Interventions for cold homes: a rapid review of the health impacts

BACKGROUND

Cold homes are associated with an increased risk of adverse health outcomes for older people. To mitigate this risk, homes need to be heated to an appropriate temperature. This review aims to identify interventions designed to improve heating and temperatures within homes and summarize its impact on health, health service utilization and cost effectiveness.

METHODS

A rapid review was conducted. Studies assessing the effects of structural, financial, or behavioural interventions designed to improve home temperatures of residents aged 18+ years were eligible. Searches were carried out in four databases. A search for grey literature, and backward and forward citation searching were performed. Data were summarized in a narrative synthesis and mapped using EPPI-Reviewer and EPPI-Mapper software.

RESULTS

Eighteen studies reported across 19 publications were included. Structural interventions were associated with better mental health and quality of life, a reduction in health service utilization, and improvements in satisfaction with internal home temperature, social interactions and financial difficulties. The impact on physical health outcomes varied by age, gender and long-term conditions. Evidence about the impact of behavioural interventions was inconsistent.

CONCLUSION

Structural improvements to increase home temperatures may offer the potential to improve some aspects of health. However, the impact on physical health, including which groups are most likely to benefit, is unclear. Key gaps include the lack of evidence about the impact of financial interventions, and the impact of all types of interventions, on quality of life, mortality and costs.

What works to support carers of older people and older carers? an international evidence map of interventions and outcomes

BACKGROUND

Unpaid carers of older people, and older unpaid carers, experience a range of adverse outcomes. Supporting carers should therefore be a public health priority. Our understanding of what works to support carers could be enhanced if future evaluations prioritise under-researched interventions and outcomes. To support this, we aimed to: map evidence about interventions to support carers, and the outcomes evaluated; and identify key gaps in current evidence.

METHODS

Evidence gap map review methods were used. Searches were carried out in three bibliographic databases for quantitative evaluations of carer interventions published in OECD high-income countries between 2013 and 2023. Interventions were eligible if they supported older carers (50 + years) of any aged recipient, or any aged carers of older people (50 + years).

FINDINGS

205 studies reported across 208 publications were included in the evidence map. The majority evaluated the impact of therapeutic and educational interventions on carer burden and carers' mental health. Some studies reported evidence about physical exercise interventions and befriending and peer support for carers, but these considered a limited range of outcomes. Few studies evaluated interventions that focused on delivering financial information and advice, pain management, and physical skills training for carers. Evaluations rarely considered the impact of interventions on carers' physical health, quality of life, and social and financial wellbeing. Very few studies considered whether interventions delivered equitable outcomes.

CONCLUSION

Evidence on what works best to support carers is extensive but limited in scope. A disproportionate focus on mental health and burden outcomes neglects other important areas where carers may need support. Given the impact of caring on carers' physical health, financial and social wellbeing, future research could evaluate interventions that aim to support these outcomes. Appraisal of whether interventions deliver equitable outcomes across diverse carer populations is critical.

Effectiveness of shared medical appointments delivered in primary care for improving health outcomes in patients with long-term conditions: a systematic review of randomised controlled trials

OBJECTIVES

To examine the effectiveness of shared medical appointments (SMAs) compared with one-to-one appointments in primary care for improving health outcomes and reducing demand on healthcare services by people with one or more long-term conditions (LTCs).

DESIGN

A systematic review of the published literature.

DATA SOURCES

Six databases, including MEDLINE and Web of Science, were searched 2013-2023. Relevant pre-2013 trials identified by forward and backward citation searches of the included trials were included.

ELIGIBILITY CRITERIA

Randomised controlled trials of SMAs delivered in a primary care setting involving adults over 18 years with one or more LTCs. Studies were excluded if the SMA did not include one-to-one patient-clinician time. All countries were eligible for inclusion.

DATA EXTRACTION AND SYNTHESIS

Data were extracted and outcomes narratively synthesised, meta-analysis was undertaken where possible.

RESULTS

Twenty-nine unique trials were included. SMA models varied in terms of components, mode of delivery and target population. Most trials recruited patients with a single LTC, most commonly diabetes (n=16). There was substantial heterogeneity in outcome measures. Meta-analysis showed that participants in SMA groups had lower diastolic blood pressure than those in usual care (d=-0.086, 95% CI=-0.16 to -0.02, n=10) (p=0.014). No statistically significant differences were found across other outcomes. Compared with usual care, SMAs had no significant effect on healthcare service use. For example, no difference between SMAs and usual care was found for admissions to emergency departments at follow-up (d=-0.094, 95% CI=-0.27 to 0.08, n=6, p=0.289).

CONCLUSIONS

There was a little difference in the effectiveness of SMAs compared with usual care in terms of health outcomes or healthcare service use in the short-term (range 12 weeks to 24 months). To strengthen the evidence base, future studies should include a wider array of LTCs, standardised outcome measures and more details on SMA components to help inform economic evaluation.

PROSPERO REGISTRATION NUMBER

CRD42020173084.

Characteristics and Components of Self-Management Interventions for Improving Quality of Life in Cancer Survivors: A Systematic Review

Self-management can improve clinical and psychosocial outcomes in cancer survivors. Which intervention characteristics and components are beneficial is unclear, hindering implementation into practice. We systematically searched six databases from inception to 17 November 2021 for studies evaluating self-management interventions for adult cancer survivors post-treatment. Independent reviewers screened for eligibility. Data extraction included population and study characteristics, intervention characteristics (TIDieR) and components (PRISMS), (associations with) quality of life (QoL), self-efficacy, and economic outcomes. Study quality was appraised, and narrative synthesis was conducted. We identified 53 papers reporting 32 interventions. Studies had varying quality. They were most often randomised controlled trials (n = 20), targeted at survivors of breast (n = 10), prostate (n = 7), or mixed cancers (n = 11). Intervention characteristics (e.g., provider, location) varied considerably. On average, five (range 1-10) self-management components were delivered, mostly "Information about condition and its management" (n = 26). Twenty-two studies reported significant QoL improvements (6 also reported significant self-efficacy improvements); these were associated most consistently with combined individual and group delivery. Economic evaluations were limited and inconclusive. Self-management interventions showed promise for improving QoL, but study quality was variable, with substantial heterogeneity in intervention characteristics and components. By identifying what to adapt from existing interventions, these findings can inform development and implementation of self-management interventions in cancer.

Interventions to improve oral health and related health behaviours of substance use, smoking, and diet in people with severe and multiple disadvantage: a systematic review of effectiveness and cost-effectiveness

BACKGROUND

Homelessness overlapping with substance use and offending is described as severe and multiple disadvantage (SMD). People experiencing SMD have poor oral health along with high levels of related behaviours such as substance use, smoking, and poor diet. Existing evidence largely describes the prevalence of oral health problems, substance use, and smoking in SMD groups. Little is known about interventions that can address these conditions in SMD groups. We aimed to review the effectiveness and cost-effectiveness of interventions on oral health and related health behaviours in adults experiencing SMD.

METHODS

For this systematic review, we searched bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, EBSCO, Scopus) and grey literature for papers published from inception to February 2023. Two researchers independently reviewed the searches. Randomised controlled trials (RCTs), comparative studies and economic evaluations were included. Risk of bias was assessed. Population included adults experiencing SMD (including homelessness and substance use or repeat offending). Outcomes included oral health, and related behaviours (substance use, smoking, poor diet). Results were narratively synthesised. This review was registered with PROSPERO, CRD42020202416.

FINDINGS

The review included 38 studies (published between 1991 and 2023), with 34 reporting effectiveness. These studies comprised of 23 RCTs and 11 quasi-experimental studies conducted in the USA (25 studies), Canada (seven studies), France (one study), and Spain (one study). The interventions involving multiple components, such as housing services with substance use and mental health support, effectively reduced substance use in SMD groups; these were mostly individual-level interventions. However, these studies had short follow-up periods and high attrition rates. Only one study addressed oral health outcomes, none focused on diet, and three RCTs covered smoking, with one intervention showing smoking abstinence at 4 weeks. Some limited evidence suggested cost-effectiveness of substance use interventions.

INTERPRETATION

This review found that integrating services such as housing with other health-care services together could be effective in improving health behaviours, especially substance use among SMD groups. More evidence is needed specifically on oral health, smoking, and diet-related interventions. The generalisability of findings of this review is limited to high-income countries and shorter-term outcomes.

FUNDING

National Institute for Health and Care Research (NIHR) Policy Research Programme.

Clinical and cost effectiveness of endoscopic bipolar radiofrequency ablation for the treatment of malignant biliary obstruction: a systematic review

Background

Early evidence suggests that using radiofrequency ablation as an adjunct to standard care (i.e. endoscopic retrograde cholangiopancreatography with stenting) may improve outcomes in patients with malignant biliary obstruction.

Objectives

To assess the clinical effectiveness, cost-effectiveness and potential risks of endoscopic bipolar radiofrequency ablation for malignant biliary obstruction, and the value of future research.

Data sources

Seven bibliographic databases, three websites and seven trials registers were searched from 2008 until 21 January 2021.

Review methods

The study inclusion criteria were as follows: patients with biliary obstruction caused by any form of unresectable malignancy; the intervention was reported as an endoscopic biliary radiofrequency ablation to ablate malignant tissue that obstructs the bile or pancreatic ducts, either to fit a stent (primary radiofrequency ablation) or to clear an obstructed stent (secondary radiofrequency ablation); the primary outcomes were survival, quality of life or procedure-related adverse events; and the study design was a controlled study, an observational study or a case report. Risk of bias was assessed using Cochrane tools. The primary analysis was meta-analysis of the hazard ratio of mortality. Subgroup analyses were planned according to the type of probe, the type of stent (i.e. metal or plastic) and cancer type. A de novo Markov model was developed to model cost and quality-of-life outcomes associated with radiofrequency ablation in patients with primary advanced bile duct cancer. Insufficient data were available for pancreatic cancer and secondary bile duct cancer. An NHS and Personal Social Services perspective was adopted for the analysis. A probabilistic analysis was conducted to estimate the incremental cost-effectiveness ratio for radiofrequency ablation and the probability that radiofrequency ablation was cost-effective at different thresholds. The population expected value of perfect information was estimated in total and for the effectiveness parameters.

