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Development of effective policy responses to address complex public health problems can be challenged by a lack of clarity about the interaction of risk factors driving the problem, differing views of stakeholders on the most appropriate and effective intervention approaches, a lack of evidence to support commonly implemented and acceptable intervention approaches, and a lack of acceptance of effective interventions. Consequently, political considerations, community advocacy and industry lobbying can contribute to a hotly contested debate about the most appropriate course of action; this can hinder consensus and give rise to policy resistance. The problem of alcohol misuse and its associated harms in New South Wales (NSW), Australia, provides a relevant example of such challenges. Dynamic simulation modelling is increasingly being valued by the health sector as a robust tool to support decision making to address complex problems. It allows policy makers to ask 'what-if' questions and test the potential impacts of different policy scenarios over time, before solutions are implemented in the real world. Participatory approaches to modelling enable researchers, policy makers, program planners, practitioners and consumer representatives to collaborate with expert modellers to ensure that models are transparent, incorporate diverse evidence and perspectives, are better aligned to the decision-support needs of policy makers, and can facilitate consensus building for action. This paper outlines a procedure for embedding stakeholder engagement and consensus building in the development of dynamic simulation models that can guide the development of effective, coordinated and acceptable policy responses to complex public health problems, such as alcohol-related harms in NSW.

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ObjectivesAlcohol misuse is a complex systemic problem. The aim of this study was to explore the feasibility of using a transparent and participatory agent-based modelling approach to develop a robust decision support tool to test alcohol policy scenarios before they are implemented in the real world.MethodsA consortium of Australia’s leading alcohol experts was engaged to collaboratively develop an agent-based model of alcohol consumption behaviour and related harms. As a case study, four policy scenarios were examined.ResultsA 19.5 ± 2.5% reduction in acute alcohol-related harms was estimated with the implementation of a 3 a.m. licensed venue closing time plus 1 a.m. lockout; and a 9 ± 2.6% reduction in incidence was estimated with expansion of treatment services to reach 20% of heavy drinkers. Combining the two scenarios produced a 33.3 ± 2.7% reduction in the incidence of acute alcohol-related harms, suggesting a synergistic effect.ConclusionsThis study demonstrates the feasibility of participatory development of a contextually relevant computer simulation model of alcohol-related harms and highlights the value of the approach in identifying potential policy responses that best leverage limited resources.Electronic supplementary materialThe online version of this article (doi:10.1007/s00038-017-1041-y) contains supplementary material, which is available to authorized users.

Drawing on the long tradition of evidence-based medicine that aims to improve the efficiency and effectiveness of clinical practice, the field of public health has sought to apply 'hierarchies of evidence' to appraise and synthesise public health research. Various critiques of this approach led to the development of synthesis methods that include broader evidence typologies and more 'fit for purpose' privileging of methodological designs. While such adaptations offer great utility for evidence-informed public health policy and practice, this paper offers an alternative perspective on the synthesis of evidence that necessitates a yet more egalitarian approach. Dynamic simulation modelling is increasingly recognised as a valuable evidence synthesis tool to inform public health policy and programme planning for complex problems. The development of simulation models draws on and privileges a wide range of evidence typologies, thus challenging the traditional use of 'hierarchies of evidence' to support decisions on complex dynamic problems.

Background and aimEvaluations of alcohol policy changes demonstrate that restriction of trading hours of both ‘on’‐ and ‘off’‐licence venues can be an effective means of reducing rates of alcohol‐related harm. Despite this, the effects of different trading hour policy options over time, accounting for different contexts and demographic characteristics, and the common co‐occurrence of other harm reduction strategies in trading hour policy initiatives, are difficult to estimate. The aim of this study was to use dynamic simulation modelling to compare estimated impacts over time of a range of trading hour policy options on various indicators of acute alcohol‐related harm.MethodsAn agent‐based model of alcohol consumption in New South Wales, Australia was developed using existing research evidence, analysis of available data and a structured approach to incorporating expert opinion. Five policy scenarios were simulated, including restrictions to trading hours of on‐licence venues and extensions to trading hours of bottle shops. The impact of the scenarios on four measures of alcohol‐related harm were considered: total acute harms, alcohol‐related violence, emergency department (ED) presentations and hospitalizations.ResultsSimulation of a 3 a.m. (rather than 5 a.m.) closing time resulted in an estimated 12.3 ± 2.4% reduction in total acute alcohol‐related harms, a 7.9 ± 0.8% reduction in violence, an 11.9 ± 2.1% reduction in ED presentations and a 9.5 ± 1.8% reduction in hospitalizations. Further reductions were achieved simulating a 1 a.m. closing time, including a 17.5 ± 1.1% reduction in alcohol‐related violence. Simulated extensions to bottle shop trading hours resulted in increases in rates of all four measures of harm, although most of the effects came from increasing operating hours from 10 p.m. to 11 p.m.ConclusionsAn agent‐based simulation model suggests that restricting trading hours of licensed venues reduces rates of alcohol‐related harm and extending trading hours of bottle shops increases rates of alcohol‐related harm. The model can estimate the effects of a range of policy options.

IMPORTANCE The Merit-based Incentive Payment System (MIPS) is a major Medicare value-based purchasing program, influencing payment for more than 1 million clinicians annually. There is a growing concern that MIPS increases administrative burden, and little is known about what it costs physician practices to participate in the program. OBJECTIVE To examine the costs for independent physician practices to participate in MIPS in 2019. DESIGN, SETTING, AND PARTICIPANTS This qualitative study identified and interviewed leaders of physician practices participating in the US Centers for Medicare & Medicaid Services (CMS) MIPS program, including those in MIPS alternative payment models. Time required and financial costs were calculated from responses to in-depth, semistructured interviews conducted from December 12, 2019, to June 23, 2020. Physician practices were categorized by size (small, 1-9 physicians; medium, 10-25; and large, Ն50), specialty (primary care, general surgery, or multispecialty), and US census region. Participants were asked about 2019 costs related to clinician and staff time, information technology, and external vendors. Time was converted to financial costs using the Medical Group Management Association's Provider Compensation and the Management and Staff Compensation databases. MAIN OUTCOMES AND MEASURES Annual time spent by staff on MIPS-related activities and mean per-physician costs to physician practices in 2019. RESULTS Leaders of 30 physician practices (9 [30.0%] small primary care, 6 [20.0%] small general surgery, 4 [13.3%] medium primary care, 4 [13.3%] medium general surgery, and 7 [23.3%] large multispecialty) represented all US census regions, and 14 of the 30 (46.7%) practices participated in a MIPS alternative payment model in 2019. The mean per-physician cost to practices of participating

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