Delivery of public health interventions by the ambulance sector: a scoping review.

BACKGROUND: With millions of unscheduled patient contacts every year and increasing call outs clustered around the most deprived communities, it is clear the ambulance sector could have a role to play in improving population health. However, the application and value of a public health approach within the ambulance sector has not been comprehensively explored. A scoping review was undertaken to explore the role of the ambulance sector in the delivery of public health interventions and what impact this has on population health and ambulance sector outcomes. METHODS: A search strategy was developed on MEDLINE and translated to other major medical and health related bibliographic databases (Embase; CINAHL; HMIC; Science and Social Sciences Citation Index; Cochrane Library) to identify literature published since 2000 in OECD countries. Targeted grey literature, reference list, and citation searching was also carried out. Search results were downloaded to Microsoft Excel and screened by three reviewers according to pre-determined inclusion / exclusion criteria. Data from included studies, such as the type of activity noted within the paper, the population involved and the public health approach that was utilised, was extracted from within the paper using a data extraction form and narratively synthesised. RESULTS: Fifty-two references were included in the final review (37 database searching; 9 reference list searching; 6 grey literature). Included articles were categorised according to the relevant public health domains and subdomains as articulated by the UK Faculty of Public Health: 1. Health improvement domain: Public health education and advice (Health promotion sub-domain) (n=13) Emergency Services personnel providing vaccines (Disease prevention sub-domain) (n=1) 2. Health care public health domain Paramedicine (Service delivery sub-domain) (n=30) Screening tools and referral pathways used by the ambulance sector (Service delivery sub-domain) (n=28) Health intelligence using ambulance sector data (population health management sub-domain) (n=26) Of note, some domains (e.g. health protection) returned nil results. DISCUSSION: The scoping review demonstrates the breadth of public health related activities in which the ambulance sector is involved. However, an overemphasis on demand management outcomes precludes definitive conclusions on the impact of ambulance sector-led public health initiatives on public health outcomes. Future evaluations of public health initiatives should incorporate wider health system perspectives beyond the immediately apparent remit of the ambulance sector.

The impact of hypoglycaemia in children and adolescents with type 1 diabetes on parental quality of life and related outcomes: A systematic review.

This systematic review aims to summarize and critically evaluate the current evidence regarding the impact of hypoglycaemia in children and adolescents with type 1 diabetes on parental quality of life. MEDLINE, PsycINFO, CINAHL, and the Cochrane Library were searched. Inclusion criteria were: 1) quantitative design, 2) included parents of children or adolescents with type 1 diabetes, 3) assessment of hypoglycemia in children/adolescents with type 1 diabetes, 4) assessment of parent quality of life (or related domains of life), and 5) analysis of the relationship(s) between the child's hypoglycaemia and parents' quality of life. The data were summarised in accordance with Synthesis Without Meta-Analysis Guidelines. Twelve studies were included, reporting data from 1895 parents across six countries. Ten studies were cross-sectional; two included prospective data. Evidence suggested that greater frequency and severity of hypoglycemia was associated with greater parental fear of hypoglycemia, emotional distress and family burden. Children's hypoglycaemia has a negative impact on the well-being of parents, but there is an absence of evidence regarding the impact on their overall quality of life. Research into the hypoglycaemia-specific quality of life of parents is needed to explore the impact on various areas, such as social and physical dimensions.

What influences decisions to transfer older care-home residents to the emergency department? A synthesis of qualitative reviews.

BACKGROUND: care home residents aged over 65 have disproportionate rates of emergency department (ED) attendance and hospitalisation. Around 40% attendances may be avoidable, and hospitalisation is associated with harms. We synthesised the evidence available in qualitative systematic reviews of different stakeholders' experiences of decisions to transfer residents to the ED. METHODS: six electronic databases, references and citations of included reviews and relevant policy documents were searched. Reviews of qualitative studies exploring factors that influenced care home staff, medical practitioners, residents' family or residents' experiences and factors influencing decisions to transfer residents to the ED were included. Thematic analysis was used to synthesise findings. RESULTS: six previous reviews were included, which synthesised the findings of 34 primary studies encompassing 152 care home residents, 283 resident family members or carers and 447 care home staff. Of the primary studies, 19 were conducted in the North America, seven in Australia, five were conducted in Scandinavia, two in the United Kingdom and one in Holland. Three themes were identified: (i) power dynamics between residents, family members, care home staff and health care professionals (external to the care home) influence decisions; (ii) admission can be necessary; however, (iii) some decisions may be driven by factors other than clinical need. CONCLUSION: transfer decisions are complex and are determined not just by changes in health status interventions aimed at reducing avoidable transfers need to address the key role family members have in transfer decisions, the medical legal fears of care home staff and barriers to accessing community services.