Results

Sixty-eight studies (1742 patients) were included in the systematic review. Four studies (336 participants) were combined in a meta-analysis, which showed that the pooled hazard ratio for mortality following primary radiofrequency ablation compared with a stent-only control was 0.34 (95% confidence interval 0.21 to 0.55). Little evidence relating to the impact on quality of life was found. There was no evidence to suggest an increased risk of cholangitis or pancreatitis, but radiofrequency ablation may be associated with an increase in cholecystitis. The results of the cost-effectiveness analysis were that the costs of radiofrequency ablation was £2659 and radiofrequency ablation produced 0.18 quality-adjusted life-years, which was more than no radiofrequency ablation on average. With an incremental cost-effectiveness ratio of £14,392 per quality-adjusted life-year, radiofrequency ablation was likely to be cost-effective at a threshold of £20,000 per quality-adjusted life-year across most scenario analyses, with moderate uncertainty. The source of the vast majority of decision uncertainty lay in the effect of radiofrequency ablation on stent patency.

Limitations

Only 6 of 18 comparative studies contributed to the survival meta-analysis, and few data were found concerning secondary radiofrequency ablation. The economic model and cost-effectiveness meta-analysis required simplification because of data limitations. Inconsistencies in standard reporting and study design were noted.

Conclusions

Primary radiofrequency ablation increases survival and is likely to be cost-effective. The evidence for the impact of secondary radiofrequency ablation on survival and of quality of life is limited. There was a lack of robust clinical effectiveness data and, therefore, more information is needed for this indication.

Future work

Future work investigating radiofrequency ablation must collect quality-of-life data. High-quality randomised controlled trials in secondary radiofrequency ablation are needed, with appropriate outcomes recorded.

Study registration

This study is registered as PROSPERO CRD42020170233.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 7. See the NIHR Journals Library website for further project information.

Are non-invasive or minimally invasive autopsy techniques for detecting cause of death in prenates, neonates and infants accurate? A systematic review of diagnostic test accuracy

OBJECTIVES

To assess the diagnostic accuracy of non-invasive or minimally invasive autopsy techniques in deaths under 1 year of age.

DESIGN

This is a systematic review of diagnostic test accuracy. The protocol is registered on PROSPERO.

PARTICIPANTS

Deaths from conception to one adjusted year of age.

SEARCH METHODS

MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO), the Cochrane Library, Scopus and grey literature sources were searched from inception to November 2021.

DIAGNOSTIC TESTS

Non-invasive or minimally invasive diagnostic tests as an alternative to traditional autopsy.

DATA COLLECTION AND ANALYSIS

Studies were included if participants were under one adjusted year of age, with index tests conducted prior to the reference standard.Data were extracted from eligible studies using piloted forms. Risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2. A narrative synthesis was conducted following the Synthesis without Meta-Analysis guidelines. Vote counting was used to assess the direction of effect.

MAIN OUTCOME MEASURES

Direction of effect was expressed as percentage of patients per study.

FINDINGS

We included 54 direct evidence studies (68 articles/trials), encompassing 3268 cases and eight index tests. The direction of effect was positive for postmortem ultrasound and antenatal echography, although with varying levels of success. Conversely, the direction of effect was against virtual autopsy. For the remaining tests, the direction of effect was inconclusive.A further 134 indirect evidence studies (135 articles/trials) were included, encompassing 6242 perinatal cases. The addition of these results had minimal impact on the direct findings yet did reveal other techniques, which may be favourable alternatives to autopsy.Seven trial registrations were included but yielded no results.

CONCLUSIONS

Current evidence is insufficient to make firm conclusions about the generalised use of non-invasive or minimally invasive autopsy techniques in relation to all perinatal population groups.PROSPERO registration numberCRD42021223254.

Investigation of text-mining methodologies to aid the construction of search strategies in systematic reviews of diagnostic test accuracy-a case study

Current methodologies for designing search strategies rely heavily on the knowledge and expertise of information specialists. Yet, the volume and complexity of scientific literature is overwhelming for even the most experienced information specialists, making it difficult to produce robust search strategies for complex systematic reviews. In this case study, we aimed to assess and describe the benefits and limitations of using semi-automated text-mining tools for designing search strategies in a systematic review of diagnostic test accuracy. An experienced information specialist designed a search strategy using traditional methods. This strategy was then amended to include additional terms identified by text-mining tools. We evaluated the usability and expertise required, risk of introducing bias to the search, precision of the search strategy and rated the usefulness of the tools. Thirteen of the 16 investigated tools produced a total of 40 additional terms, beyond those in the original search strategy. This resulted in 11 previously unidentified relevant articles being retrieved. Precision was reduced or remained the same in all cases. After considering all aspects of the investigation we rated each application, with two being 'extremely useful', three being 'useful', three having 'no impact' and eight being 'not very useful'. Comparative analysis revealed discrepancies between similar tools. Our findings have implications for the way in which these methodologies are used and applied to search strategies. If semi-automated techniques are to become mainstream in information retrieval for complex systematic reviews, we need tailored tools that fit information specialists' requirements across disciplines.

Factors associated with unmet need for support to maintain independence in later life: a systematic review of quantitative and qualitative evidence

BACKGROUND

populations are considered to have an 'unmet need' when they could benefit from, but do not get, the necessary support. Policy efforts to achieve equitable access to long-term care require an understanding of patterns of unmet need. A systematic review was conducted to identify factors associated with unmet need for support to maintain independence in later life.

METHODS

seven bibliographic databases and four non-bibliographic evidence sources were searched. Quantitative observational studies and qualitative systematic reviews were included if they reported factors associated with unmet need for support to maintain independence in populations aged 50+, in high-income countries. No limits to publication date were imposed. Studies were quality assessed and a narrative synthesis used, supported by forest plots to visualise data.

FINDINGS

forty-three quantitative studies and 10 qualitative systematic reviews were included. Evidence across multiple studies suggests that being male, younger age, living alone, having lower levels of income, poor self-rated health, more functional limitations and greater severity of depression were linked to unmet need. Other factors that were reported in single studies were also identified. In the qualitative reviews, care eligibility criteria, the quality, adequacy and absence of care, and cultural and language barriers were implicated in unmet need.

CONCLUSIONS

this review identifies which groups of older people may be most at risk of not accessing the support they need to maintain independence. Ongoing monitoring of unmet need is critical to support policy efforts to achieve equal ageing and equitable access to care.

Dietary and serum tyrosine, white matter microstructure and inter-individual variability in executive functions in overweight adults: Relation to sex/gender and age

Tyrosine (tyr), the precursor of the neurotransmitter dopamine, is known to modulate cognitive functions including executive attention. Tyr supplementation is suggested to influence dopamine-modulated cognitive performance. However, results are inconclusive regarding the presence or strength and also the direction of the association between tyr and cognitive function. This pre-registered cross-sectional analysis investigates whether diet-associated serum tyr relates to executive attention performance, and whether this relationship is moderated by differences in white matter microstructure. 59 healthy, overweight, young to middle-aged adults (20 female, 28.3 ± 6.6 years, BMI: 27.3 ± 1.5 kg/m²) drawn from a longitudinal study reported dietary habits, donated blood and completed diffusion-weighted brain magnetic resonance imaging and the attention network test. Main analyses were performed using linear regressions and non-parametric voxel-wise inference testing. Confirmatory analyses did neither support an association between dietary and serum tyr nor a relationship between relative serum tyr/large neutral amino acids (LNAA) levels or white matter microstructure and executive attention performance. However, exploratory analyses revealed higher tyr intake, higher serum tyr and better executive attention performance in the male sex/gender group. In addition, older age was associated with higher dietary tyr intake and lower fractional anisotropy in a widespread cluster across the brain. Finally, a positive association between relative serum tyr/LNAA and executive attention performance was found in the male sex/gender group when accounting for age effects. Our analysis advances the field of dopamine-modulated cognitive functions by revealing sex/gender and age differences which might be diet-related. Longitudinal or intervention studies and larger sample sizes are needed to provide more reliable evidence for links between tyr and executive attention.

Brain charts for the human lifespan

Over the past few decades, neuroimaging has become a ubiquitous tool in basic research and clinical studies of the human brain. However, no reference standards currently exist to quantify individual differences in neuroimaging metrics over time, in contrast to growth charts for anthropometric traits such as height and weight1. Here we assemble an interactive open resource to benchmark brain morphology derived from any current or future sample of MRI data ( http://www.brainchart.io/ ). With the goal of basing these reference charts on the largest and most inclusive dataset available, acknowledging limitations due to known biases of MRI studies relative to the diversity of the global population, we aggregated 123,984 MRI scans, across more than 100 primary studies, from 101,457 human participants between 115 days post-conception to 100 years of age. MRI metrics were quantified by centile scores, relative to non-linear trajectories2 of brain structural changes, and rates of change, over the lifespan. Brain charts identified previously unreported neurodevelopmental milestones3, showed high stability of individuals across longitudinal assessments, and demonstrated robustness to technical and methodological differences between primary studies. Centile scores showed increased heritability compared with non-centiled MRI phenotypes, and provided a standardized measure of atypical brain structure that revealed patterns of neuroanatomical variation across neurological and psychiatric disorders. In summary, brain charts are an essential step towards robust quantification of individual variation benchmarked to normative trajectories in multiple, commonly used neuroimaging phenotypes.

Effectiveness of digital interventions for people with comorbid heavy drinking and depression: A systematic review and narrative synthesis

INTRODUCTION

Heavy drinking and depression frequently co-occur and make a substantial contribution to the global non-communicable disease burden. Positive evidence exists for the use of digital interventions with these conditions alone, but there has been limited assessment of combined approaches.

OBJECTIVE

A systematic review of the effectiveness of combined digital interventions for comorbid heavy drinking and major depression in community-dwelling populations.

METHODS AND ANALYSIS

Electronic databases were searched to October 2021 for randomised controlled trials that evaluated any personalised digital intervention for comorbid heavy drinking and depression. Primary outcomes were changes in quantity of alcohol consumed and depressive symptoms. Two reviewers independently assessed study eligibility, extracted data, and undertook risk of bias assessment. Due to the limited number and heterogeneity of studies identified, meta-analysis was not possible, therefore data were synthesised narratively.

