The Water-Energy-Food (WEF) nexus approach is increasingly being used for supporting a transition to sustainable development, with initiatives involving the concept of circular economy (CE). In the agricultural sector in particular, assessing this nexus is crucial to ensure food security, control the consumption of key resources such as water and energy, as well as measure atmospheric emissions linked to climate change. This manuscript aims to propose a novel approach by coupling the WEF nexus with a circularity indicator, seeking to capture in a single index (the WEF+CEi) both performances in a sample of companies. The novel approach is applied to 30 dairy farms located in Galicia (NW Spain) to benchmark them in a holistic manner. To do this, the WEF nexus of each farm was represented through the following indicators: carbon footprint, water footprint, energy footprint, and food productivity. In addition, the percentage of circularity for each farm, and for the agro-industrial cooperative was measured thanks to the application of a circularity tool in percentage terms. Finally, the WEF+CEi indicator was obtained using the multicriteria mathematical tool of Data Envelopment Analysis (DEA). The results show that without considering the agro-industrial cooperative, the system is 51 % circular. On the other hand, considering the farms and the cooperative, the system goes up to 80 % of circularity. Finally, the proposed approach can support decision-making and provide insights for producers and stakeholders in the area.

The world has been facing an increase in various natural hazards. The coastal regions are recognized as one of the most vulnerable due to high population pressure and climate change intensity. Mediterranean countries have one of the most burnable ecosystems in the world, one of the most exposed to pluvial floods, and have the highest erosion rates within the EU. Therefore, the aim of this study was to develop the first multihazard susceptibility model in Croatia for the Sali settlement (island of Dugi otok). The creation of a multi-hazard susceptibility model (MHSM) combined the application of geospatial technology (GST) with a local perception survey. The methodology consisted of two main steps: (1) creating individual hazard susceptibility models (soil erosion, wildfires, pluvial floods), and (2) overall hazard susceptibility modeling. Multicriterial GIS analyses and the Analytical Hierarchy Process were used to create individual hazard models. Criteria used (32) to create models are derived from very-high-resolution (VHR) models. Two versions of MHSM are created: 1) all criteria with equal weighting coefficients and 2) weight coefficients determined based on public perception. According to MHSM 1, most of the research (58%) area is moderately susceptible to multiple hazards. Highly and very highly susceptible areas are 27% of the drainage basin and are mostly located near roads and houses. MHSM 2 reveals similar results to MHSM 1. The public perceives that the research area is the most susceptible to wildfires. The wildfire ignition risk is ranked as moderate (3.00) with a standard deviation of 1.16. Pluvial flood risk is ranked low (2.78), with a standard deviation of 1.15. The risk of soil is most inferior (2.24) with a standard deviation of 0.91. The the most significant difference between public perception and the GIS-MCDA model of hazard susceptibility is related to soil erosion. However, the accuracy of the soil erosion model was confirmed by ROC curves based on recent traces of soil erosion in the research area. The proposed methodological framework of multi-hazard susceptibility modeling can be applied, with minor modifications, to other Mediterranean countries.

Many pathogens cause disease in dogs; however, meaningful surveillance in small companion animals is often only possible for the most impactful diseases. We describe the first stakeholder opinion-led approach to identify which canine infectious diseases should be prioritised for inclusion in surveillance and control strategies in the UK.
Participants were identified through a stakeholder analysis. A multicriteria decision analysis was undertaken to establish and weight epidemiological criteria for evaluating diseases, and a Delphi technique was employed to achieve a consensus among participants on the top-priority canine diseases.
Nineteen stakeholders from multiple backgrounds participated in this study. Leptospirosis and parvovirus were identified as the top two endemic diseases of concern, while leishmaniosis and babesiosis were the top two exotic diseases. Respiratory and gastrointestinal diseases were identified as the top two syndromes of concern.
Due to the COVID-19 pandemic, the number of participants was reduced. Despite this, a representative multidisciplinary sample of relevant stakeholders contributed to the present study.
Findings from this study are being used to inform the development of a future UK-wide epidemic response strategy. This methodology could provide a blueprint for other countries.

