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Institutional narratives, appealing both to the intellect and the imagination, are powerful mechanisms of entrenchment. Drawing on close examination of legislative debates, interview transcripts, and official documents, this article analyzes institutional narratives of the British National Health Service (NHS) and American Medicare and Medicaid. These narratives take the form of epics, featuring founding heroes, adversaries, stewards, saviors, and other characters, and are retold on multiple occasions, and especially on anniversaries of the founding date. In the process, certain elements of history are remembered, and others forgotten. The myth of the NHS as a single national institution obscured much of the complexity and compromise that went into its founding and subsequent development, but preserved fidelity to its founding principles. In the United States, the dominant narrative belonged to Medicare, while Medicaid featured as an afterthought. In the case of the NHS, narrative entrenchment served to preserve universal access to comprehensive health care. In the case of American Medicare, entrenchment preserved the original mission of the institution but kept it from expanding to a broader swath of the population, even as its less-entrenched companion Medicaid provided a vehicle for coverage of an increasingly wide range of population groups. A distinct Medicaid narrative developed only after incremental expansion was well underway.

Objective The purpose of this quality improvement initiative was to evaluate satisfaction of family members of patients in a neuro trauma ICU (NTICU). Methods Adult patients (age 18+) admitted to the NTICU for at least 24 hours between June 2017 and November 2018 were identified. Near or at the time of discharge from the NTICU, the health unit coordinator or registered nurse identified the family member who was either the next-of-kin, surrogate decision-maker, or person who had been most frequently present at the patient's bedside. This person was provided a packet containing a letter of consent and the Critical Care Family Satisfaction Survey (CCFSS). Results Surveys were completed by 78 family members, the majority of whom were the wife of the patient (n = 35, 44%), 60 years and older (n = 48, 60.8%). Fifty-seven percent of patients (n = 45) were in the ICU less than 3 days and 59% (n = 47) of medical events were injury-related. Total CCFSS scores ranged from 69 to 100 (median 95). The item with the largest number of dissatisfied responses was "Noise level in the critical care unit" (n = 4, 5.3% not satisfied). Open-ended question comments were primarily positive (n = 60, 66%), with 32% (n = 29) representing areas for improvement. Conclusions Results of this satisfaction survey have been disseminated to leadership and have been taken into consideration in the planning of a new hospital building currently being built, including ICU patient rooms that allow for more privacy and reduced noise, and more comfortable family rooms. Relevance to clinical practice Family members are a very useful source of feedback for ICU care. Several concerns identified by family members in this study are likely to be relevant to other sites. These included: communication between health care providers and family about patient status, noise in the ICU, peaceful waiting areas for family, and slow transfers.

The American Democratic leadership in the White House and Congress in 2009–10 and the British Conservative/Liberal-Democrat Coalition government in 2010–12 each pursued a strategy of rapidly assembled multiple adjustments to the prevailing policy framework for health care rather than attempting a “big-bang” strategy of sweeping institutional change. Despite their relative modesty, each set of reforms encountered a highly conflictual and tortuous process of legislative passage. Subsequently, the reforms failed to gain broad public acceptance and were variously hobbled (in the United States) and transformed (in the United Kingdom) in the course of implementation. These two cases thus offer some common lessons about the potential and the pitfalls of such complex “mosaic” reforms.

The experience of the COVID-19 pandemic has fuelled demands for national threshold standards of quality for long-term care in Canada. The federal government, however, lacks jurisdiction for and experience with the provision of long-term care, which rests constitutionally with the provinces. A creative approach to providing new funding and effective regulatory standard setting would seize the potential of an area of jurisdiction shared by federal and provincial governments - old age security - to establish a long-term care insurance program administered by the federal government and jointly governed by federal and provincial governments.