RESULTS

Of 898 articles identified, 24 papers were reviewed in full, five of which met the inclusion criteria (N = 1503 participants). Three utilised web-based intervention delivery; two computer programmes delivered in a clinic setting. All involved multi-component interventions; treatment length varied from one to ten sessions. Four studies found no evidence for the superiority of combined digital interventions for comorbid heavy drinking and depression over therapist-delivered approaches, single condition interventions (including online), or assessment-only controls. Positive impacts of integrated online therapy compared to generalist online health advice were reported in a fifth study, but not maintained beyond the 1-month follow-up.

LIMITATIONS

Few eligible, heterogeneous studies prevented meta-analysis.

CONCLUSION

Limited evidence exists of the effectiveness of combined digital interventions for comorbid heavy drinking and depression in community dwelling populations.

Optimal Surveillance Strategies for Early-Stage Cutaneous Melanoma Post Primary Tumor Excision: An Economic Evaluation

Background. Consensus on standardized active surveillance or follow-up care by clinicians is lacking leading to considerable variation in practice across countries. An important structural modelling consideration is that self-examination by patients and their partners can detect melanoma recurrence outside of active surveillance regimes. Objectives. To identify candidate melanoma surveillance strategies for American Joint Committee on Cancer (AJCC) stage I disease and compare them with the current recommended practice in a cost-utility analysis framework. Methods. In consultation with UK clinical experts, a microsimulation model was built in TreeAge Pro 2019 R1.0 (Williamstown, MA, USA) to evaluate surveillance strategies for AJCC stage IA and IB melanoma patients separately. The model incorporated patient behaviors such as self-detection and emergency visits to examine suspicious lesions. A National Health Service (NHS) perspective was taken. Model input parameters were taken from the literature and where data were not available, local expert opinion was sought. Probabilistic sensitivity analysis, one-way sensitivity analysis on pertinent parameters and value of information was performed. Results. In the base-case probabilistic sensitivity analysis, less intensive surveillance strategies for AJCC stage IA and IB had lower total lifetime costs than the current National Institute for Health and Care Excellence (NICE) recommended strategy with similar effectiveness in terms of quality-adjusted life years and thereby likely to be cost-effective. Many strategies had similar effectiveness due to the relatively low chance of recurrence and the high rate of self-detection. Sensitivity and scenario analyses did not change these findings. Conclusions. Our model findings suggest that less resource intensive surveillance may be cost-effective compared with the current NICE surveillance guidelines. However, to advocate convincingly for changes, better evidence is required.

The effects of radiofrequency exposure on male fertility and adverse reproductive outcomes: A protocol for two systematic reviews of human observational studies with meta-analysis

BACKGROUND

The World Health Organization (WHO) is bringing together evidence on radiofrequency electromagnetic field (RF-EMF) exposure in relation to health outcomes, previously identified as priorities for evaluation by experts in the field, to inform exposure guidelines. A suite of systematic reviews are being undertaken by a network of topic experts and methodologists in order to collect, assess and synthesise data relevant to these guidelines. Here, we present the protocol for the systematic review on the effect of exposure to RF on adverse reproductive outcomes (human observational studies), also referred to as Systematic Review (SR) 3 within the series of systematic reviews currently being commissioned.

OBJECTIVES

Following the WHO handbook for guideline development and the COSTER conduct guidelines, we will systematically review the effect of RF-EMF exposure on both male fertility (SR3A) and adverse pregnancy outcomes (SR3B) in human observational studies. Herein we adhere to the PRISMA-P reporting guidelines.

DATA SOURCES

We will conduct a broad search for potentially relevant records relevant for both reviews within the following bibliographic databases: MEDLINE; Embase; and EMF Portal. We will also conduct searches of grey literature through relevant databases and organisational websites. RF-EMF experts will also be consulted. We will hand search citation and reference lists of included study records.

STUDY ELIGIBILITY CRITERIA

We will include quantitative human observational studies on the effect of RF-EMF exposure: (in SR3A) in adult male participants on infertility, sperm morphology, concentration or total sperm count or motility; and (in SR3B) in preconception adults or pregnant women on preterm birth, small for gestational age (associated with intrauterine growth restriction), miscarriage, stillbirth and congenital anomalies.

STUDY APPRAISAL AND SYNTHESIS METHODS

Titles, abstracts and then full texts will be screened in blinded duplicate against eligibility criteria with input from a third reviewer as required. Data extraction from included studies will be completed by two reviewers as will risk of bias assessment using the Office of Health Assessment and Translation (OHAT) tool. If appropriate we will undertake meta-analysis to pool effect measures and explore heterogeneity using sub-group analyses or meta-regression as feasible. We will conduct sensitivity analysis to assess the impact of any assumptions made throughout the review process. The OHAT methodology, based on the GRADE guidelines for evidence assessment, will be used to evaluate the certainty of evidence per outcome and to conclude the level of evidence of a health effect.

CONCLUSION

This manuscript details the protocols for two systematic reviews. The aims of publishing details of both protocols are to: pre-specify their scope and methods; reduce the impact of reviewer bias; promote transparency and replicability; and improve the review process.

PROSPERO REGISTRATION

CRD42021265401 (SR3A), CRD42021266268 (SR3B).

The impact of long-term conditions on disability-free life expectancy: A systematic review

Although leading causes of death are regularly reported, there is disagreement on which long-term conditions (LTCs) reduce disability-free life expectancy (DFLE) the most. We aimed to estimate increases in DFLE associated with elimination of a range of LTCs. This is a comprehensive systematic review and meta-analysis of studies assessing the effects of LTCs on health expectancy (HE). MEDLINE, Embase, HMIC, Science Citation Index, and Social Science Citation Index were systematically searched for studies published in English from July 2007 to July 2020 with updated searches from inception to April 8, 2021. LTCs considered included: arthritis, diabetes, cardiovascular disease including stroke and peripheral vascular disease, respiratory disease, visual and hearing impairment, dementia, cognitive impairment, depression, cancer, and comorbidity. Studies were included if they estimated HE outcomes (disability-free, active or healthy life expectancy) at age 50 or older for individuals with and without the LTC. Study selection and quality assessment were undertaken by teams of independent reviewers. Meta-analysis was feasible if three or more studies assessed the impact of the same LTC on the same HE at the same age using comparable methods, with narrative syntheses for the remaining studies. Studies reporting Years of Life Lost (YLL), Years of Life with Disability (YLD) and Disability Adjusted Life Years (DALYs = YLL+YLD) were included but reported separately as incomparable with other HE outcomes (PROSPERO registration: CRD42020196049). Searches returned 6072 unique records, yielding 404 eligible for full text retrieval from which 30 DFLE-related and 7 DALY-related were eligible for inclusion. Thirteen studies reported a single condition, and 17 studies reported on more than one condition (two to nine LTCs). Only seven studies examined the impact of comorbidities. Random effects meta-analyses were feasible for a subgroup of studies examining diabetes (four studies) or respiratory diseases (three studies) on DFLE. From pooled results, individuals at age 65 without diabetes gain on average 2.28 years disability-free compared to those with diabetes (95% CI: 0.57-3.99, p<0.01, I2 = 96.7%), whilst individuals without respiratory diseases gain on average 1.47 years compared to those with respiratory diseases (95% CI: 0.77-2.17, p<0.01, I2 = 79.8%). Eliminating diabetes, stroke, hypertension or arthritis would result in compression of disability. Of the seven longitudinal studies assessing the impact of multiple LTCs, three found that stroke had the greatest effect on DFLE for both genders. This study is the first to systematically quantify the impact of LTCs on both HE and LE at a global level, to assess potential compression of disability. Diabetes, stroke, hypertension and arthritis had a greater effect on DFLE than LE and so elimination would result in compression of disability. Guidelines for reporting HE outcomes would assist data synthesis in the future, which would in turn aid public health policy.

P-P21 Endoscopic bipolar radiofrequency ablation for treating biliary obstruction caused by unresectable cancer: systematic review of clinical and cost effectiveness

Background

Early evidence suggests using radiofrequency ablation (RFA) as an adjunct to stenting may improve outcomes in patients with malignant biliary obstruction. RFA can be deployed either at the initial stent insertion or to clear tumour ingrowth in a previously placed stent.

Methods

To assess the clinical and cost effectiveness and potential risks of RFA for malignant biliary obstruction. MEDLINE, EMBASE, Cochrane Library, Scopus, CINAHL, HTA and DARE, 3 websites and 7 trial registers were searched from 2008 to 2021. Study inclusion criteria were: malignant biliary obstruction; intervention as endoscopic RFA, either to fit a stent (primary RFA) or to clear a blocked stent (secondary RFA); primary outcomes were survival, quality of life or procedure-related adverse events. Risk of bias was assessed using the RoB 2.0 and ROBINS-I tools. Primary analysis was meta-analysis of the hazard ratio of mortality.

Results

68 studies (1742 patients) were identified but only 2 randomised trials, 1 retrospective case-control study and 3 retrospective cohort studies reported a hazard ratio of death for primary RFA compared to stent-only control. The pooled hazard ratio of mortality for primary RFA compared to stent-only was 0.34 (95% confidence interval (CI) 0.21 to 0.55). There was moderate heterogeneity (I2 = 53%) however studies were consistently in favour of primary RFA. There was insufficient evidence available to analyse effectiveness in secondary RFA. No evidence relating to quality of life. There was no evidence of increased risk of cholangitis (risk ratio 1.15, 95% CI 0.63 to 2.12) or pancreatitis (risk ratio 1.34, 95% CI 0.55 to 3.25), but there was an increase in cholecystitis (risk ratio 11.47, 95% CI 2.28 to 57.66). Inconsistencies in standard reporting and study design were noted e.g. adverse outcomes and lack of standardised comparator groups. RFA was estimated to cost £2,659 and produced 0.18 QALYs more than no RFA on average. With an ICER of £14,392/QALY, RFA was likely to be cost-effective at a threshold of £20,000/QALY. The source of the vast majority of decision uncertainty lay in the effect of RFA on stent patency.

Conclusions

Primary RFA is associated with increased survival and appears cost-effective. The evidence for the impact of secondary RFA on survival and of quality of life is limited. There was no increase in the risk of post-ERCP cholangitis or pancreatitis but increased risk of cholecystitis. High quality RCTs to investigate primary and secondary RFA are needed with accurate documentation of quality of life, adverse event rates and survival.