Factors that influence mental health of university and college students in the UK: a systematic review.

BACKGROUND: Worsening mental health of students in higher education is a public policy concern and the impact of measures to reduce transmission of COVID-19 has heightened awareness of this issue. Preventing poor mental health and supporting positive mental wellbeing needs to be based on an evidence informed understanding what factors influence the mental health of students. OBJECTIVES: To identify factors associated with mental health of students in higher education. METHODS: We undertook a systematic review of observational studies that measured factors associated with student mental wellbeing and poor mental health. Extensive searches were undertaken across five databases. We included studies undertaken in the UK and published within the last decade (2010-2020). Due to heterogeneity of factors, and diversity of outcomes used to measure wellbeing and poor mental health the findings were analysed and described narratively. FINDINGS: We included 31 studies, most of which were cross sectional in design. Those factors most strongly and consistently associated with increased risk of developing poor mental health included students with experiences of trauma in childhood, those that identify as LGBTQ and students with autism. Factors that promote wellbeing include developing strong and supportive social networks. Students who are prepared and able to adjust to the changes that moving into higher education presents also experience better mental health. Some behaviours that are associated with poor mental health include lack of engagement both with learning and leisure activities and poor mental health literacy. CONCLUSION: Improved knowledge of factors associated with poor mental health and also those that increase mental wellbeing can provide a foundation for designing strategies and specific interventions that can prevent poor mental health and ensuring targeted support is available for students at increased risk.

A systematic review case study of urgent and emergency care configuration found citation searching of Web of Science and Google Scholar of similar value.

BACKGROUND: Supplementary search methods, including citation searching, are essential if systematic reviews are to avoid producing biased conclusions. Little evidence exists on how to prioritise databases for citation searching or to establish whether using multiple sources is beneficial. OBJECTIVES: A systematic review examining urgent and emergency care reconfiguration was used to investigate the utility of citation searching on Web of Science (WOS) and/or Google Scholar (GS). METHODS: This case study investigated numbers of studies, additional studies and unique studies retrieved from both sources. In addition, the time to search, the ease of adding references to reference management software and obtaining abstracts of studies for screening are briefly considered. RESULTS: WOS retrieved 62 references after deduplication of the results, 52 being additional references not retrieved during the database searching. GS retrieved 134 unique references with 63 additional references. WOS and GS retrieved the same three additional included studies. WOS was less time intensive to search given the facility to restrict to English language papers and availability of abstracts. CONCLUSIONS: In a single systematic review case study, citation searching was required to identify all included studies. Citation searching on WOS is more efficient, where a subscription is available. Both databases identified the same studies but GS required additional time to remove non-English language studies and locate abstracts.

Is working in later life good for your health? A systematic review of health outcomes resulting from extended working lives.

BACKGROUND: Work, rather than unemployment, is recognised as being good for health, but there may be an age when the benefits are outweighed by adverse impacts. As countries around the world increase their typical retirement age, the potential effect on population health and health inequalities requires scrutiny. METHODS: We carried out a systematic review of literature published since 2011 from developed countries on the health effects of employment in those over 64 years of age. We completed a narrative synthesis and used harvest plots to map the direction and volume of evidence for the outcomes reported. We followed the Preferred Reporting Items for Systematic Reviews (PRISMA) checklist in our methods and reporting. RESULTS: We identified seventeen relevant studies, which were of cohort or cross-sectional design. The results indicate evidence of beneficial or neutral effects from extended working on overall health status and physical health for many employees, and mixed effects on mental health. The benefits reported however, are most likely to be for males, those working part-time or reducing to part-time, and employees in jobs which are not low quality or low reward. CONCLUSIONS: Extending working life (particularly part time) may have benefits or a neutral effect for some, but adverse effects for others in high demand or low reward jobs. There is the potential for widening health inequalities between those who can choose to reduce their working hours, and those who need to continue working full time for financial reasons. There is a lack of evidence for effects on quality of life, and a dearth of interventions enabling older workers to extend their healthy working life.

Recognition of risk and prevention in safeguarding of children and young people: a mapping review and component analysis of service development interventions aimed at health and social care professionals.

