The topic of regional economic resilience has been the subject of intense debate in the academic and political fields over the past decade and gained a new sense of urgency because of the pandemic caused by the SARS-CoV-2 virus as territories faced relevant impacts on their economies and social structures. The economic downturn, the increase in unemployment, and the deterioration of social conditions lead policy makers to search for solutions to make their territories more resilient to this type of event. The current article discusses how multicriteria decision analysis (MCDA) was used to help a Portuguese Intermunicipal Community, formed by 16 councils, develop a strategy to make its territory more cohesive, competitive, sustainable, and resilient. In addition to discussing an innovative application of a MCDA technique, this article illustrates how, through a MCDA approach, it was possible to reach a consensus among several policymakers, despite each of them having their own political agendas.

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.

The objective of this study is to propose and apply a novel approach to develop a drinking water quality index that enables water managers to routinely identify the vulnerabilities in a distribution system (DS) while taking into account the priorities of water managers and operators. Here, we propose an innovative approach based on the participation of eight researchers and water managers. The input from these participants was included through a combination of the Delphi and MACBETH (Measuring Attractiveness by a Categorical-Based Evaluation Technique) methods, which were applied to an index developed using fuzzy logic. The index was then validated by conducting sensitivity and comparative analyses on a database from field sampling campaigns conducted in various small municipal DSs in two Canadian provinces: Quebec and Newfoundland and Labrador. Finally, the drinking water quality index was applied to a database of the DS in Quebec City, Canada. Sensitivity and comparative analyses revealed that the developed index could allow for the characterization of water sample quality and could prove useful for prioritizing interventions in the DS. The index was also useful for representing the spatial variability of water quality, and provided nuanced information about water quality, especially when the water quality parameter values complied with guidelines and regulations. These results provide a transferable and integrated approach for developing customized drinking water quality indices. This study will help pave the way for water quality managers to better prevent episodes of possible water quality deterioration.

Group deliberation can be a pathway to understanding reasons behind judgement decisions. This pilot study implemented a deliberative process to elicit public values about health-related quality of life. In this study, participants deliberated scales and weights for a German adaption of the Short-Form Six-Dimension (SF-6D) Version 2 from a public perspective.
This article examines the reasons participants stated for health state valuations and investigates the feasibility of eliciting public reasons for judgement decisions in a deliberative setting.
The 1-day deliberation was guided by MACBETH as a method of multi-criteria decision analysis and involved qualitative comparisons of SF-6D health states and dimensions. Participants deliberated in parallel small groups and a subsequent plenary assembly. A qualitative content analysis was conducted to assess the value judgements and reasons behind them.
A total of 34 students participated in the study. Common reasoning was the level of impairment, marginal benefit, possibility of adjustment and expectation satisfaction. While the small groups agreed on scales for the SF-6D dimensions, the plenary assembly did not reach consensus on one scale and dimension weights. When dimensions were prioritized, these were pain and mental health.
While no consented value set was derived, this pilot study presents a promising approach for eliciting public reasoning behind judgements on health state values. Furthermore, it demonstrates that participants consider diverse motives when valuing health-related quality of life.

BACKGROUND: Health economists have shown a growing interest in deliberation and multi-criteria decision analysis (MCDA) as possible pathways to transparently integrate value judgments in cost-utility analyses. In line with these developments, this study piloted a consensus process to derive a German value set for the Short-Form Six-Dimension (SF-6D). In a conference setting, a group was tasked to deliberate on scores and weights for the SF-6D from the perspective of a self-determined and independent life.
METHODS: The one-day consensus conference was based on a deliberative process in combination with the MCDA method MACBETH (Measuring Attractiveness by a Categorical Based Evaluation Technique). According to MACBETH, participants were asked to qualitatively rate pairwise comparisons of SF-6D health states. The scoring within each dimension was conducted in parallel group sessions. Final agreement on the scores as well as weights for the SF-6D dimensions were derived in a subsequent plenary assembly. Results were analyzed using the software M-MACBETH and qualitative content analysis.
RESULTS: A total of 34 participants were recruited. While each of the 6 small groups presented a consented score, the plenary assembly reached consensus on all dimensions apart from pain. Concerning dimension weights, some participants favored prioritizing pain and mental health. Others disputed that trade-offs between dimensions and thus assigning weights were not acceptable in a context where this may involve withholding care from someone. As a consequence, no consensus on a value set was reached. Participants identified the group size of the plenary session and the applied weighting procedure as main obstacles to the process.
CONCLUSIONS: This pilot study presents a consensus-based approach for valuing health-related quality of life. However, further research is needed on deliberative processes that yield quantifiable results. Future conferences should explore smaller group sizes, longer durations of the deliberative process and alternatives to the additive value function applied in MACBETH.