Identifying older adults with frailty approaching end-of-life: A systematic review

BACKGROUND

People with frailty may have specific needs for end-of-life care, but there is no consensus on how to identify these people in a timely way, or whether they will benefit from intervention.

AIM

To synthesise evidence on identification of older people with frailty approaching end-of-life, and whether associated intervention improves outcomes.

DESIGN

Systematic review (PROSPERO: CRD42020462624).

DATA SOURCES

Six databases were searched, with no date restrictions, for articles reporting prognostic or intervention studies. Key inclusion criteria were adults aged 65 and over, identified as frail via an established measure. End-of-life was defined as the final 12 months. Key exclusion criteria were proxy definitions of frailty, or studies involving people with cancer, even if also frail.

RESULTS

Three articles met the inclusion criteria. Strongest evidence came from one study in English primary care, which showed distinct trajectories in electronic Frailty Index scores in the last 12 months of life, associated with increased risk of death. We found no studies evaluating established clinical tools (e.g. Gold Standards Framework) with existing frail populations. We found no intervention studies; the literature on advance care planning with people with frailty has relied on proxy definitions of frailty.

CONCLUSION

Clear implications for policy and practice are hindered by the lack of studies using an established approach to assessing frailty. Future end-of-life research needs to use explicit approaches to the measurement and reporting of frailty, and address the evidence gap on interventions. A focus on models of care that incorporate a palliative approach is essential.

Optimal surveillance strategies for patients with stage 1 cutaneous melanoma post primary tumour excision: three systematic reviews and an economic model

BACKGROUND

Malignant melanoma is the fifth most common cancer in the UK, with rates continuing to rise, resulting in considerable burden to patients and the NHS.

OBJECTIVES

The objectives were to evaluate the effectiveness and cost-effectiveness of current and alternative follow-up strategies for stage IA and IB melanoma.

REVIEW METHODS

Three systematic reviews were conducted. (1) The effectiveness of surveillance strategies. Outcomes were detection of new primaries, recurrences, metastases and survival. Risk of bias was assessed using the Cochrane Collaboration's Risk-of-Bias 2.0 tool. (2) Prediction models to stratify by risk of recurrence, metastases and survival. Model performance was assessed by study-reported measures of discrimination (e.g. D-statistic, Harrel's c-statistic), calibration (e.g. the Hosmer-Lemeshow 'goodness-of-fit' test) or overall performance (e.g. Brier score, R ²). Risk of bias was assessed using the Prediction model Risk Of Bias ASsessment Tool (PROBAST). (3) Diagnostic test accuracy of fine-needle biopsy and ultrasonography. Outcomes were detection of new primaries, recurrences, metastases and overall survival. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Review data and data from elsewhere were used to model the cost-effectiveness of alternative surveillance strategies and the value of further research.

RESULTS

(1) The surveillance review included one randomised controlled trial. There was no evidence of a difference in new primary or recurrence detected (risk ratio 0.75, 95% confidence interval 0.43 to 1.31). Risk of bias was considered to be of some concern. Certainty of the evidence was low. (2) Eleven risk prediction models were identified. Discrimination measures were reported for six models, with the area under the operating curve ranging from 0.59 to 0.88. Three models reported calibration measures, with coefficients of ≥ 0.88. Overall performance was reported by two models. In one, the Brier score was slightly better than the American Joint Committee on Cancer scheme score. The other reported an R ² of 0.47 (95% confidence interval 0.45 to 0.49). All studies were judged to have a high risk of bias. (3) The diagnostic test accuracy review identified two studies. One study considered fine-needle biopsy and the other considered ultrasonography. The sensitivity and specificity for fine-needle biopsy were 0.94 (95% confidence interval 0.90 to 0.97) and 0.95 (95% confidence interval 0.90 to 0.97), respectively. For ultrasonography, sensitivity and specificity were 1.00 (95% confidence interval 0.03 to 1.00) and 0.99 (95% confidence interval 0.96 to 0.99), respectively. For the reference standards and flow and timing domains, the risk of bias was rated as being high for both studies. The cost-effectiveness results suggest that, over a lifetime, less intensive surveillance than recommended by the National Institute for Health and Care Excellence might be worthwhile. There was considerable uncertainty. Improving the diagnostic performance of cancer nurse specialists and introducing a risk prediction tool could be promising. Further research on transition probabilities between different stages of melanoma and on improving diagnostic accuracy would be of most value.

LIMITATIONS

Overall, few data of limited quality were available, and these related to earlier versions of the American Joint Committee on Cancer staging. Consequently, there was considerable uncertainty in the economic evaluation.

CONCLUSIONS

Despite adoption of rigorous methods, too few data are available to justify changes to the National Institute for Health and Care Excellence recommendations on surveillance. However, alternative strategies warrant further research, specifically on improving estimates of incidence, progression of recurrent disease; diagnostic accuracy and health-related quality of life; developing and evaluating risk stratification tools; and understanding patient preferences.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018086784.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol 25, No. 64. See the NIHR Journals Library website for further project information.

Exploring Interventions to Improve the Oral Health and Related Health Behaviours of Adults Experiencing Severe and Multiple Disadvantage: Protocol for a Qualitative Study with Stakeholders

The number of individuals in England experiencing homelessness, substance use, and involvement with the criminal justice system is increasing. These issues, referred to as severe and multiple disadvantage (SMD), are often interlinked and co-occur. Health inequalities, particularly poor oral health, persist for those facing these inter-related issues and are closely linked with high levels of substance use, smoking, and poor diet. However, evidence for interventions that can improve these health outcomes for those experiencing these issues is limited. This paper outlines the design of a qualitative study which aims to explore the perspectives of stakeholders to understand what interventions can help to support SMD groups with their oral health and related health behaviours (i.e., substance use, smoking, diet). Interviews and focus groups will be undertaken with stakeholders comprising two groups: (1) individuals with experience of SMD, and (2) service providers (staff and volunteers), policy makers, and commissioners who support such individuals. Public involvement and engagement is central to the project. For example, stakeholders and research partners in policy and practice and people with lived experience of SMD will provide input at all stages of this study. Findings from the study will inform an ‘evidence for practice’ briefing outlining recommendations for policy. Dissemination will occur through presentations to a range of practice, policy and academic beneficiaries, and through peer-reviewed publications.

Investigating the Effectiveness and Acceptability of Oral Health and Related Health Behaviour Interventions in Adults with Severe and Multiple Disadvantage: Protocol for a Mixed-Methods Systematic Review

Increasing numbers of people in England experience homelessness, substance use, and repeated offending (known as 'severe and multiple disadvantage'; SMD). Populations experiencing SMD often have extremely poor oral health, which is closely inter-linked with high levels of substance use, smoking, and poor diet. This study aims to undertake an evidence synthesis to identify the effectiveness, resource requirements, and factors influencing the implementation and acceptability of oral health and related health behaviour interventions in adults experiencing SMD. Two systematic reviews will be conducted using mixed-methods. Review 1 will investigate the effectiveness and resource implications of oral health and related health behaviours (substance use, smoking, diet) interventions; Review 2 will investigate factors influencing the implementation of such interventions. The population includes adults (≥18 years) experiencing SMD. Standard review methods in terms of searches, screening, data extraction, and quality appraisal will be conducted. Narrative syntheses will be conducted. If feasible, a meta-analysis will be conducted for Review 1 and a thematic synthesis for Review 2. Evidence from the two reviews will then be synthesised together. Input from people with experience of SMD will be sought throughout to inform the reviews. An initial logic model will be iteratively refined during the review.

Examining the effectiveness of place-based interventions to improve public health and reduce health inequalities: an umbrella review

BACKGROUND

Locally delivered, place-based public health interventions are receiving increasing attention as a way of improving health and reducing inequalities. However, there is limited evidence on their effectiveness. This umbrella review synthesises systematic review evidence of the health and health inequalities impacts of locally delivered place-based interventions across three elements of place and health: the physical, social, and economic environments.

METHODS

Systematic review methodology was used to identify recent published systematic reviews of the effectiveness of place-based interventions on health and health inequalities (PROGRESS+) in high-income countries. Nine databases were searched from 1st January 2008 to 1st March 2020. The quality of the included articles was determined using the Revised Assessment of Multiple Systematic Reviews tool (R-AMSTAR).

RESULTS

Thirteen systematic reviews were identified - reporting 51 unique primary studies. Fifty of these studies reported on interventions that changed the physical environment and one reported on changes to the economic environment. Only one primary study reported cost-effectiveness data. No reviews were identified that assessed the impact of social interventions. Given heterogeneity and quality issues, we found tentative evidence that the provision of housing/home modifications, improving the public realm, parks and playgrounds, supermarkets, transport, cycle lanes, walking routes, and outdoor gyms - can all have positive impacts on health outcomes - particularly physical activity. However, as no studies reported an assessment of variation in PROGRESS+ factors, the effect of these interventions on health inequalities remains unclear.

CONCLUSIONS

Place-based interventions can be effective at improving physical health, health behaviours and social determinants of health outcomes. High agentic interventions indicate greater improvements for those living in greater proximity to the intervention, which may suggest that in order for interventions to reduce inequalities, they should be implemented at a scale commensurate with the level of disadvantage. Future research needs to ensure equity data is collected, as this is severely lacking and impeding progress on identifying interventions that are effective in reducing health inequalities.

TRIAL REGISTRATION

PROSPERO CRD42019158309.

What are the consequences of caring for older people and what interventions are effective for supporting unpaid carers? A rapid review of systematic reviews

OBJECTIVES

To identify and map evidence about the consequences of unpaid caring for all carers of older people, and effective interventions to support this carer population.

DESIGN

A rapid review of systematic reviews, focused on the consequences for carers of unpaid caring for older people, and interventions to support this heterogeneous group of carers. Reviews of carers of all ages were eligible, with any outcome measures relating to carers' health, and social and financial well-being. Searches were conducted in MEDLINE, PsycInfo and Epistemonikos (January 2000 to January 2020). Records were screened, and included systematic reviews were quality appraised. Summary data were extracted and a narrative synthesis produced.

