome-wide association analyses included 18,086 cases and 131,019 controls of European ancestry. We estimated single nucleotide polymorphism (SNP)-based heritability, genetic correlations, and polygenic overlap; performed subset-based meta-analysis; and conducted functional annotation, gene prioritisation, pathway and protein network analyses, adult-IMID comparison, and drug-target prioritisation. RESULTS: SNP-based heritability ranged from 28.9% for allergic IMIDs to 61.9% for autoimmune IMIDs. Genetic correlation and polygenic modelling supported partial sharing across categories with category-specific components. Meta-analysis identified 39 genome-wide significant loci outside the Major Histocompatibility Complex (MHC) region, including 15 previously unreported loci; 19 loci were shared between categories. Gene-prioritisation and protein interaction analyses identified a core MHC-centred antigen-presentation network, with category-enriched modules involving complement, innate/barrier pathways, epithelial biology, and type 2 immunity. Enriched pathways included nuclear factor κB signalling, T helper 17 related pathways, Janus kinase-signal transducer and activator of transcription signalling, programmed cell death protein 1/programmed death‑ligand 1, cytotoxic T‑lymphocyte associated protein 4 regulation, and osteoclast differentiation, several of which are relevant to rheumatic diseases. Paediatric IMIDs shared broad polygenic architecture with adult IMIDs, whereas top-ranked genes converged strongly with adult rheumatic diseases. Priority Index analysis identified 178 high-scoring genes, including 43 approved or investigational IMID drug targets. CONCLUSIONS: Paediatric-onset IMIDs share core pathways with adult forms but exhibit distinct genetic architecture shaped by age-specific immune and neurodevelopmental biology. These findings provide a genomic framework for paediatric precision medicine, guiding classification, risk prediction, and therapeutic development.

Humans↗

PubMed2004

Devising and establishing the face and content validity of explicit criteria of consultation competence for UK secondary care nurses.

AIM: The aims of this study were (a) to devise a set of prioritised criteria of consultation competence for UK secondary care nurses, and (b) to determine their face and content validity. METHOD: The criteria of consultation competence as contained in the Consultation Assessment and Improvement Instrument (CAIIN) for primary care nurses were adapted as a result of focus group discussions and observation of videotaped consultations with nurses working in secondary care. The amended criteria were sent to a sample of nurse consultants, specialist nurses and nurse practitioners (n = 394) to determine their face and content validity. RESULTS: Support for the seven categories of consultation competence varied from 96% to 99% and for the 37 component competences from 94% to 99%. There was no consensus for alternative or additional categories or components. 87% of respondents strongly agreed or agreed that the categories of consultation competence should be prioritised and 63% strongly agreed or agreed with the suggested weightings. CONCLUSION: We have devised prioritised criteria of consultation competence of UK secondary care nurses and established their face and content validity. This can now facilitate the assessment and improvement of the consultation competence of secondary care nurses for both formative and regulatory purposes.

Clinical Competence↗

PubMed2005

How do clinical nurse specialists influence primary care management of asthma? A qualitative study.

METHODS: We carried out a qualitative interview study alongside a randomised controlled trial which tested the effectiveness of asthma nurse specialists in east London. We carried out face-to-face interviews with five asthma nurse specialists, eight general practitioners (GPs) and six practice nurses, and also held a focus group session with six people who had attended hospital with acute asthma. RESULTS: Four factors were associated with effective specialist nurse liaison: (1) primary care practices which prioritised asthma care; (2) GPs who trusted practice nurses to manage chronic disease autonomously; (3) GPs who recognised specialist nurse expertise and acted on their advice; and (4) practices which had simple systems in place to deal with recommendations. Patients found nurse specialists approachable and informative. CONCLUSIONS: Asthma specialist nurse influence was greatest in practices that prioritised asthma care and where practice nurses had clinical autonomy. Patients valued specialist nurses but found advice from a multiplicity of clinicians confusing. Ensuring that practices prioritise chronic disease care, and improving the credibility of nurse specialists amongst GPs, may improve the effectiveness of asthma nurse specialists.

Journal Article↗

PubMed2006

Women's groups' perceptions of maternal health issues in rural Malawi.