Quantitative benefit-risk assessment (qBRA) is a structured process to evaluate the benefit-risk balance of treatment options to support decision making. The ISPOR qBRA Task Force was recently established to provide recommendations for the design, conduct, and reporting of qBRA. This report presents a hypothetical case study illustrating how to apply the Task Force\'s recommendations toward a qBRA to inform the benefit-risk assessment of brodalumab at the time of initial marketing approval. The qBRA evaluated 2 dosing regimens of brodalumab (210 mg or 140 mg twice weekly) compared with weight-based dosing of ustekinumab and placebo.
We followed the 5 steps recommended by the Task Force. Attributes included treatment response (≥75% improvement in Psoriasis Area and Severity Index), suicidal ideation and behavior, and infections. Performance data were drawn from pivotal clinical trials of brodalumab. The qBRA used multicriteria decision analysis and preference weights from a hypothetical discrete choice experiment. Sensitivity analyses examined the robustness of benefit-risk ranking to uncertainty in clinical effect and preference estimates, consideration of a subgroup (nail psoriasis), and the maintenance phase of treatment (52 weeks instead of 12).
Results from this hypothetical qBRA suggest that brodalumab 210 mg had a more favorable benefit-risk profile compared with ustekinumab and placebo. Ranking of brodalumab compared with ustekinumab was dependent on brodalumab\'s dose. Sensitivity analyses demonstrated robustness of benefit-risk ranking to uncertainty in clinical effect and preference estimates, as well as choice of attributes and length of follow-up.
This case study demonstrates how to implement the ISPOR Task Force\'s good practice recommendations on qBRA.

This paper proposes a Water Access Index (WAI). Using this tool, decision-makers can identify and prioritize areas that need state intervention to develop actions to guarantee rural population access to water. Thus, was carried out is a case study, rural communities in the semi-arid region of Brazil to validate the suggested method. The WAI is based on a combined method of multicriteria decision analysis (MCDA), Geographic Information System (GIS), cluster analysis (CA) using Ward\'s agglomeration method and participation of rural inhabitants. The data for calculating the WAI were obtained by conducting interviews following a script of themes in the structured questionnaire closed to 370 residents of the communities evaluated. To calculate the WAI, weightings were used, in which the scores of the indicators and the weights of the dimensions were determined and analyzed using the Delphi method, what found to be a valid method for calculating the dimensions and indicators weights. Due to difficulty of rural population to have water access and suffer from drought, the proposed model showed appropriate to conduct a robust and well-structured decision-making. The main contributions were the study in region suffering from drought and difficulty in water access, as well as the combination of MCDA, SIG, CA and participation of rural inhabitants methods to aid in this problem. For use in other areas, researchers need to conduct public and specialized consultations to adjust the dimension weights, so the WAI method can estimate the water access situation and generate maps anywhere in the world for decision-making.

Patient access to orphan medicinal products (OMPs) is limited and varies between countries, reimbursement decisions on OMPs are complex, and there is a need for more transparent processes to know which criteria should be considered to inform these decisions. This study aimed to determine the most relevant criteria for the reimbursement of OMPs in Spain, from a multi-stakeholder perspective, and using multicriteria decision analysis (MCDA).
An MCDA was developed in 3 phases and included 28 stakeholders closely related to the field of rare diseases (6 physicians, 5 hospital pharmacists, 7 health economists, 4 patient representatives and 6 members from national and regional health authorities). Initially [phase A], a bibliographic review was conducted to identify the potential reimbursement criteria. Then, a reduced advisory board (8 members) proposed, selected, and defined the final list of criteria that could be relevant for reimbursement. A discrete choice experiment (DCE) [phase B] was developed to determine the relevance and relative importance weight of such criteria according to the stakeholders\' preferences by choosing between pairs of hypothetical financing scenarios. A multinomial logit model was fitted to analyze the DCE responses. Finally [phase C], the advisory board review the results using a deliberative process.
Thirteen criteria were selected, related to 4 dimensions: patient population, disease, treatment, and economic evaluation. Nine criteria were deemed relevant for decision-making and associated with a higher relative importance: Health-related quality of life (HRQL) (23.53%), treatment efficacy (14.64%), availability of treatment alternatives (13.51%), disease severity (12.62%), avoided costs (11.21%), age of target population (7.75%), safety (seriousness of adverse events) (4.72%), quality of evidence (3.82%) and size of target population (3.12%). The remaining criteria had a < 3% relative importance: economic burden of disease (2.50%), cost of treatment (1.73%), cost-effectiveness (0.83%) and safety (frequency of adverse events) (0.03%).
The reimbursement of OMPs in Spain should be determined by its effect on patient\'s HRQL, the extent of its therapeutic benefit from efficacy and the availability of other therapeutic options. Furthermore, the severity of the rare disease should also influence the decision along with the potential of the treatment to avoid associated costs.