RESULTS

Twelve systematic reviews reporting evidence about the consequences of caring for carers (n=6) and assessing the effectiveness of carer interventions (n=6) were included. The review evidence typically focused on mental health outcomes, with little information identified about carers' physical, social and financial well-being. Clear estimates of the prevalence and severity of carer outcomes, and how these differ between carers and non-carers, were absent. A range of interventions were identified, but there was no strong evidence of effectiveness. In some studies, the choice of outcome measure may underestimate the full impact of an intervention.

CONCLUSIONS

Current evidence fails to fully quantify the impacts that caring for older people has on carers' health and well-being. Information on social patterning of the consequences of caring is absent. Systematic measurement of a broad range of outcomes, with comparison to the general population, is needed to better understand the true consequences of caring. Classification of unpaid caring as a social determinant of health could be an effective lever to bring greater focus and support to this population. Further work is needed to develop and identify suitable interventions in order to support evidence-based policymaking and practice.

Powered mobility interventions for very young children with mobility limitations to aid participation and positive development: the EMPoWER evidence synthesis

BACKGROUND

One-fifth of all disabled children have mobility limitations. Early provision of powered mobility for very young children (aged < 5 years) is hypothesised to trigger positive developmental changes. However, the optimum age at which to introduce powered mobility is unknown.

OBJECTIVE

The aim of this project was to synthesise existing evidence regarding the effectiveness and cost-effectiveness of powered mobility for very young children, compared with the more common practice of powered mobility provision from the age of 5 years.

REVIEW METHODS

The study was planned as a mixed-methods evidence synthesis and economic modelling study. First, evidence relating to the effectiveness, cost-effectiveness, acceptability, feasibility and anticipated outcomes of paediatric powered mobility interventions was reviewed. A convergent mixed-methods evidence synthesis was undertaken using framework synthesis, and a separate qualitative evidence synthesis was undertaken using thematic synthesis. The two syntheses were subsequently compared and contrasted to develop a logic model for evaluating the outcomes of powered mobility interventions for children. Because there were insufficient published data, it was not possible to develop a robust economic model. Instead, a budget impact analysis was conducted to estimate the cost of increased powered mobility provision for very young children, using cost data from publicly available sources.

DATA SOURCES

A range of bibliographic databases [Cumulative Index to Nursing and Allied Health Literature (CINHAL), MEDLINE, EMBASE™ (Elsevier, Amsterdam, the Netherlands), Physiotherapy Evidence Database (PEDro), Occupational Therapy Systematic Evaluation of Evidence (OTseeker), Applied Social Sciences Index and Abstracts (ASSIA), PsycINFO, Science Citation Index (SCI; Clarivate Analytics, Philadelphia, PA, USA), Social Sciences Citation Index™ (SSCI; Clarivate Analytics), Conference Proceedings Citation Index - Science (CPCI-S; Clarivate Analytics), Conference Proceedings Citation Index - Social Science & Humanities (CPCI-SSH; Clarivate Analytics), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), NHS Economic Evaluation Database (NHS EED), Health Technology Assessment (HTA) Database and OpenGrey] was systematically searched and the included studies were quality appraised. Searches were carried out in June 2018 and updated in October 2019. The date ranges searched covered from 1946 to September 2019.

RESULTS

In total, 89 studies were included in the review. Only two randomised controlled trials were identified. The overall quality of the evidence was low. No conclusive evidence was found about the effectiveness or cost-effectiveness of powered mobility in children aged either < 5 or ≥ 5 years. However, strong support was found that powered mobility interventions have a positive impact on children's movement and mobility, and moderate support was found for the impact on children's participation, play and social interactions and on the safety outcome of accidents and pain. 'Fit' between the child, the equipment and the environment was found to be important, as were the outcomes related to a child's independence, freedom and self-expression. The evidence supported two distinct conceptualisations of the primary powered mobility outcome, movement and mobility: the former is 'movement for movement's sake' and the latter destination-focused mobility. Powered mobility should be focused on 'movement for movement's sake' in the first instance. From the budget impact analysis, it was estimated that, annually, the NHS spends £1.89M on the provision of powered mobility for very young children, which is < 2% of total wheelchair service expenditure.

LIMITATIONS

The original research question could not be answered because there was a lack of appropriately powered published research.

CONCLUSIONS

Early powered mobility is likely to have multiple benefits for very young children, despite the lack of robust evidence to demonstrate this. Age is not the key factor; instead, the focus should be on providing developmentally appropriate interventions and focusing on 'movement for movement's sake'.

FUTURE WORK

Future research should focus on developing, implementing, evaluating and comparing different approaches to early powered mobility.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018096449.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology programme and will be published in full in Health Technology Assessment; Vol. 24, No. 50. See the NIHR Journals Library website for further project information.

Promoting regular dental attendance in problem-orientated dental attenders: A systematic review of potential interventions

BACKGROUND

Problem-orientated dental attenders account for around one-third of the UK population, these being patients who do not seek regular dental care, instead only attending with dental pain. In order to develop intervention(s) to encourage regular dental attendance in these patients, any previous intervention development should be identified to aid idea generation or retrofitting of interventions.

OBJECTIVE

To identify previous interventions which have been developed targeted at problem-orientated dental attenders to facilitate the development and co-design of a new intervention.

METHODS

Eight electronic databases were searched for studies which included an intervention targeted at adult problem-orientated or irregular dental attenders to encourage regular dental attendance. Data on the intervention design mapped to the theoretical domains framework were extracted, alongside effectiveness and patient views where available.

RESULTS

Three studies fitted the inclusion criteria for the review. Interventions identified were attendance at a dental anxiety clinic, and a large advertising campaign promoting a free dental update where members of the public could visit local dental practices to look around and meet the dentists. One study looked at the effect of policy change by introducing free dental check-ups in Scotland. Interventions were poorly reported, with significant omissions in their description and a lack of clear identification of what composed the intervention.

CONCLUSION

There are very few interventions developed targeted at problem-orientated dental attendance, but important areas to consider in future intervention development include the following: dentist communication; dentist-patient relationship; increasing the awareness of need; the effect of free dental check-ups.

Trends in health expectancies: a systematic review of international evidence

OBJECTIVES

A clear understanding of whether increases in longevity are spent in good health is necessary to support ageing, health and care-related policy.

DESIGN

We conducted a systematic review to update and summarise evidence on trends in health expectancies, in Organisation for Economic Co-operation and Development (OECD) high-income countries.

DATA SOURCES

Four electronic databases (MEDLINE, 1946-19 September 2019; Embase 1980-2019 week 38; Scopus 1966-22 September 2019, Health Management Information Consortium, 1979-September 2019), and the UK Office for National Statistics website (November 2019).

ELIGIBILITY CRITERIA

English language studies published from 2016 that reported trends in healthy, active and/or disability-free life expectancy in an OECD high-income country.

DATA EXTRACTION AND SYNTHESIS

Records were screened independently by two researchers. Study quality was assessed using published criteria designed to identify sources of bias in studies reporting trends, and evidence summarised by narrative synthesis.

FINDINGS

Twenty-eight publications from 11 countries were included, covering periods from 6 to 40 years, between 1970 and 2017. In most countries, gains in healthy and disability-free life expectancy do not match the growth in total life expectancy. Exceptions were demonstrated for women in Sweden, where there were greater gains in disability-free years than life expectancy. Gains in healthy and disability-free life expectancy were greater for men than women in most countries except the USA (age 85), Japan (birth), Korea (age 65) and Sweden (age 77).

CONCLUSION

An expansion of disability in later life is evident in a number of high-income countries, with implications for the sustainability of health and care systems. The recent COVID-19 pandemic may also impact health expectancies in the longer term.

Effectiveness of personal letters to healthcare professionals in changing professional behaviours: a systematic review protocol

BACKGROUND

Letters are regularly sent by healthcare organisations to healthcare professionals to encourage them to take action, change practice or implement guidance. However, whether letters are an effective tool in delivering a change in healthcare professional behaviour is currently uncertain. In addition, there are currently no evidence-based guidelines to support health providers and authorities with advice on how to formulate the communication, what information and behaviour change techniques to include in order to optimise the potential effect on the behaviour of the receivers. To address this research gap, we seek to inform such guidance through this systematic review, which aims to provide comprehensive evidence of the effectiveness of personal letters to healthcare professionals in changing their professional behaviours.

METHODS/DESIGN

A comprehensive literature search of published and unpublished studies (the grey literature) in electronic databases will be conducted to identify randomised controlled trials (RCTs) that meet our inclusion criteria. We will include RCTs evaluating the effectiveness of personal letters to healthcare professionals in changing professional behaviours. The primary outcome will be behavioural change. The search will be conducted in five electronic databases (from their inception onwards): MEDLINE, Embase, PsycINFO, the Cochrane Library and CINAHL. We will also conduct supplementary searches in Google Scholar, hand search relevant journals, and conduct backward and forward citation searching for included studies and relevant reviews. A systematic approach to searching, screening, reviewing and data extraction will be applied in accordance with the process recommended by the Cochrane Collaboration. Two researchers will examine titles, abstracts, full-texts for eligibility independently. Risk of bias will be assessed using the Cochrane Risk of Bias 2 (RoB 2) tool for randomised controlled trials. Disagreements will be resolved by a consensus procedure.

DISCUSSION

Health policy makers across government are expected to benefit from being able to increase compliance in clinical settings by applying theories of behaviour to design of policy communications. The synthesised findings will be disseminated through peer-reviewed publication.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020167674.

Measuring frailty in younger populations: a rapid review of evidence

OBJECTIVES

Frailty is typically assessed in older populations. Identifying frailty in adults aged under 60 years may also have value, if it supports the delivery of timely care. We sought to identify how frailty is measured in younger populations, including evidence of the impact on patient outcomes and care.

DESIGN

A rapid review of primary studies was conducted.

DATA SOURCES

Four databases, three sources of grey literature and reference lists of systematic reviews were searched in March 2020.

ELIGIBILITY CRITERIA

Eligible studies measured frailty in populations aged under 60 years using experimental or observational designs, published after 2000 in English.

DATA EXTRACTION AND SYNTHESIS

Records were screened against review criteria. Study data were extracted with 20% of records checked for accuracy by a second researcher. Data were synthesised using a narrative approach.