BACKGROUND: Improvements in preventive and care-seeking behaviours to reduce maternal mortality in rural Africa depend on the knowledge and attitudes of women and communities. Surveys have indicated a poor awareness of maternal health problems by individual women. We report the perceptions of women's groups to such issues in the rural Mchinji district of Malawi. METHODS: Participatory women's groups in the Mchinji district identified maternal health problems (172 groups, 3171 women) and prioritised problems they considered most important (171 groups, 2833 women). In-depth qualitative data was obtained through six focus-group discussions with the women's groups, three with women's group facilitators, and four interviews with facilitator supervisors. FINDINGS: The maternal health problems most commonly identified by more than half the groups were anaemia (87%), malaria (80%), retained placenta (77%), obstructed labour (76%), malpresentation (71%), antepartum and postpartum haemorrhage (70% each), and pre-eclampsia (56%). The five problems prioritised as most important were anaemia (sum of rank score 304), malpresentation (295), retained placenta (277), obstructed labour (276). and postpartum haemorrhage (275). HIV/AIDS and sepsis were identified or prioritised much less because complexity and contextual factors hindered their consideration. INTERPRETATION: Rural Malawian women meeting in participatory groups showed a developed awareness of maternal health problems and the concern and motivation to address them. Community mobilisation strategies, such as women's groups, might be effective at reducing maternal mortality because they can draw on the collective capacity in communities to solve problems and make women's voices heard by decision-makers.

Adolescent↗

PubMed2003

Visual marking: using time in visual selection.

Given human capacity limitations, to behave adaptively we need to prioritise the order of visual processing to ensure that the most relevant information is available to control action. One way to do this is to prioritise processing at a particular location in space. However, there are many situations where this strategy is not possible and recent studies have shown that, in such circumstances, observers can use time as well as space to prioritise selection. We propose that selection by time can be influenced by a process of visual marking, involving an active bias applied in parallel against old items in the field. Here we describe the properties of visual marking in relation to other mechanisms of visual selection.

Journal Article↗

PubMed2002

An exploratory qualitative study to investigate how patients evaluate complementary and conventional medicine.

OBJECTIVE: We wish to determine the constructs used by patients to evaluate conventional and complementary medicine (CAM), prioritise these constructs and determine how these characterise patients' choice for CAM and conventional medicine. METHODS: A repertory grid technique was employed, in interviews of 20 patients, 10 from a general practice and 10 from a CAM clinic. RESULTS: CAM was used with greater frequency in chronic illness and generated more constructs than conventional medicine, although the constructs were similar. The priorities for these constructs were different: specificity of treatment and severity of illness were prioritised for conventional medicine and lack of science was prioritised for CAM. The CAM characteristic most commonly cited was non-chemical. CONCLUSION: This exploratory initial study suggests that people use very similar criteria to evaluate CAM and conventional medicine. Their choice of treatment was based largely on the type of illness from which they were suffering. Further research is needed in this area.

Adolescent↗

PubMed2005

A framework for place based health planning.

Place based health planning is an effective approach to health planning with enormous benefits including the use of local characteristics, organisations and partnerships to effectively and efficiently identify and prioritise needs, and develop and deliver programs and services. Despite its inherent advantages, place based health planning has not been extensively used by health professionals, neither has it been given adequate attention in the literature. This article provides a framework to guide and encourage health professionals to use place based health planning. The framework has three main parts, namely needs assessment, program planning and implementation, and covers most aspects of the identification of needs, and the development and delivery of programs and services to address those needs. The article also includes a proposed index of prioritisation to enable health professionals to prioritise needs and improve program and service provision.

Community Health Planning↗

PubMed2025

Associations on the Fly, a new feature aiming to facilitate exploration of the Open Targets Platform evidence.

MOTIVATION: The Open Targets Platform (https://platform.opentargets.org) is a unique, comprehensive, open-source resource supporting systematic identification and prioritisation of targets for drug discovery. The Platform combines, harmonizes and integrates data from >20 diverse sources to provide target-disease associations, covering evidence derived from genetic associations, somatic mutations, known drugs, differential expression, animal models, pathways and systems biology. An in-house target identification scoring framework weighs the evidence from each data source and type, contributing to an overall score for each of the 7.8M target-disease associations. However, the old infrastructure did not allow user-led dynamic adjustments in the contribution of different evidence types for target prioritisation, a limitation frequently raised by our user community. Furthermore, the previous Platform user interface did not support navigation and exploration of the underlying target-disease evidence on the same page, occasionally making the user journey counterintuitive. RESULTS: Here, we describe 'Associations on the Fly' (AOTF), a new Platform feature-developed with a user-centred vision-that enables the user to formulate more flexible therapeutic hypotheses through dynamic adjustment of the weight of contributing evidence from each source, altering the prioritisation of targets. AVAILABILITY AND IMPLEMENTATION: The codebases that power the Platform-including our pipelines, GraphQL API, and React UI-are all open source and licensed under the APACHE LICENSE, VERSION 2.0. You can find all of our code repositories on GitHub at https://github.com/opentargets and on Zenodo at https://zenodo.org/records/14392214. This tool was implemented using React v18 and its code is accessible here: (https://github.com/opentargets/ot-ui-apps). The tools are accessible through the Open Targets Platform web interface (https://platform.opentargets.org/) and GraphQL API (https://platform-docs.opentargets.org/data-access/graphql-api). Data is available for download here: (https://platform.opentargets.org/downloads) and from the EMBL-EBI FTP: (https://ftp.ebi.ac.uk/pub/databases/opentargets/platform/).