Background Palmoplantar pustulosis (PPP) is a chronic inflammatory disease in which sterile and relapsing pustules appear on the palms and soles. Objectives To assess the effects of interventions for chronic PPP to induce and maintain complete remission. Methods We searched for randomised controlled trials (RCTs), including people with PPP or chronic palmoplantar pustular psoriasis, in Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, LILACS and eight trials registers up to July 2020. Study selection, data extraction and risk of bias assessment were carried out independently by two review authors. Certainity of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. Results We included 37 RCTs (1663 participants, 76% women, mean age 50 years).. Mean treatment duration was 11 weeks. Topical vitamin D derivative may be more effective than placebo in achieving clearance [risk ratio (RR) 7.83, 95% confidence interval (CI) 1.85 to 33.12; low-certainity evidence from 2 trials].. Concerning biologic therapies, there was little or no difference between etanercept and placebo in achieving clearance (low-certainity evidence from one trial), ustekinumab is less effective than placebo in reducing severity (low-certainty evidence from one trial), guselkumab and secukinumab probably better reduce disease severity (RR 2.88, 95% CI 1.24 to 6.69 and 1.55, 95% CI 1.02 to 2.35 respectively, moderate-certainty evidence from 2 and one trial respectively) but may cause more serious adverse events when compared to placebo. Conclusions Evidence is lacking for or against major chronic PPP treatments. Risk of bias and imprecision limit our confidence in the results.

Introduction Le nombre de traitements systemiques (TS) disponibles dans l’indication psoriasis modere a severe a augmente de facon considerable durant les 20 dernieres annees. La meta-analyse en reseau (MAR) est une methode statistique permettant de comparer des traitements n’ayant pas ete compares dans des essais (ECR) face-face et de classer les traitements en fonction de leur efficacite et tolerance. L’objectif de cette revue systematique (RS) avec MAR etait de comparer l’efficacite et la tolerance des TS chez l’adulte dans le psoriasis modere a severe. Sont presentes les resultats de la mise a jour la plus recente. Materiel et methodes Les bases bibliographiques CENTRAL, MEDLINE, Embase et les resumes de congres, les registres d’essais ont ete consultes jusqu’en septembre 2020. Les criteres d’inclusion etaient : ECR comparant un TS chez des adultes atteints de psoriasis modere a severe (Pso), par rapport a un PBO ou entre eux. La selection des ECR, l’extraction des donnees, l’evaluation du risque de biais ont ete effectuees independamment par 2 auteurs. Les criteres de jugement (CJ) principaux etaient: la proportion de participants atteignant le PASI 90 et la proportion de participants presentant des evenements indesirables graves (EIG) entre 8 et 24 semaines. Resultats Un total de 158 ECR ont ete inclus (57 831 patients, d’âge moyen de 45 ans, 68 % d’hommes, avec un score initial moyen PASI de 20) dans la revue systematique et 130 ECR (50 081 patients) dans la MAR comparant 20 TS ou PBO. Le risque de biais etait considere comme faible pour 80 ECR/158. Les patients sous infliximab, ixekizumab, secukinumab, brodalumab, risankizumab et guselkumab atteignaient significativement plus le PASI90 comparativement aux patients sous ustekinumab ou sous l’un des 3 autres anti-TNF: adalimumab, certolizumab, et etanercept. L’ustekinumab et adalimumab etaient significativement plus efficaces pour l’obtention du PASI 90 que l’etanercept; l’ustekinumab etait egalement plus efficace que le certolizumab. Aucune difference n’etait constatee entre l’ustekinumab et l’adalimumab. L’efficacite clinique de ces 7 TS par rapport au PBO a ete est detaillee. Aucune difference significative entre les TS et le PBO a ete trouvee concernant le risque d’EIG. Discussion Cette RS/MA permet de donner de facon actualisee en continu les donnees d’efficacite et de tolerance relatives des TS. Ces donnees sont importantes dans la prise de decision medicale et pour les auteurs de recommandations. Les limites de cette etude sont le manque de donnees d’efficacite et de tolerance a long terme necessaires dans le cadre d’une maladie chronique.