BACKGROUND: Quality Adjusted Life Years (QALYs) are a key outcome measure widely used within health technology assessment and health service research studies. QALYs combine quantity and quality of life, with quality of life calculations relying on the value of distinct health states. Such health states\' values capture the preferences of a population and have been typically built through numerical elicitation methods. Evidence points to these value scores being influenced by methods in use and individuals reporting cognitive difficulties in eliciting their preferences. Evidence from other areas has further suggested that individuals may prefer using distinct elicitation techniques and that this preference can be influenced by their numeracy. In this study we explore the use of the MACBETH (Measuring Attractiveness by a Categorical Based Evaluation Technique) non-numerical preference elicitation approach for health states\' evaluation.
METHODS: A new protocol for preference elicitation based on MACBETH (only requiring qualitative judgments) was developed and tested within a web survey format. A sample of the Portuguese general population (n=243) valued 25 EQ-5D-3L health states with the MACBETH protocol and with a variant of the time trade-off (TTO) protocol, for comparison purposes and for understanding respondents\' preference for distinct protocols and differences in inconsistent evaluations. Respondents answered to a short numeracy test, and basic socio-economic information collected.
RESULTS: Results show that the mean values derived from MACBETH and the TTO variant are strongly correlated; however, there are substantial differences for several health states\' values. Large and similar numbers of logical inconsistencies were found in respondents\' answers with both methods. Participants with higher levels of numeracy according to the test preferred expressing value judgments with MACBETH, while participants with lower levels were mostly indifferent to both methods. Higher correlations between MACBETH and TTO variant evaluations were observed for individuals with higher numeracy.
CONCLUSIONS: Results suggest that it is worth researching the use of non-numerical preference elicitation methods. Numeracy tests more appropriate for preference elicitation when no explicit considerations of uncertainty are made need to be explored and used. Further behavioural research is needed to fully understand the potential for using these methods in distinct settings (e.g. in different evaluation contexts and in face-to-face and non-face-to-face environments), as well as to explore the effect of literacy on assessments and on respondents\' preferences.

BACKGROUND: Healthcare organizations have far greater maintenance needs for their medical equipment than other organization, as many are used directly with patients. However, the literature on asset management in healthcare organizations is very limited. The aim of this research is to provide more rational application of maintenance policies, leading to an increase in quality of care.
METHODS: This article describes a multicriteria decision-making approach which integrates Markov chains with the multicriteria Measuring Attractiveness by a Categorical Based Evaluation Technique (MACBETH), to facilitate the best choice of combination of maintenance policies by using the judgements of a multi-disciplinary decision group. The proposed approach takes into account the level of acceptance that a given alternative would have among professionals. It also takes into account criteria related to cost, quality of care and impact of care cover.
RESULTS: This multicriteria approach is applied to four dialysis subsystems: patients infected with hepatitis C, infected with hepatitis B, acute and chronic; in all cases, the maintenance strategy obtained consists of applying corrective and preventive maintenance plus two reserve machines.
CONCLUSIONS: The added value in decision-making practices from this research comes from: (i) integrating the use of Markov chains to obtain the alternatives to be assessed by a multicriteria methodology; (ii) proposing the use of MACBETH to make rational decisions on asset management in healthcare organizations; (iii) applying the multicriteria approach to select a set or combination of maintenance policies in four dialysis subsystems of a health care organization. In the multicriteria decision making approach proposed, economic criteria have been used, related to the quality of care which is desired for patients (availability), and the acceptance that each alternative would have considering the maintenance and healthcare resources which exist in the organization, with the inclusion of a decision-making group. This approach is better suited to actual health care organization practice and depending on the subsystem analysed, improvements are introduced that are not included in normal maintenance policies; in this way, not only have different maintenance policies been suggested, but also alternatives that, in each case and according to viability, provide a more complete decision tool for the maintenance manager.