Software↗

PubMed2026

Proteome-wide Mendelian randomisation of lung function to identify potential therapeutic targets for respiratory disease.

BACKGROUND: Despite multiple clinical trials, disease-modifying treatments for COPD are currently limited. Since many drugs target proteins, identifying causality between proteins and lung function informs understanding of COPD pathophysiology and may suggest novel targets. We used Mendelian randomisation (MR) to prioritise proteins as potentially causal for imparied lung function. For prioritised proteins, we explored their potential suitability as drug targets by predicting their effects on a range of clinical outcomes. METHODS: We used genome-wide association study (GWAS) data on 2923 proteins (n=48 195, UK Biobank) to identify single genetic variants (protein quantitative trait loci (cis-pQTLs)) associated with protein levels (p≤5×10-9, variant ≤100 kb of a transcription start site). We performed cis-pQTL-MR analyses of four spirometric traits (n=149 166, 36 independent cohorts). Sensitivity analyses included colocalisation and reverse direction MR. We report associations between cis-pQTLs for prioritised proteins and multiple clinical respiratory outcomes, and use phenome-wide analysis to explore potential adverse effects or drug repurposing opportunities. FINDINGS: 1841 proteins had a suitable cis-pQTL. We implicated 16 proteins as potentially causal for lung function (p<1.71×10-5): seven proteins have not been implicated by previous lung function GWAS or MR (CCND2, DTD1, PILRA, PTPRK, TDRKH, GRHPR, NUDT5), and we provide corroborative evidence for 10 proteins. We add to the literature identifying surfactant protein D (SFTPD) as a candidate, yet predict that integrin subunit alpha V (ITGAV) inhibition could impair some lung function measures, mimicking adverse results from a recent trial. INTERPRETATION: Our approach identifies proteins (some novel) that are potentially therapeutic targets for respiratory disease, and which warrant follow-up for utility and safety.

Journal Article↗

PubMed2005

Pitfalls in the construction of cancer guidelines demonstrated by the analyses of colorectal referrals.

INTRODUCTION: The aim of this study was to develop a system to compare and validate cancer referral guidelines, identifying the pitfalls in their development and provide a mechanism to evaluate their efficacy. PATIENTS AND METHODS: 3302 patients referred from primary care with colorectal symptoms over a 3-year period were assessed. All participants had a comprehensive history obtained via a questionnaire that incorporated all colorectal symptoms. The questionnaires were completed prior to assessment at the hospital. All patients were then assessed at the Colorectal One Stop Clinic (CROSC), underwent investigation and diagnosis achieved. All data were entered into a databank. Current prioritisation guidelines and tools that are used to assess colorectal referrals were applied to this colorectal databank to test their efficacy for cancer detection and referral prioritisation. Sensitivity and specificity for cancer detection and referral rates were assessed. RESULTS: Cancer was detected in 156 patients (4.7%). All prioritisation models (NHS guidelines, Weighted Numerical Score [WNS], Netherlands, Harvard, Mersey, and Somerset) differentiated cancer from non-cancer patients. The use of a few symptoms as risk predictors (e.g. NHS guidelines) causes a decrease in specificity in contrast to a comprehensive risk tool, for example, the WNS at a score of 50 (NHS 54.1%, WNS 62.9%). This results in a significantly higher referral rate (NHS 47.6%, WNS 39.4%) and identifies fewer cancers (NHS 80.1%, WNS 85.9%). Non-evidence based modifications of the NHS guidelines (Somerset and Mersey) caused a further deterioration in specificity, which was reflected in an increased referral rate. Using the WNS, which is objective and a continuous scale, allows adaptation of the referral threshold, balancing sensitivity and specificity to the resources available within a hospital. For example, the WNS of > or = 40 has a sensitivity of 96.8% for cancer detection. CONCLUSIONS: Accurate prospective data collection into a data bank allows testing of referral guidelines as well as providing an adjunct to guideline construction.

Aged↗

PubMed2006

Estimating the value of information in strategies for identifying patients at high risk of cardiovascular disease.

