Anticipatory prescribing in community end-of-life care: systematic review and narrative synthesis of the evidence since 2017.

BACKGROUND: The anticipatory prescribing of injectable medications is recommended practice in controlling distressing symptoms in the last days of life. A 2017 systematic review found practice and guidance was based on inadequate evidence. Since then, there has been considerable additional research, warranting a new review. AIM: To review the evidence published since 2017 concerning anticipatory prescribing of injectable medications for adults at the end-of-life in the community, to inform practice and guidance. DESIGN: Systematic review and narrative synthesis. METHODS: Nine literature databases were searched from May 2017 to March 2022, alongside reference, citation and journal hand-searches. Gough's Weight of Evidence framework was used to appraise included studies. RESULTS: Twenty-eight papers were included in the synthesis. Evidence published since 2017 shows that standardised prescribing of four medications for anticipated symptoms is commonplace in the UK; evidence of practices in other countries is limited. There is limited data on how often medications are administered in the community. Prescriptions are 'accepted' by family caregivers despite inadequate explanations and they generally appreciate having access to medications. Robust evidence of the clinical and cost-effectiveness of anticipatory prescribing remains absent. CONCLUSION: The evidence underpinning anticipatory prescribing practice and policy remains based primarily on healthcare professionals' perceptions that the intervention is reassuring, provides effective, timely symptom relief in the community and prevents crisis hospital admissions. There is still inadequate evidence regarding optimal medications and dose ranges, and the effectiveness of these prescriptions. Patient and family caregiver experiences of anticipatory prescriptions warrant urgent investigation. PROSPERO REGISTRATION: CRD42016052108.

Levelling up health: A practical, evidence-based framework for reducing health inequalities.

There are substantial inequalities in health across society which have been exacerbated by the COVID-19 pandemic. The UK government have committed to a programme of levelling-up to address geographical inequalities. Here we undertake rapid review of the evidence base on interventions to reduce such health inequalities and developed a practical, evidence-based framework to 'level up' health across the country. This paper overviews a rapid review undertaken to develop a framework of guiding principles to guide policy. To that end and based on an initial theory, we searched one electrotonic database (MEDLINE) from 2007 to July 2021 to identify published umbrella reviews and undertook an internet search to identify relevant systematic reviews, primary studies, and grey literature. Titles and abstracts were screened according to the eligibility criteria. Key themes were extracted from the included studies and synthesised into an overarching framework of guiding principles in consultation with an expert panel. Included studies were cross checked with the initial theoretical domains and further searching undertaken to fill any gaps. We identified 16 published umbrella reviews (covering 667 individual studies), 19 grey literature publications, and 15 key systematic reviews or primary studies. Based on these studies, we develop a framework applicable at national, regional and local level which consisted of five principles - 1) healthy-by-default and easy to use initiatives; 2) long-term, multi-sector action; 3) locally designed focus; 4) targeting disadvantaged communities; and 5) matching of resources to need. Decision-makers working on policies to level up health should be guided by these five principles.

Systematic review of the effectiveness of the health inequalities strategy in England between 1999 and 2010.

OBJECTIVES: The purpose of this systematic review is to explore the effectiveness of the National Health Inequality Strategy, which was conducted in England between 1999 and 2010. DESIGN: Three databases (Ovid Medline, Embase and PsycINFO) and grey literature were searched for articles published that reported on changes in inequalities in health outcomes in England over the implementation period. Articles published between January 1999 and November 2021 were included. Title and abstracts were screened according to an eligibility criteria. Data were extracted from eligible studies, and risk of bias was assessed using the Risk of Bias in Non-randomized Studies of Interventions tool. RESULTS: The search strategy identified 10 311 unique studies, which were screened. 42 were reviewed in full text and 11 were included in the final review. Six studies contained data on inequalities of life expectancy or mortality, four on disease-specific mortality, three on infant mortality and three on morbidities. Early government reports suggested that inequalities in life expectancy and infant mortality had increased. However, later publications using more accurate data and more appropriate measures found that absolute and relative inequalities had decreased throughout the strategy period for both measures. Three of four studies found a narrowing of inequalities in all-cause mortality. Absolute inequalities in mortality due to cancer and cardiovascular disease decreased, but relative inequalities increased. There was a lack of change, or widening of inequalities in mental health, self-reported health, health-related quality of life and long-term conditions. CONCLUSIONS: With respect to its aims, the strategy was broadly successful. Policymakers should take courage that progress on health inequalities is achievable with long-term, multiagency, cross-government action. TRIAL REGISTRATION NUMBER: This study was registered in PROSPERO (CRD42021285770).

End of life care in UK care homes - controlled drugs: systematic review and narrative synthesis.