BACKGROUND: The term 'safeguarding' covers the protection of health, wellbeing and human rights. Effective safeguarding enables people (particularly children, young adults and other vulnerable people) to live free from fear of abuse, harm or neglect. The UK Children Act 2004 required key agencies, including health and social care providers, to consider the need to safeguard children and promote their welfare. Within a larger evidence synthesis project, we sought to identify and map service development interventions (excluding provision of training) aimed at improving awareness of safeguarding and identifying at-risk children and young people in health and social care settings. METHODS: We searched fourteen health and social care databases from 2004 (date of Children Act) to October 2019 and updated the review via a citation search in March 2021. Studies of any design were eligible if they described or evaluated an intervention (other than training) aimed at health or social care professionals in the United Kingdom and designed to improve recognition of risk in the context of safeguarding children and young people. Studies with no intervention (e.g. qualitative studies) were included to explain why interventions work or fail to work. Included studies were summarised using narrative synthesis. Risk of bias of included studies and overall strength of evidence were assessed using standard methods. We used a 5-item checklist ("TIDieR-Lite") to map intervention components. RESULTS: Thirty-nine publications were included, of which 31 dealt with service developments, six with use of data and two with other initiatives. Promising service development initiatives include liaison nurses, assessment clinics, secondment, joint protocols and a 'hub and spoke' model. Initiatives involving use of routine data appeared promising and unlikely to generate significant additional costs. However, the quality of the evidence was generally low, with a shortage of controlled and long-term studies. CONCLUSIONS: Health and social care services wishing to improve awareness of child safeguarding issues may benefit from looking beyond high-quality training provision. Future research should focus on service-relevant outcomes and ensure the active involvement of young people and their families/carers.

A systematic review of meta-analyses assessing the validity of tumour response endpoints as surrogates for progression-free or overall survival in cancer.

BACKGROUND: Tumour response endpoints, such as overall response rate (ORR) and complete response (CR), are increasingly used in cancer trials. However, the validity of response-based surrogates is unclear. This systematic review summarises meta-analyses assessing the association between response-based outcomes and overall survival (OS), progression-free survival (PFS) or time-to-progression (TTP). METHODS: Five databases were searched to March 2019. Meta-analyses reporting correlation or regression between response-based outcomes and OS, PFS or TTP were summarised. RESULTS: The systematic review included 63 studies across 20 cancer types, most commonly non-small cell lung cancer (NSCLC), colorectal cancer (CRC) and breast cancer. The strength of association between ORR or CR and either PFS or OS varied widely between and within studies, with no clear pattern by cancer type. The association between ORR and OS appeared weaker and more variable than that between ORR and PFS, both for associations between absolute endpoints and associations between treatment effects. CONCLUSIONS: This systematic review suggests that response-based endpoints, such as ORR and CR, may not be reliable surrogates for PFS or OS. Where it is necessary to use tumour response to predict treatment effects on survival outcomes, it is important to fully reflect all statistical uncertainty in the surrogate relationship.

Effects of service changes affecting distance/time to access urgent and emergency care facilities on patient outcomes: a systematic review.

BACKGROUND: Reconfiguration of urgent and emergency care services often increases travel time/distance for patients to reach an appropriate facility. Evidence of the effects of reconfiguration is important for local communities and commissioners and providers of health services. METHODS: We performed a systematic review of the evidence regarding effects of service reconfigurations that increase the time/distance for some patients to reach an urgent and emergency care (UEC) facility. We searched seven bibliographic databases from 2000 to February 2019 and used citation tracking and reference lists to identify additional studies. We included studies of any design that compared outcomes for people with conditions requiring emergency treatment before and after service reconfiguration with an associated change in travel time/distance to access UEC. Studies had to be conducted in the UK or other developed countries. Data extraction and quality assessment (using the Joanna Briggs Institute checklist for quasi-experimental studies) were undertaken by a single reviewer with a sample checked for accuracy and consistency. We performed a narrative synthesis of the included studies. Overall strength of evidence was assessed using a previously published method that considers volume, quality and consistency. RESULTS: We included 12 studies, of which six were conducted in the USA, two in the UK and four in other European countries. The studies used a variety of observational designs, with before-after and cohort designs being most common. Only two studies included an independent control site/sites where no reconfiguration had taken place. The reconfigurations evaluated in these studies reported relatively small effects on average travel times/distance. DISCUSSION: For studies of general UEC populations, there was no convincing evidence as to whether reconfiguration affected mortality risk. However, evidence of increased risk was identified from studies of patients with acute myocardial infarction, particularly 1 to 4 years after reconfiguration. Evidence for other conditions was inconsistent or very limited. CONCLUSIONS: We found insufficient evidence to determine whether increased distance to UEC increases mortality risk for the general population of people requiring UEC, although this conclusion may not extend to people with specific conditions.

Uncovering a multitude of human glucocorticoid receptor variants: an expansive survey of a single gene.