Background Psoriasis is an immune-mediated disease for which some people have a genetic predisposition. The condition manifests in inflammatory effects on either the skin or joints, or both, and it has a major impact on quality of life. Although there is currently no cure for psoriasis, various treatment strategies allow sustained control of disease signs and symptoms. Several randomised controlled trials (RCTs) have compared the efficacy of the different systemic treatments in psoriasis against placebo. However, the relative benefit of these treatments remains unclear due to the limited number of trials comparing them directly head to head, which is why we chose to conduct a network meta-analysis. Objectives To compare the efficacy and safety of conventional systemic agents (acitretin, ciclosporin, fumaric acid esters, methotrexate), small molecules (apremilast, tofacitinib, ponesimod), anti-TNF alpha (etanercept, infliximab, adalimumab, certolizumab), anti-IL12/23 (ustekinumab), anti-IL17 (secukinumab, ixekizumab, brodalumab), anti-IL23 (guselkumab, tildrakizumab), and other biologics (alefacept, itolizumab) for patients with moderate to severe psoriasis and to provide a ranking of these treatments according to their efficacy and safety. Search methods We searched the following databases to December 2016: the Cochrane Skin Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and LILACS. We also searched five trials registers and the U.S. Food and Drug Administration (FDA) and European Medicines Agency (EMA) reports. We checked the reference lists of included and excluded studies for further references to relevant RCTs. We searched the trial results databases of a number of pharmaceutical companies and handsearched the conference proceedings of a number of dermatology meetings. Selection criteria Randomised controlled trials (RCTs) of systemic and biological treatments in adults (over 18 years of age) with moderate to severe plaque psoriasis or psoriatic arthritis whose skin had been clinically diagnosed with moderate to severe psoriasis, at any stage of treatment, in comparison to placebo or another active agent. Data collection and analysis Three groups of two review authors independently undertook study selection, data extraction, 'Risk of bias' assessment, and analyses. We synthesised the data using pair-wise and network meta-analysis (NMA) to compare the treatments of interest and rank them according to their effectiveness (as measured by the Psoriasis Area and Severity Index score (PASI) 90) and acceptability (the inverse of serious adverse effects). We assessed the certainty of the body of evidence from the NMA for the two primary outcomes, according to GRADE; we evaluated evidence as either very low, low, moderate, or high. We contacted study authors when data were unclear or missing. Main results We included 109 studies in our review (39,882 randomised participants, 68% men, all recruited from a hospital). The overall average age was 44 years; the overall mean PASI score at baseline was 20 (range: 9.5 to 39). Most of these studies were placebo controlled (67%), 23% were head-to-head studies, and 10% were multi-armed studies with both an active comparator and placebo. We have assessed all treatments listed in the objectives (19 in total). In all, 86 trials were multicentric trials (two to 231 centres). All of the trials included in this review were limited to the induction phase (assessment at less than 24 weeks after randomisation); in fact, all trials included in the network meta-analysis were measured between 12 and 16 weeks after randomisation. We assessed the majority of studies (48/109) as being at high risk of bias; 38 were assessed as at an unclear risk, and 23, low risk. Network meta-analysis at class level showed that all of the interventions (conventional systemic agents, small molecules, and biological treatments) were significantly more effective than placebo in terms of reaching PASI 90. In terms of reaching PASI 90, the biologic treatments anti-IL17, anti-IL12/23, anti-IL23, and anti-TNF alpha were significantly more effective than the small molecules and the conventional systemic agents. Small molecules were associated with a higher chance of reaching PASI 90 compared to conventional systemic agents. At drug level, in terms of reaching PASI 90, all of the anti-IL17 agents and guselkumab (an anti-IL23 drug) were significantly more effective than the anti-TNF alpha agents infliximab, adalimumab, and etanercept, but not certolizumab. Ustekinumab was superior to etanercept. No clear difference was shown between infliximab, adalimumab, and etanercept. Only one trial assessed the efficacy of infliximab in this network; thus, these results have to be interpreted with caution. Tofacitinib was significantly superior to methotrexate, and no clear difference was shown between any of the other small molecules versus conventional