BACKGROUND: It\'s estimated that 40% to 60% of patients undergoing major orthopedic surgery of the hip or knee who do not receive thromboprophylaxis will develop deep venous thrombosis Instituto Nacional de Traumatologia e Ortopedia has established a guideline to prevent DVT with the administration of the Enoxaparin. Recently, institute stakeholders have been questioning this guideline as new oral anticoagulants that offer more comfort and efficacy, but present higher risk of bleeding, have been appearing in the market for treating deep venous thrombosis.
OBJECTIVE: This study aims to validate the application of a multicriteria decision analysis in a real-world problem, the use of rivaroxaban and enoxaparin to prevent deep venous thrombosis.
METHODS: The multicriteria method MACBETH (Measuring Attractiveness by a Categorical Based Evaluation Technique) was used in a decision conferencing process to develop an evaluation model for measuring the relative value of the drugs on each evaluation criterion, separately and globally. The model-building process was informed by a literature review and meta-analysis of randomized clinical trials with a critical appraisal of the evidence.
RESULTS: We report a model-structure with eight criteria, each one associated with a weighting coefficient and value function. Following a simple additive aggregation process, the model-outputs showed that Rivaroxaban was considered a robust option for DVT. Sensitivity analysis and robustness analysis were performed and testify the consistency of the results.
CONCLUSIONS: This article contributes to literature by showing how MACBETH method can be combined with scientific evidence and participatory group processes, for health technology assessment in hospitals.

Agriculture and its allied sector contribute significantly to the gross domestic product of every country. Several small-scale enterprises engaged in waste biomass processing have been setup recently. Such industrial setups not only help in solving the waste management issues but also play an important role in offering employment at the grass root level generating a significant social impact along with economic advantage to the local entrepreneur. Hence, assessment of such biomass processing enterprise (BPE) based on economic, environment, and social parameters has become necessary. In this paper, a general framework for sustainability assessment is discussed using a case study of cow dung-urine biorefinery as a representative BPE. Real-time data of BPE has been collected for evaluation and a sustainability index (SI) is evaluated using multicriteria decision method. The SI is calculated as per the weightage assigned and value function of the indicator and criteria. The SI for the BPE was observed to be 0.69 for the chosen set of criteria and indicator and weightages. A sensitivity analysis has been performed to check the dependence of the results on the weightages assigned to various criteria and indicators. It was also observed that the results were more sensitive to the indicators having a low value function.

The accountability for reasonableness (A4R) framework defines 4 conditions for legitimate healthcare coverage decision processes: Relevance, Publicity, Appeals, and Enforcement. The aim of this study was to reflect on how the diverse features of decision-making processes can be aligned with A4R conditions to guide decision-making towards legitimacy. Rare disease and regenerative therapies (RDRTs) pose special decision-making challenges and offer therefore a useful case study.
Features operationalizing each A4R condition as well as three different approaches to address these features (cost-per-QALY-focused and multicriteria-based) were defined and organized into a matrix. Seven experts explored these features during a panel run under the Chatham House Rule and provided general and RDRT-specific recommendations. Responses were analyzed to identify converging and diverging recommendations.
Regarding Relevance, recommendations included supporting deliberation, stakeholder participation and grounding coverage decision criteria in normative and societal objectives. Thirteen of 17 proposed decision criteria were recommended by a majority of panelists. The usefulness of universal cost-effectiveness thresholds to inform allocative efficiency was challenged, particularly in the RDRT context. RDRTs raise specific issues that need to be considered; however, rarity should be viewed in relation to other aspects, such as disease severity and budget impact. Regarding Publicity, panelists recommended transparency about the values underlying a decision and value judgements used in selecting evidence. For Appeals, recommendations included a life-cycle approach with clear provisions for re-evaluations. For Enforcement, external quality reviews of decisions were recommended.
Moving coverage decision-making processes towards enhanced legitimacy in general and in the RDRT context involves designing and refining approaches to support participation and deliberation, enhancing transparency, and allowing explicit consideration of multiple decision criteria that reflect normative and societal objectives.

In this study, the irrigation water quality of Eryaman region in Ankara (Turkey) has been investigated using a Geographic Information System-Multicriteria Decision Analysis (GIS-MCDA)-based model. Two different irrigation water quality indices (IWQI-A and IWQI-B) based on Analytic Hierarchy Process (AHP) and Data Envelopment Analysis (DEA) have been developed to provide a single suitability score for all criteria of irrigation water quality. The irrigation water quality indices were composed of 3 main criteria and 11 sub-criteria. Based on irrigation water quality indices, four suitability classes have been identified as (a) excellent, (b) good, (c) permissible, and (d) unsuitable. Irrigation water quality maps were created by using kriging method and the water quality index scores. The temporal variation of irrigation water quality was evaluated using the models created for July 2007, 2010, and 2015 years. The most suitable areas for irrigation water are concentrated in the eastern and western parts of the region where the IWQI-B scores were >0.85. In recent years, the deterioration in irrigation water quality has increased in the southern parts of the basin. This research has demonstrated that the indices created by using DEA and AHP methods are reliable indicators to assess irrigation water quality. PRACTITIONER POINTS: Water quality indices can be used to depict the overall water quality status in water management planning. To avoid problems when modeling groundwater quality, the factors that have the most effect on water quality should be selected. Analytic Hierarchy Process and Data Envelopment Analysis techniques are efficient and reliable methods to determine water quality.