RESULTS

We identified 268 studies that measured frailty in samples that included people aged under 60 years. Of these, 85 studies reported evidence about measure validity. No measures were identified that were designed and validated to identify frailty exclusively in younger groups. However, in populations that included people aged over and under 60 years, cumulative deficit frailty indices, phenotype measures, the FRAIL Scale, the Liver Frailty Index and the Short Physical Performance Battery all demonstrated predictive validity for mortality and/or hospital admission. Evidence of criterion validity was rare. The extent to which measures possess validity across the younger adult age (18-59 years) spectrum was unclear. There was no evidence about the impact of measuring frailty in younger populations on patient outcomes and care.

CONCLUSIONS

Limited evidence suggests that frailty measures have predictive validity in younger populations. Further research is needed to clarify the validity of measures across the adult age spectrum, and explore the utility of measuring frailty in younger groups.

Inequalities in Trends in Healthy and Disability-Free Life Expectancies: A Systematic Review

To update previous reviews, we searched Medline, Embase, Scopus and the Office for National Statistics (ONS) website for studies and reports published after 2016 that describe trends in healthy life expectancy, active life expectancy or disability-free life expectancy (DFLE) in the UK and other OECD high-income countries. We focus here on studies reporting inequalities by socioeconomic position (SEP) in these trends. There was mixed evidence of educational and area-level deprivation inequalities in trends in DFLE, with four studies indicating that educational inequalities were widening in European countries. No studies were identified that examined inequalities in disability-free life expectancy trends in the UK. All studies were based on cross-sectional data from multiple time points or longitudinal panel studies. We discuss the size of inequalities in DFLE between SEP groups and the limitations of previous studies.

Relationship between pubertal testicular ultrasonographic evaluation and future reproductive performance potential in Piétrain boars

New ways of predicting sperm quality and output performance in young artificial insemination (AI) boars are important for breeding companies to ensure that the pubertal boars delivered to the AI studs have a high chance of meeting minimum quality standards to be used for insemination and therewith dissemination of desirable characteristics. The aim of the current study was to characterize the testicular development of 218 pubertal Piétrain boars (Line 408, Pig Improvement Company) to identify traits with predictable characteristics relative to their sperm quality as an adult AI boar. Scrotum, testes and epididymis were examined ultrasonographically at day (d) 100 (on-test) and 170 (off-test) followed by a computer-assisted grayscale analysis (GSA). Over the test period, paired testicular volume increased 7.3-fold from 22.7 ± 10.8 cm³ to 166.6 ± 62.2 cm³. The right testis was significantly (P = 0.014) larger than the left one at the off-test. Based on the sperm quality (ejaculate volume, sperm concentration, total sperm number, morphologically abnormal sperm and total sperm motility at day 3 of semen storage), 82.11% (n = 179) of the boars were classified as "productive" boars. These boars had a significantly (P = 0.039) larger paired testicular volume than "non-productive" boars (45.9 ± 19.9 cm³vs. 38.5 ± 12.6 cm³) at the on-test. For the right testis at on-test, significant differences for the standard deviation of mean gray value (P = 0.022), area under the curve (P = 0.004) and mean gradient value (GRAD, P = 0.030) regarding the future sperm production capacity (SPC) were shown. At off-test, there was a significant difference for minimum gray value (MIN GV, P = 0.003) and mean gray value (P = 0.001) related to SPC. To find SPC related cut-off values for GSA data, a two segmental non-linear regression analysis was carried out indicating breakpoints for GRAD ≥12 and MIN GV ≥ 40 for boars with low SPC. Off-test boars with MIN GV ≥ 40 showed a 2.4 higher risk to display low SPC (Odds ratio = 2.4 [1.1, 5.4]; P = 0.024). The results may enable breeding companies to include new sperm quality associated traits in their boar testing and selection programs.

Does health and social care provision for the community dwelling older population help to reduce unplanned secondary care, support timely discharge and improve patient well-being? A mixed method meta-review of systematic reviews

Background: This study aimed to identify and examine systematic review evidence of health and social care interventions for the community-dwelling older population regarding unplanned hospital admissions, timely hospital discharge and patient well-being. Methods: A meta-review was conducted using Joanna Briggs and PRISMA guidance. A search strategy was developed: eight bibliographic medical and social science databases were searched, and references of included studies checked. Searches were restricted to OECD countries and to systematic reviews published between January 2013-March 2018. Data extraction and quality appraisal was undertaken by one reviewer with a random sample screened independently by two others. Results: Searches retrieved 21,233 records; using data mining techniques, we identified 8,720 reviews. Following title and abstract and full-paper screening, 71 systematic reviews were included: 62 quantitative, seven qualitative and two mixed methods reviews. There were 52 reviews concerned with healthcare interventions and 19 reviews concerned with social care interventions. This meta-review summarises the evidence and evidence gaps of nine broad types of health and social care interventions. It scrutinises the presence of research in combined health and social care provision, finding it lacking in both definition and detail given. This meta-review debates the overlap of some of the person-centred support provided by community health and social care provision. Research recommendations have been generated by this process for both primary and secondary research. Finally, it proposes that research recommendations can be delivered on an ongoing basis if meta-reviews are conducted as living systematic reviews. Conclusions: This meta-review provides evidence of the effect of health and social care interventions for the community-dwelling older population and identification of evidence gaps. It highlights the lack of evidence for combined health and social care interventions and for the impact of social care interventions on health care outcomes. Registration: PROSPERO ID CRD42018087534; registered on 15 March 2018.

Interventions to reduce inequalities in avoidable hospital admissions: explanatory framework and systematic review protocol

INTRODUCTION

Internationally there is pressure to contain costs due to rising numbers of hospital admissions. Alongside age, socioeconomic disadvantage is the strongest risk factor for avoidable hospital admission. This equity-focussed systematic review is required for policymakers to understand what has been shown to work to reduce inequalities in hospital admissions, what does not work and where the current gaps in the evidence-base are.

METHODS AND ANALYSIS

An initial framework shows how interventions are hypothesised to reduce socioeconomic inequalities in avoidable hospital admissions. Studies will be included if the intervention focusses exclusively on socioeconomically disadvantaged populations or if the study reports differential effects by socioeconomic status (education, income, occupation, social class, deprivation, poverty or an area-based proxy for deprivation derived from place of residence) with respect to hospital admission or readmission (overall or condition-specific for those classified as ambulatory care sensitive). Studies involving individuals of any age, undertaken in OECD (Organisation for Economic Co-operation and Development) countries, published from 2000 to 29^th February 2020 in any language will be included. Electronic searches will include MEDLINE, Embase, CINAHL, Cochrane CENTRAL and the Web of Knowledge platform. Electronic searches will be supplemented with full citation searches of included studies, website searches and retrieval of relevant unpublished information. Study inclusion, data extraction and quality appraisal will be conducted by two reviewers. Narrative synthesis will be conducted and also meta-analysis where possible. The main analysis will examine the effectiveness of interventions at reducing socioeconomic inequalities in hospital admissions. Interventions will be characterised by their domain of action and approach to addressing inequalities. For included studies, contextual information on where, for whom and how these interventions are organised, implemented and delivered will be examined where possible.

ETHICS AND DISSEMINATION

Ethical approval was not required for this protocol. The research will be disseminated via peer-reviewed publication, conferences and an open-access policy-orientated paper.

PROSPERO REGISTRATION NUMBER

CRD42019153666.

Health-related quality of life and patient-reported outcome measures in NASH-related cirrhosis

BACKGROUND & AIMS

Non-alcoholic steatohepatitis (NASH) is known to have a negative impact on patients' health-related quality of life (HRQoL), even before progression to cirrhosis has occurred. The burden of NASH-related cirrhosis from the patient perspective remains poorly understood. Herein, we aimed to identify the burden of disease and HRQoL impairment among patients with NASH-related compensated cirrhosis.

METHODS

This targeted literature review sought first to identify the humanistic burden of disease from the perspective of patients with diagnosed NASH-cirrhosis and, secondly, to identify generic or disease-specific patient-reported outcome measures (PROMs) used to assess the impact of NASH-cirrhosis. Searches were conducted in bibliographical databases, grey or unpublished literature, liver disease websites, support group websites and online blogs. A quality assessment of specific PROMs was conducted.

RESULTS

Patients with NASH-cirrhosis are reported to suffer from lower HRQoL than patients with non-cirrhotic NASH and the general population with respect to physical health/functioning, emotional health and worry, and mental health. Thirteen PROMs were identified, of which 4 were liver-disease specific: CLDQ, CLDQ-NAFLD, LDQoL and LDSI. The most commonly used measures do not comply with current industry or regulatory standards for PROMs and/or are not validated for use in a cirrhotic NASH population.

CONCLUSIONS

Patients with NASH-cirrhosis have lower HRQoL and poorer physical health than patients with non-cirrhotic NASH. However, the literature lacked detail of the everyday impact on patients' lives. Currently, a number of PROMs are available to measure the impact of the disease in patients with chronic liver conditions. The lack of studies that include qualitative insights in this population mandates further exploration and research.

LAY SUMMARY

It is not well understood how having non-alcoholic fatty liver disease (NAFLD)-related cirrhosis affects a person's everyday wellbeing and quality of life. Some research has been done with patients who have early stages of liver disease but not people with cirrhosis. We found that patients with NAFLD-related cirrhosis tended to have poorer health than patients without cirrhosis. But there was not very much information from patients themselves and there were no tools or questionnaires just for this group of patients.

Fluid resuscitation after severe trauma injury : U-shaped associations between tetrastarch dose and survival time or frequency of acute kidney failure

BACKGROUND

Using tetrastarch for fluid resuscitation after a severe trauma injury may increase risks of death and acute kidney injury. The importance of tetrastarch dose, however, is unknown.

METHODS

A retrospective observational study was performed in two trauma centres using data on type and amount of fluids (balanced crystalloids or tetrastarch) used for pre- and acute in-hospital shock management. We evaluate independent associations between the relative and absolute volumes of tetrastarch and 90-day survival time or the frequency of severe acute kidney failure (AKF).