BACKGROUND: There are many different potential strategies for identification of patients eligible for primary prevention of cardiovascular disease. The ability to use a more efficient strategy has a value. This paper models the costs and benefits of a number of identification strategies and estimates the additional value of an information-based strategy. DESIGN: Modelling study. METHODS: Ten-year Framingham cardiovascular risk was calculated for each individual in a population of 4471 persons aged 35-74 drawn from the Health Survey for England (equivalent to a total practice population of 12,000). Estimated Framingham risk was calculated using limited risk factor information and default risk factors. Costs of risk factor assessment were calculated using standard NHS costs. The outcomes of risk factor assessment were the total number of patients identified as eligible for treatment and the total burden of cardiovascular disease in eligible patients. Several strategies for prioritising patients for assessment were defined: opportunistic, diabetics and treated hypertensives first, ranked by estimated cardiovascular risk. The costs and outcomes of assessing increasing numbers of patients under each strategy were presented in graphical form. RESULTS: To identify 70% of the burden of cardiovascular disease in this population opportunistically costs Pounds 82,102; under a 'diabetics and hypertensives first' strategy it costs Pounds 72,916; under a strategy prioritising by estimated cardiovascular risk, Pounds 27,795. The value of information in this scenario is therefore at least Pounds 45,121. CONCLUSIONS: Because strategies prioritising patients by estimated cardiovascular risk dominate alternative strategies, it is possible to estimate the value of information in terms of reduced resources to achieve the same results. These resource savings largely represent savings in staff time.

Adult↗

PubMed2004

Odour management plans: a risk-based approach using stakeholder data.

Annoyance is a familiar reaction to odours arising from wastewater treatment sites, a reaction which can result in complaints and prosecutions. Odour management plans can be used to assess the extent of nuisance caused and prioritise mitigation measures. Often, these plans have been developed purely on the basis of technical assessments of emission and dispersion, with the general aim of limiting odour concentrations to a specific threshold at some distance from the works. They have often been prepared with inconsistent communication between the site staff and consultant during the development process, and may not directly refer to the affected population. This paper describes a risk-based approach to developing odour management plans, in which mitigation measures are assessed and prioritised on the basis of the likely frequency and intensity of odour exposure. A key element of the approach is the use of knowledge from data gained from key stakeholder groups: customers, staff, and regulators. Emphasis is placed on the development of clear communications between these groups, which helps both in terms of raising awareness amongst operators as to the significance of odour problems, and also in managing the expectations of customers and regulators. The practical application of this approach is demonstrated by the development of odour management plans for wastewater treatment sites by Yorkshire Water Services Ltd. These have used data from staff, customers and regulators to develop risk grids, which are then used to prioritise remediation measures. Involving staff in the data collection operations has been successful in raising awareness of the significance of odours, and has in turn led to low-cost emission reductions through improved housekeeping. Improved communications between operators, customers and regulators has led to more realistic expectations with regard to odour problems, a situation which can reduce conflict and prevent the imposition of stringent and sometimes unrealistic odour standards.

Communication↗

PubMed2026

Strategies to improve recruitment to randomised trials.