Generally, groundwater is naturally of good quality for human consumption and represents an essential source of drinking water. In Canada, small municipalities and individuals are particularly reliant on groundwater, since they cannot afford complex water treatment installations. However, groundwater is a vulnerable resource that, depending on its characteristics, can be contaminated by almost any land use. In recent decades, governments have launched programs to acquire more information on groundwater, in order to better protect it. Nevertheless, the data produced are rarely adequate to be understood and used by land planners. The aim of this study was to develop a method that helps planners interpret hydrogeological data in the Province of Quebec, Canada. Based on the requests and needs of planners during semi-directed interviews, a methodology was developed to qualitatively evaluate groundwater contamination risk by land uses. The method combines land planning data and hydrogeological data through the MACBETH multicriteria analysis method, to obtain maps of groundwater contamination risk. The method was developed through group and individual meetings with numerous hydrogeology, land planning, water\'s economics and drinking water specialists. The resulting maps allow planners to understand the dynamics of groundwater within their territory, identify problem areas where groundwater is threatened and analyse the potential impact of planning scenarios on the risk of groundwater contamination.

The arts can provide unique ways for determining how people not directly involved in medicine were viewing and informing others about physical and mental disorders. With operas, one need only think about how various perturbations of madness have been portrayed. Somnambulism has long been a particularly perplexing disorder, both to physicians and the laity, and it features in a number of operas. Two mid-nineteenth-century masterpieces are examined in detail in this contribution: Verdi\'s Macbeth and Bellini\'s La Sonnambula. In the former, the sleepwalking scene is faithful to what Shakespeare\'s had written early in the seventeenth century, a time of witchcraft, superstition, and the belief that nocturnal wanderings might be caused by guilt. In Bellini\'s opera, in contrast, the victim is an innocent girl who suffers from a quirk of nature, hence eliciting sympathy and compassion. By examining the early literature on somnambulism and comparing this disorder in these operas, we can see how thinking about this condition has changed and, more generally, how music was helping to generate new ways of thinking about specific diseases and medicine.

An outbreak of the highly contagious animal disease classical swine fever (CSF) requires the selection of an optimal control strategy. The choice of a control strategy is a decision process depending on different aspects. Besides epidemiology, economic and ethical/social aspects must be taken into account. In this study, multicriteria decision-making (MCDM) was used to evaluate six control strategies for two regions with different farm densities. A strategy including only the minimum EU control measures and the traditional control strategy based on preventive culling were compared to alternative control strategies using emergency vaccination and/or rapid PCR testing (\'emergency vaccination\', \'test to slaughter\', \'test to control\' and \'vaccination in conjunction with rapid testing\'). The MACBETH approach was used in order to assess the three main criteria (epidemiology, economics and ethical/social aspects). Subcriteria with both quantitative and qualitative performance levels were translated into a normalized scale. The Choquet integral approach was adopted to obtain a ranking of the six CSF control strategies based on the three main criteria, taking interactions into account. Three different rankings of the importance of the main criteria, which were to reflect the potential perceptions of stakeholders, were examined. Both the region under investigation and the ranking of the main criteria had an influence on the \'best\' choice. Alternative control strategies were favourable to the minimum EU control and the traditional control measures independent of the farm density. Because the choice of the \'best\' control strategy does not solely depend on the epidemiological efficiency, MCDM can help to find the best solution. Both MACBETH and the Choquet integral approach are feasible MCDM approaches. MACBETH only needs a qualitative evaluation and is therefore a comparatively intuitive approach. The Choquet integral does not only take the importance of the criteria into account but also the interaction between them.