treatments. Network meta-analysis also showed that ixekizumab, secukinumab, brodalumab, guselkumab, certolizumab, and ustekinumab outperformed other drugs when compared to placebo in terms of reaching PASI 90: the most effective drug was ixekizumab (risk ratio (RR) 32.45, 95% confidence interval (CI) 23.61 to 44.60; Surface Under the Cumulative Ranking (SUCRA) = 94.3; high-certainty evidence), followed by secukinumab (RR 26.55, 95% CI 20.32 to 34.69; SUCRA = 86.5; high-certainty evidence), brodalumab (RR 25.45, 95% CI 18.74 to 34.57; SUCRA = 84.3; moderate-certainty evidence), guselkumab (RR 21.03, 95% CI 14.56 to 30.38; SUCRA = 77; moderate-certainty evidence), certolizumab (RR 24.58, 95% CI 3.46 to 174.73; SUCRA = 75.7; moderate-certainty evidence), and ustekinumab (RR 19.91, 95% CI 15.11 to 26.23; SUCRA = 72.6; high-certainty evidence). We found no significant difference between all of the interventions and the placebo regarding the risk of serious adverse effects (SAEs): the relative ranking strongly suggested that methotrexate was associated with the best safety profile regarding all of the SAEs (RR 0.23, 95% CI 0.05 to 0.99; SUCRA = 90.7; moderate-certainty evidence), followed by ciclosporin (RR 0.23, 95% CI 0.01 to 5.10; SUCRA = 78.2; very low-certainty evidence), certolizumab (RR 0.49, 95% CI 0.10 to 2.36; SUCRA = 70.9; moderate-certainty evidence), infliximab (RR 0.56, 95% CI 0.10 to 3.00; SUCRA = 64.4; very low-certainty evidence), alefacept (RR 0.72, 95% CI 0.34 to 1.55; SUCRA = 62.6; low-certainty evidence), and fumaric acid esters (RR 0.77, 95% CI 0.30 to 1.99; SUCRA = 57.7; very low-certainty evidence). Major adverse cardiac events, serious infections, or malignancies were reported in both the placebo and intervention groups. Nevertheless, the SAEs analyses were based on a very low number of events with low to very low certainty for just over half of the treatment estimates in total, moderate for the others. Thus, the results have to be considered with caution. Considering both efficacy (PASI 90 outcome) and acceptability (SAEs outcome), highly effective treatments also had more SAEs compared to the other treatments, and ustekinumab, infliximab, and certolizumab appeared to have the better trade-off between efficacy and acceptability. Regarding the other efficacy outcomes, PASI 75 and Physician Global Assessment (PGA) 0/1, the results were very similar to the results for PASI 90. Information on quality of life was often poorly reported and was absent for a third of the interventions. Authors' conclusions Our review shows that compared to placebo, the biologics ixekizumab, secukinumab, brodalumab, guselkumab, certolizumab, and ustekinumab are the best choices for achieving PASI 90 in people with moderate to severe psoriasis on the basis of moderate- to high-certainty evidence. At class level, the biologic treatments anti-IL17, anti-IL12/23, anti-IL23, and anti-TNF alpha were significantly more effective than the small molecules and the conventional systemic agents, too. This NMA evidence is limited to induction therapy (outcomes were measured between 12 to 16 weeks after randomisation) and is not sufficiently relevant for a chronic disease. Moreover, low numbers of studies were found for some of the interventions, and the young age (mean age of 44 years) and high level of disease severity (PASI 20 at baseline) may not be typical of patients seen in daily clinical practice. Another major concern is that short-term trials provide scanty and sometimes poorly reported safety data and thus do not provide useful evidence to create a reliable risk profile of treatments. Indeed, we found no significant difference in the assessed interventions and placebo in terms of SAEs. Methotrexate appeared to have the best safety profile, but as the evidence was of very low to moderate quality, we cannot be sure of the ranking. In order to provide long-term information on the safety of the treatments included in this review, it will be necessary to evaluate non-randomised studies and postmarketing reports released from regulatory agencies as well. In terms of future research, randomised trials comparing directly active agents are necessary once high-quality evidence of benefit against placebo is established, including head-to-head trials amongst and between conventional systemic and small molecules, and between biological agents (anti-IL17 versus anti-IL23, anti-IL23 versus anti-IL12/23, anti-TNF alpha versus anti-IL12/23). Future trials should also undertake systematic subgroup analyses (e.g. assessing biological-naive patients, baseline psoriasis severity, presence of psoriatic arthritis, etc.). Finally, outcome measure harmonisation is needed in psoriasis trials, and researchers should look at the medium- and long-term benefit and safety of the interventions and the comparative safety of different agents.

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