RESULTS

We studied 271 patients who had sustained a severe blunt trauma injury (average predicted mortality according to the Revised Injury Severity Classification Score (RISC) 15.1 ± 1.4% [mean, standard deviation]), and who had required more than 2 days of intensive care therapy. In all, 75.3% of patients had received tetrastarch with a crystalloid/colloid ratio of 2.93 ± 2.60. The 90-day mortality was 11.1%, and 7.8% of the patients developed severe AKF. After adjusting for confounders, we found a U-shaped, nonlinear association between absolute or relative volumes of tetrastarch and survival time (p = 0.003 and 0.025, respectively). Optimal relative volumes of tetrastarch approximately ranged from 20 to 30% of total fluids. Giving less than about 1000 ml, or more than about 2000 ml tetrastarch was significantly associated with an increased risk of developing severe AKF (p = 0.023).

CONCLUSIONS

There was a complex U‑shaped association between the tetrastarch dose and morbidity/mortality of patients after a severe trauma injury. The optimal crystalloid/tetrastarch ratio for acute shock management appears to range from about 2.5 to 4.0.

Study protocol for a systematic review of evidence for digital interventions for comorbid excessive drinking and depression in community-dwelling populations

INTRODUCTION

Excessive drinking and depression are frequently comorbid and make a substantial contribution to the global non-communicable disease burden. A range of effective interventions and treatments exist for either excessive drinking or depression alone, including a positive emerging evidence base for the use of digital interventions. Computerised and/or smartphone delivered advice could provide flexible, coordinated support for patients with comorbid excessive drinking and depression. However, to date, no systematic review of the evidence has been conducted focused on the effectiveness of digital interventions for this specific comorbid population. This systematic review will identify and evaluate the effectiveness of digital interventions for reducing comorbid excessive drinking and depression in community-dwelling populations.

METHODS AND ANALYSIS

We will search MEDLINE, The Cochrane Library, CENTRAL, CINAHL, PsycINFO, ERIC and SCI from inception to end of July 2019 for randomised controlled trials that evaluate any personalised digital intervention for comorbid excessive drinking and depression and published in any language. Primary outcomes will be changes in quantity of alcohol consumed and depressive symptoms. Screening, data extraction and risk of bias assessment will be undertaken independently by two reviewers, with disagreements resolved through discussion. Meta-analytic methods will be used to synthesise the data collected relating to the primary outcomes of interest.

ETHICS AND DISSEMINATION

As a systematic review, ethical approval is not needed. Findings will be published in peer-reviewed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

CRD42019130134.

Developing an Intervention for Fall-Related Injuries in Dementia (DIFRID): an integrated, mixed-methods approach

BACKGROUND

Falls in people with dementia can result in a number of physical and psychosocial consequences. However, there is limited evidence to inform how best to deliver services to people with dementia following a fall. The aim of the DIFRID study was to determine the feasibility of developing and implementing a new intervention to improve outcomes for people with dementia with fall-related injuries; this encompasses both short-term recovery and reducing the likelihood of future falls. This paper details the development of the DIFRID intervention.

METHODS

The intervention was designed using an integrated, mixed-methods approach. This involved a realist synthesis of the literature and qualitative data gathered through interviews and focus groups with health and social care professionals (n = 81). An effectiveness review and further interviews and observation were also conducted and are reported elsewhere. A modified Delphi panel approach with 24 experts was then used to establish a consensus on how the findings should translate into a new intervention. After feedback from key stakeholders (n = 15) on the proposed model, the intervention was manualised and training developed.

RESULTS

We identified key components of a new intervention covering three broad areas: • Ensuring that the circumstances of rehabilitation are optimised for people with dementia • Compensating for the reduced ability of people with dementia to self-manage • Equipping the workforce with the necessary skills and information to care for this patient group Consensus was achieved on 54 of 69 statements over two rounds of the Delphi surveys. The statements were used to model the intervention and finalise the accompanying manual and protocol for a feasibility study. Stakeholder feedback was generally positive and the majority of suggested intervention components were approved. The proposed outcome was a 12-week complex multidisciplinary intervention primarily based at the patient's home.

CONCLUSIONS

A new intervention has been developed to improve outcomes for people with dementia following a fall requiring healthcare attention. The feasibility of this intervention is currently being tested.

TRIAL REGISTRATION

ISRCTN41760734 (16/11/2015).

Non-Pharmacological Interventions to Reduce Unhealthy Eating and Risky Drinking in Young Adults Aged 18⁻25 Years: A Systematic Review and Meta-Analysis

Alcohol use peaks in early adulthood and can contribute both directly and indirectly to unhealthy weight gain. This review aimed to systematically evaluate the effectiveness of preventative targeted interventions focused on reducing unhealthy eating behavior and linked alcohol use in 18⁻25-year-olds. Twelve electronic databases were searched from inception to June 2018 for trials or experimental studies, of any duration or follow-up. Eight studies (seven with student populations) met the inclusion criteria. Pooled estimates demonstrated inconclusive evidence that receiving an intervention resulted in changes to self-reported fruit and vegetable consumption (mean change/daily servings: 0.33; 95% CI -0.22 to 0.87) and alcohol consumption (mean reduction of 0.6 units/week; CI -1.35 to 0.19). There was also little difference in the number of binge drinking episodes per week between intervention and control groups (-0.01 sessions; CI -0.07 to 0.04). This review identified only a small number of relevant studies. Importantly, included studies did not assess whether (and how) unhealthy eating behaviors and alcohol use link together. Further exploratory work is needed to inform the development of appropriate interventions, with outcome measures that have the capacity to link food and alcohol consumption, in order to establish behavior change in this population group.

The age-dependent relationship between resting heart rate variability and functional brain connectivity

Resting heart rate variability (HRV), an index of parasympathetic cardioregulation and an individual trait marker related to mental and physical health, decreases with age. Previous studies have associated resting HRV with structural and functional properties of the brain - mainly in cortical midline and limbic structures. We hypothesized that aging affects the relationship between resting HRV and brain structure and function. In 388 healthy subjects of three age groups (140 younger: 26.0 ± 4.2 years, 119 middle-aged: 46.3 ± 6.2 years, 129 older: 66.9 ± 4.7 years), gray matter volume (GMV, voxel-based morphometry) and resting state functional connectivity (eigenvector centrality mapping and exploratory seed-based functional connectivity) were related to resting HRV, measured as the root mean square of successive differences (RMSSD). Confirming previous findings, resting HRV decreased with age. For HRV-related GMV, there were no statistically significant differences between the age groups, nor similarities across all age groups. In whole-brain functional connectivity analyses, we found an age-dependent association between resting HRV and eigenvector centrality in the bilateral ventromedial prefrontal cortex (vmPFC), driven by the younger adults. Across all age groups, HRV was positively correlated with network centrality in the bilateral posterior cingulate cortex. Seed-based functional connectivity analysis using the vmPFC cluster revealed an HRV-related cortico-cerebellar network in younger but not in middle-aged or older adults. Our results indicate that the decrease of HRV with age is accompanied by changes in functional connectivity along the cortical midline. This extends our knowledge of brain-body interactions and their changes over the lifespan.

Brief Interventions in Primary Care: an Evidence Overview of Practitioner and Digital Intervention Programmes

PURPOSE OF THE REVIEW

Excessive drinking is a major public health problem that adversely affects all parts of the population. Previous systematic reviews and meta-analyses have reported that brief interventions delivered in primary care are effective at reducing alcohol consumption, albeit with small effect sizes that have decreased over time. This review summarises the updated evidence base on practitioner and digitally delivered brief interventions.

RECENT FINDINGS

Using Cochrane methodology, 69 primary care brief intervention trials (33,642 participants) and 57 digital intervention trials (34,390 participants) were identified. Meta-analyses showed both approaches significantly reduced consumption compared to controls. Five trials (390 participants) compared practitioner-delivered and digital interventions directly with no evidence of difference in outcomes at follow-up.

SUMMARY

Brief interventions have the potential to impact at both individual and population levels. Future research should focus on optimising components and delivery mechanisms, and on alcohol-related harms. Digital interventions may overcome some of the implementation barriers faced by practitioner-delivered interventions.

Reported Theory Use by Digital Interventions for Hazardous and Harmful Alcohol Consumption, and Association With Effectiveness: Meta-Regression

BACKGROUND

Applying theory to the design and evaluation of interventions is likely to increase effectiveness and improve the evidence base from which future interventions are developed, though few interventions report this.

OBJECTIVE

The aim of this paper was to assess how digital interventions to reduce hazardous and harmful alcohol consumption report the use of theory in their development and evaluation, and whether reporting of theory use is associated with intervention effectiveness.

METHODS

Randomized controlled trials were extracted from a Cochrane review on digital interventions for reducing hazardous and harmful alcohol consumption. Reporting of theory use within these digital interventions was investigated using the theory coding scheme (TCS). Reported theory use was analyzed by frequency counts and descriptive statistics. Associations were analyzed with meta-regression models.

RESULTS

Of 41 trials involving 42 comparisons, half did not mention theory (50% [21/42]), and only 38% (16/42) used theory to select or develop the intervention techniques. Significant heterogeneity existed between studies in the effect of interventions on alcohol reduction (I2=77.6%, P<.001). No significant associations were detected between reporting of theory use and intervention effectiveness in unadjusted models, though the meta-regression was underpowered to detect modest associations.

CONCLUSIONS

Digital interventions offer a unique opportunity to refine and develop new dynamic, temporally sensitive theories, yet none of the studies reported refining or developing theory. Clearer selection, application, and reporting of theory use is needed to accurately assess how useful theory is in this field and to advance the field of behavior change theories.

Treatments for hyperemesis gravidarum and nausea and vomiting in pregnancy: a systematic review and economic assessment

BACKGROUND

Nausea and vomiting in pregnancy (NVP) affects up to 85% of all women during pregnancy, but for the majority self-management suffices. For the remainder, symptoms are more severe and the most severe form of NVP - hyperemesis gravidarum (HG) - affects 0.3-1.0% of pregnant women. There is no widely accepted point at which NVP becomes HG.

OBJECTIVES

This study aimed to determine the relative clinical effectiveness and cost-effectiveness of treatments for NVP and HG.

DATA SOURCES

MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, PsycINFO, Commonwealth Agricultural Bureaux (CAB) Abstracts, Latin American and Caribbean Health Sciences Literature, Allied and Complementary Medicine Database, British Nursing Index, Science Citation Index, Social Sciences Citation Index, Scopus, Conference Proceedings Index, NHS Economic Evaluation Database, Health Economic Evaluations Database, China National Knowledge Infrastructure, Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effects were searched from inception to September 2014. References from studies and literature reviews identified were also examined. Obstetric Medicine was hand-searched, as were websites of relevant organisations. Costs came from NHS sources.