BACKGROUND: Controlled drugs (CDs) such as opioids and midazolam are commonly used in end-of-life care symptom management for care home residents. AIM: To review the published evidence concerning the prescribing, storage, use and disposal of CDs for end-of-life care for care home residents in the UK. DESIGN: Systematic review and narrative synthesis. METHODS: Seven databases (Medline, CINAHL, Embase, PsycINFO, Web of Science, Cochrane Library, and Social Care Online) were searched from January 2000 to January 2021, alongside reference, citation and journal hand searches. Gough's 'Weight of Evidence' framework was used to appraise the relevance of studies to the review questions. RESULTS: The search yielded 1279 titles, from which 125 abstracts and then 42 full-text papers were screened. 14 papers were included in the synthesis. Prescribing is primarily by general practitioners, with administration by nurses. Nurses frequently report feeling inadequately trained in the use of CDs. The storage, monitoring and disposal of end-of-life care CDs in UK care homes has not been researched to date. The attitudes and experiences of residents and family members regarding these medications also remain unknown. CONCLUSION: The current widespread use of CDs for end-of-life care in care homes has a limited evidence base. The lack of research concerning the storing, monitoring and disposing of CDs, alongside the limited evidence concerning resident and family members' perspectives, is a significant knowledge deficit that requires urgent attention. PROSPERO REGISTRATION NUMBER: CRD42020173014.

Software tools to support title and abstract screening for systematic reviews in healthcare: an evaluation.

BACKGROUND: Systematic reviews are vital to the pursuit of evidence-based medicine within healthcare. Screening titles and abstracts (T&Ab) for inclusion in a systematic review is an intensive, and often collaborative, step. The use of appropriate tools is therefore important. In this study, we identified and evaluated the usability of software tools that support T&Ab screening for systematic reviews within healthcare research. METHODS: We identified software tools using three search methods: a web-based search; a search of the online "systematic review toolbox"; and screening of references in existing literature. We included tools that were accessible and available for testing at the time of the study (December 2018), do not require specific computing infrastructure and provide basic screening functionality for systematic reviews. Key properties of each software tool were identified using a feature analysis adapted for this purpose. This analysis included a weighting developed by a group of medical researchers, therefore prioritising the most relevant features. The highest scoring tools from the feature analysis were then included in a user survey, in which we further investigated the suitability of the tools for supporting T&Ab screening amongst systematic reviewers working in medical research. RESULTS: Fifteen tools met our inclusion criteria. They vary significantly in relation to cost, scope and intended user community. Six of the identified tools (Abstrackr, Colandr, Covidence, DRAGON, EPPI-Reviewer and Rayyan) scored higher than 75% in the feature analysis and were included in the user survey. Of these, Covidence and Rayyan were the most popular with the survey respondents. Their usability scored highly across a range of metrics, with all surveyed researchers (n = 6) stating that they would be likely (or very likely) to use these tools in the future. CONCLUSIONS: Based on this study, we would recommend Covidence and Rayyan to systematic reviewers looking for suitable and easy to use tools to support T&Ab screening within healthcare research. These two tools consistently demonstrated good alignment with user requirements. We acknowledge, however, the role of some of the other tools we considered in providing more specialist features that may be of great importance to many researchers.

Reducing health inequalities through general practice: protocol for a realist review (EQUALISE).

INTRODUCTION: Healthcare organisations recognise the moral imperative to address inequalities in health outcomes but often lack an understanding of which types of interventions are likely to reduce them. This realist review will examine the existing evidence on the types of interventions or aspects of routine care in general practice that are likely to decrease or increase health inequalities (ie, inequality-generating interventions) across cardiovascular disease, cancer, diabetes and chronic obstructive pulmonary disease. METHODS AND ANALYSIS: Our realist review will follow Pawson's five iterative stages. We will start by developing an initial programme theory based on existing theories and discussions with stakeholders. To navigate the large volume of literature, we will access the primary studies through the identification of published systematic reviews of interventions delivered in general practice across the four key conditions. We will examine the primary studies included within each systematic review to identify those reporting on inequalities across PROGRESS-Plus categories. We will collect data on a range of clinical outcomes including prevention, diagnosis, follow-up and treatment. The data will be synthesised using a realist logic of analysis. The findings will be a description and explanation of the general practice interventions which are likely to increase or decrease inequalities across the major conditions. ETHICS AND DISSEMINATION: Ethics approval is not required because this study does not include any primary research. The findings will be integrated into a series of guiding principles and a toolkit for healthcare organisations to reduce health inequalities. Findings will be disseminated through peer-reviewed publications, conference presentations and user-friendly summaries. PROSPERO REGISTRATION NUMBER: CRD42020217871.