BACKGROUND: Recruiting participants to randomised controlled trials (RCTs) is challenging. Identifying effective recruitment strategies would benefit health research: poor recruitment leads to underpowered trials, reducing the reliability of findings and increasing the risk of wasted resources, ethical concerns, and trial failure. Evidence to inform recruitment strategies is increasingly generated through Studies Within A Trial (SWATs), which are methodological studies embedded within host RCTs. This is an update of a review last published in 2018. OBJECTIVES: Primary: to quantify the effects of strategies to improve recruitment of participants to RCTs. Secondary: to evaluate recruitment strategies' cost-effectiveness and impact on retention, and the equity, diversity, and inclusion (EDI) characteristics of recruited participants. SEARCH METHODS: We used MEDLINE, Embase, and six other databases to identify the studies included in the review. We also sought unpublished recruitment SWATs through social media and targeted email dissemination to trial methodology networks. The latest search date was 16 February 2023. SELECTION CRITERIA: We included randomised SWATs evaluating trial recruitment strategies embedded in healthcare and non-healthcare trials. We excluded quasi-randomised, hypothetical, questionnaire-only, retention-only, or clinician incentive studies. DATA COLLECTION AND ANALYSIS: Primary outcome: proportion of eligible participants or centres recruited. SECONDARY OUTCOMES: cost-effectiveness, retention rates, and EDI characteristics of included participants. We conducted random-effects meta-analysis for strategies evaluated in at least two studies; otherwise, we synthesised results narratively. We reported effects as risk differences (RDs) with 95% confidence intervals (CIs), and assessed between-trial heterogeneity. We used GRADE to assess the certainty of evidence for the primary outcome. We expressed cost-effectiveness as the incremental cost per additional participant recruited in pounds sterling (GBP). MAIN RESULTS: We identified 91 eligible studies (53 new to this update), providing 94 comparisons and involving at least 176,747 participants. Eighty-one studies involved strategies aimed at trial participants, while 10 evaluated strategies aimed at recruiters. All were healthcare studies. We found 65 recruitment strategies; 49 were evaluated in a single study. Only five strategies were supported by high-certainty evidence according to GRADE criteria, and we focus on these strategies in the summary below. Open-label trials versus blinded, placebo trials. Open-label trials recruited more participants than blinded trials (RD 10%, 95% CI 8% to 12%; 3 studies, 9004 participants), corresponding to approximately 10 additional participants per 100 approached. The studies involved mostly women in the UK and Estonia. No cost or retention data were reported. Telephone reminder versus no telephone reminder. Telephone reminders to people who did not respond to an initial postal invitation boosted recruitment by 6% (95% CI 3% to 9%; 2 studies, 1450 participants), in trials with low underlying recruitment (we are less certain for trials with over 10% recruitment). The studies involved people with a mean age of 58 years in Canada and Norway. No cost or retention data were reported. Recruitment primer letter versus no letter. Pre-recruitment letters and leaflets designed to encourage participation made little or no difference to recruitment (absolute improvement 1%, 95% CI -1% to 2%; 2 studies, 5376 participants), and were associated with increased costs compared to not sending a primer (incremental cost: GBP 2.08). The studies involved mostly older white people in the UK and Ireland. Multimedia information via a digital link/QR code plus paper participant information leaflet (PIL) versus paper PIL alone. This made little or no difference to recruitment (absolute improvement 0%, 95% CI -1% to 1%; 7 studies, 11,612 participants) and retention (absolute improvement 0%, 95% CI -2% to 3%; 5 studies, 7403 participants), and increased costs compared to not including multimedia information (incremental cost: GBP 0.78). The studies involved people in the UK. Optimised, user-tested PIL versus standard PIL. Optimising participant information leaflets (e.g. through user-testing the leaflet with the target population to shape its content, format, and appearance) made little or no difference to recruitment: absolute improvement was 0% (95% CI 0% to 1%; 6 studies, 27,805 participants). The studies involved people in the UK. Only one study reported EDI data; participants were mostly older women. No cost or retention data were reported. We had moderate-certainty evidence for 13 other strategies; confidence was often reduced because the results came from single studies. Seven strategies involved changes to how potential participants received information; four involved changes to trial conduct; one targeted the recruiter or recruitment site; and one tested non-monetary incentives. We had much less confidence in the other 47 comparisons because the studies had design flaws, were single studies, or had very uncertain results. Costs were reported in only 17 of 91 studies. Strategy impact on retention was reported in 15 studies. All but one study (99%) were from high-income countries. The most reported demographics were age (49 studies), sex (32 studies), gender (27 studies), and education level (16 studies). AUTHORS' CONCLUSIONS: The evidence on strategies to improve trial recruitment remains broad but lacks depth. Of 65 strategies evaluated, only five were supported by high-certainty evidence. Open-label trial designs and telephone reminders to non-responders increased recruitment, while optimised participant information leaflets, recruitment primer letters, and multimedia information provided alongside a paper participant information leaflet had little or no effect. Reporting of participant characteristics was poor, limiting assessment of equity, diversity, and inclusion across most studies. Evidence is heavily skewed toward high-income countries. Future research must prioritise evaluations in low-to-middle-income settings and consistently report cost, retention, and EDI outcomes. We strongly urge the methodology research community to strengthen the evidence base by prioritising replications of existing strategies over the development and testing of new ones. FUNDING: National Institute for Health and Care Research (Advanced Fellowship, Adwoa Parker, reference:NIHR302256). Health Research Board, Republic of Ireland, Evidence Synthesis Ireland (grant ESI-2021-001) REGISTRATION: This review updates an earlier Cochrane review, which was first published in 2002 and subsequently updated in 2007, 2010, and 2018. Previous versions of the review and their protocols are available at: https://doi.org/10.1002/14651858.MR000013.pub2 https://doi.org/10.1002/14651858.MR000013.pub3 https://doi.org/10.1002/14651858.MR000013.pub4 https://doi.org/10.1002/14651858.MR000013.pub5 https://doi.org/10.1002/14651858.MR000013.pub6.

Randomized Controlled Trials as Topic↗