REVIEW METHODS

A systematic review of randomised and non-randomised controlled trials (RCTs) for effectiveness, and population-based case series for adverse events and fetal outcomes. Treatments: vitamins B6 and B12, ginger, acupressure/acupuncture, hypnotherapy, antiemetics, dopamine antagonists, 5-hydroxytryptamine receptor antagonists, intravenous (i.v.) fluids, corticosteroids, enteral and parenteral feeding or other novel treatment. Two reviewers extracted data and quality assessed studies. Results were narratively synthesised; planned meta-analysis was not possible due to heterogeneity and incomplete reporting. A simple economic evaluation considered the implied values of treatments.

RESULTS

Seventy-three studies (75 reports) met the inclusion criteria. For RCTs, 33 and 11 studies had a low and high risk of bias respectively. For the remainder (n = 20) it was unclear. The non-randomised studies (n = 9) were low quality. There were 33 separate comparators. The most common were acupressure versus placebo (n = 12); steroid versus usual treatment (n = 7); ginger versus placebo (n = 6); ginger versus vitamin B6 (n = 6); and vitamin B6 versus placebo (n = 4). There was evidence that ginger, antihistamines, metoclopramide (mild disease) and vitamin B6 (mild to severe disease) are better than placebo. Diclectin^® [Duchesnay Inc.; doxylamine succinate (10 mg) plus pyridoxine hydrochloride (10 mg) slow release tablet] is more effective than placebo and ondansetron is more effective at reducing nausea than pyridoxine plus doxylamine. Diclectin before symptoms of NVP begin for women at high risk of severe NVP recurrence reduces risk of moderate/severe NVP compared with taking Diclectin once symptoms begin. Promethazine is as, and ondansetron is more, effective than metoclopramide for severe NVP/HG. I.v. fluids help correct dehydration and improve symptoms. Dextrose saline may be more effective at reducing nausea than normal saline. Transdermal clonidine patches may be effective for severe HG. Enteral feeding is effective but extreme method treatment for very severe symptoms. Day case management for moderate/severe symptoms is feasible, acceptable and as effective as inpatient care. For all other interventions and comparisons, evidence is unclear. The economic analysis was limited by lack of effectiveness data, but comparison of costs between treatments highlights the implications of different choices.

LIMITATIONS

The main limitations were the quantity and quality of the data available.

CONCLUSION

There was evidence of some improvement in symptoms for some treatments, but these data may not be transferable across disease severities. Methodologically sound and larger trials of the main therapies considered within the UK NHS are needed.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013006642.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Qualitative systematic review of barriers and facilitators to self-management of chronic obstructive pulmonary disease: views of patients and healthcare professionals

Self-management interventions for chronic obstructive pulmonary disease (COPD) can improve quality of life, reduce hospital admissions, and improve symptoms. However, many factors impede engagement for patients and practitioners. Qualitative research, with its focus on subjective experience, can provide invaluable insights into such factors. Therefore, a systematic review and synthesis of qualitative evidence on COPD self-management from the perspective of patients, carers, and practitioners was conducted. Following a systematic search and screening, 31 studies were appraised and data extracted for analysis. This review found that patients can adapt to COPD; however, learning to self-manage is often a protracted process. Emotional needs are considerable; frustration, depression, and anxiety are common. In addition, patients can face an assortment of losses and limitations on their lifestyle and social interaction. Over time, COPD can consume their existence, reducing motivation. Support from family can prove vital, yet tinged with ambivalence and burden. Practitioners may not have sufficient time, resources, or appropriate skills or confidence to provide effective self-management support, particularly in regard to patients' psychosocial needs. This can compound patients' capability to engage in self-management. For COPD self-management to be effective, patients' psychosocial needs must be prioritised alongside medication and exacerbation management. In addition, patients' personal beliefs regarding COPD and its management should be reviewed periodically to avoid problematic behaviours and enhance positive adaptions to the disease. Patients with COPD are not a homogenous group and no one intervention will prove effective for all. Finally, practitioners require greater education, training, and support to successfully assist patients.

Treatments for Hyperemesis Gravidarum and Nausea and Vomiting in Pregnancy: A Systematic Review

Importance

Nausea and vomiting affects approximately 85% of pregnant women. The most severe form, hyperemesis gravidarum, affects up to 3% of women and can have significant adverse physical and psychological sequelae.

Objective

To summarize current evidence on effective treatments for nausea and vomiting in pregnancy and hyperemesis gravidarum.

Evidence Review

Databases were searched to June 8, 2016. Relevant websites and bibliographies were also searched. Titles and abstracts were assessed independently by 2 reviewers. Results were narratively synthesized; planned meta-analysis was not possible because of heterogeneity and incomplete reporting of findings.

Findings

Seventy-eight studies (n  = 8930 participants) were included: 67 randomized clinical trials (RCTs) and 11 nonrandomized studies. Evidence from 35 RCTs at low risk of bias indicated that ginger, vitamin B6, antihistamines, metoclopramide (for mild symptoms), pyridoxine-doxylamine, and ondansetron (for moderate symptoms) were associated with improved symptoms compared with placebo. One RCT (n = 86) reported greater improvements in moderate symptoms following psychotherapy (change in Rhodes score [range, 0 {no symptoms} to 40 {worst possible symptoms}], 18.76 [SD, 5.48] to 7.06 [SD, 5.79] for intervention vs 19.18 [SD, 5.63] to 12.81 [SD, 6.88] for comparator [P < .001]). For moderate-severe symptoms, 1 RCT (n = 60) suggested that pyridoxine-doxylamine combination taken preemptively reduced risk of recurrence of moderate-severe symptoms compared with treatment once symptoms begin (15.4% vs 39.1% [P < .04]). One RCT (n = 83) found that ondansetron was associated with lower nausea scores on day 4 than metoclopramide (mean visual analog scale [VAS] score, 4.1 [SD, 2.9] for ondansetron vs 5.7 [SD, 2.3] for metoclopramide [P = .023]) but not episodes of emesis (5.0 [SD, 3.1] vs 3.3 [SD, 3], respectively [P = .013]). Although there was no difference in trend in nausea scores over the 14-day study period, trend in vomiting scores was better in the ondansetron group (P = .042). One RCT (n = 159) found no difference between metoclopramide and promethazine after 24 hours (episodes of vomiting, 1 [IQR, 0-5] for metoclopramide vs 2 [IQR, 0-3] for promethazine [P = .81], VAS [0-10 scale] for nausea, 2 [IQR, 1-5] vs 2 [IQR, 1-4], respectively [P = .99]). Three RCTs compared corticosteroids with placebo or promethazine or metoclopramide in women with severe symptoms. Improvements were seen in all corticosteroid groups, but only a significant difference between corticosteroids vs metoclopramide was reported (emesis reduction, 40.9% vs 16.5% at day 2; 71.6% vs 51.2% at day 3; 95.8% vs 76.6% at day 7 [n = 40, P < .001]). For other interventions, evidence was limited.

Conclusions and Relevance

For mild symptoms of nausea and emesis of pregnancy, ginger, pyridoxine, antihistamines, and metoclopramide were associated with greater benefit than placebo. For moderate symptoms, pyridoxine-doxylamine, promethazine, and metoclopramide were associated with greater benefit than placebo. Ondansetron was associated with improvement for a range of symptom severity. Corticosteroids may be associated with benefit in severe cases. Overall the quality of evidence was low.

An external pilot study to test the feasibility of a randomised controlled trial comparing eye muscle surgery against active monitoring for childhood intermittent exotropia [X(T)]

INTRODUCTION

The evidence base for the treatment of strabismus (squint) is poor. Our main aim is to improve this evidence base for the treatment of a common type of childhood squint {intermittent exotropia, [X(T)]}. We conducted an external pilot study in order to inform the design and conduct of a future full randomised controlled trial (RCT).

METHODS

Children of between 6 months and 16 years with a recent diagnosis of X(T) were eligible for recruitment. Participants were recruited from secondary care at the ophthalmology departments at four UK NHS foundation trusts. Participants were randomised to either active monitoring or surgery. This report describes the findings of the Pilot Rehearsal Trial and Qualitative Study, and assesses the success against the objectives proposed.

RECRUITMENT AND RETENTION

The experience gained during the Pilot Rehearsal Trial demonstrates the ability to recruit and retain sites that are willing to randomise children to both trial arms, and for parents to agree to randomisation of their children to such a study. One child declined the group allocation. A total of 231 children were screened (expected 240), of whom 138 (60%) were eligible (expected 228: 95%) and 49 (35% of eligible) children were recruited (expected 144: 63% of eligible). Strategies that improved recruitment over the course of the trial are discussed, together with the reasons why fewer children were eligible for recruitment than initially anticipated. Attrition was low. Outcome data were obtained for 47 of 49 randomised children.

TRIAL PROCESSES AND DATA COLLECTION

The Trial Management processes proved effective. There were high levels of completion on all of the data collection forms. However, the feedback from the treatment orthoptists revealed that some modifications should be made to the length and frequency of the health service assessment and travel assessment questionnaires, thus reducing the burden on participants in the main trial. Modifications to the wording of the questions also need to be made.

MONITORING OF BIAS

Children who recruited to the trial were older and had more severe strabismus than those children eligible but declining participation. Strategies to account for this in a full trial are proposed.

REASONS FOR PARTICIPATION OR DECLINING STUDY

These were identified using qualitative interviews. The principal reasons for declining entry into the study were strong preferences for and against surgical treatment.

HARMS

There were no serious unexpected adverse events. Two children had overcorrection of their X(T) with reduction in binocular vision following surgery, which is in line with previous studies. No children in the active monitoring arm developed a constant strabismus although two showed some reduction in control.

CONCLUSIONS

The SamExo study has demonstrated that it is possible to recruit and retain participants to a randomised trial of surgery compared with active monitoring for X(T). For longer-term full RCTs, in order to maximise the generalisability of future studies, consideration needs to be given to planning more time and clinic appointments to assess eligibility and to allow consideration of participation; the greater use of research nurses for recruitment; and accommodating the strong preferences of some parents both for and against surgical intervention.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN44114892.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 39. See the NIHR Journals Library website for further project information.