BACKGROUND: Glucocorticoids are commonly used in the clinical setting for their potent anti-inflammatory effects; however, significant variations in response to treatment have been demonstrated. Although the underlying mechanisms have yet to be fully understood, this variable response may be a result of alterations in human glucocorticoid receptor (hGR) expression and function. In addition to hGRα, the biologically active isoform, a screening of current databases and publications revealed five alternative splice isoforms and hundreds of variants that have been reported to date. Many of these changes in the hGR-coding gene, NR3C1, have been linked to pathophysiology. However, many studies focus on evaluating hGR expression in vitro or detecting previously reported variants. RESULTS: In this study, blood from healthy volunteers, burn and asthma patients, as well as from peripheral blood mononuclear cells isolated from leukoreduced donor whole blood, were screened for NR3C1 isoforms. We identified more than 1500 variants, including an additional 21 unique splice isoforms which contain 15 new cryptic exons. A dynamic database, named the Universal hGR (UhGR), was created to annotate and visualize the variants. CONCLUSION: This identification of naturally occurring and stress-induced hGR isoforms, as well as the establishment of an hGR-specific database, may reveal new patterns or suggest areas of interest that will lead to the improved understanding of the human stress response system.

The state of the art in non-pharmacological interventions for developmental stuttering. Part 2: qualitative evidence synthesis of views and experiences.

BACKGROUND: A range of interventions have been developed to treat stuttering in recent years. The effectiveness of these interventions has largely been assessed in studies focusing on the impact of specific types of therapy on patient outcomes. Relatively little is known about the factors that influence how the delivery and impact of different types of intervention may be experienced from the perspective of both people who deliver as well as those who receive interventions. AIMS: To synthesize the available evidence in relation to factors that might enhance or mitigate against successful outcomes following interventions for stuttering by identifying and synthesizing relevant qualitative research that explored the experiences of people delivering and receiving interventions that aim to improve fluency. METHODS & PROCEDURES: We carried out a systematic review including research that had used in-depth interviews and focus groups and conducted a substantive qualitative analysis of the data collected. Included study populations were either adults or children affected by a diagnosed stutter and/or providers of therapy for stuttering. An iterative approach was used to search for published qualitative evidence in relevant databases from 1990 to 2014. Retrieved citations were sifted for relevance and the data from articles that met the inclusion criteria were extracted. Each included paper was assessed for quality and a thematic analysis and synthesis of findings was carried out. MAIN CONTRIBUTION: Synthesized qualitative evidence highlights the changing experiences for people who stutter both historically and, for individuals, over the life course. Barriers and facilitators to the implementation of interventions for stuttering are encountered at the individual, intervention, interpersonal and social levels. Interventions may be particularly pertinent at certain transition points in the life course. Attention to emotional as well as practical aspects of stuttering is valued by people receiving therapy. The client-therapist relationship and support from others are also key factors in achieving successful outcomes. CONCLUSIONS & IMPLICATIONS: A synthesis of qualitative findings from published papers has added to the effectiveness data reported in an accompanying paper in understanding how stuttering impacts on people across the life course. Evidence suggests that a client-centred and individually tailored approach enhances the likelihood of successful intervention outcomes through attention to emotional, situational and practical needs.

Tramadol for premature ejaculation: a systematic review and meta-analysis.

BACKGROUND: Tramadol is a centrally acting analgesic prescribed off-label for the treatment of premature ejaculation (PE). However, tramadol may cause addiction and difficulty in breathing and the beneficial effect of tramadol in PE is yet not supported by a high level of evidence. The purpose of this study was to systematically review the evidence from randomised controlled trials (RCT) for tramadol in the management of PE. METHODS: We searched bibliographic databases including MEDLINE to August 2014 for RCTs. The primary outcome was intra-vaginal ejaculatory latency time (IELT). Methodological quality of RCTs was assessed. Between-group differences in IELT and other outcomes were pooled across RCTs in a meta-analysis. Statistical and clinical between-trial heterogeneity was assessed. RESULTS: A total of eight RCTs that evaluated tramadol against a comparator were included. The majority of RCTs were of unclear methodological quality due to limited reporting. Pooled evidence (four RCTs, 721 participants), suggests that tramadol is significantly more effective than placebo at increasing IELT over eight to 12 weeks (p = 0.0007). However, a high level of statistical heterogeneity is evident (I-squared = 74%). Single RCT evidence indicates that tramadol is significantly more effective than paroxetine taken on-demand, sildenafil, lidocaine gel, or behavioural therapy on IELT in men with PE. Tramadol is associated with significantly more adverse events including: erectile dysfunction, constipation, nausea, headache, somnolence, dry mouth, dizziness, pruritus, and vomiting, than placebo or behavioural therapy over eight to 12 weeks of treatment. However, addiction problems or breathing difficulties reported by patients for PE is not assessed in the current evidence base. CONCLUSIONS: Tramadol appears effective in the treatment of PE. However, these findings should be interpreted with caution given the observed levels of between-trial heterogeneity and the reporting quality of the available evidence. The variability across placebo-controlled trials in terms of the tramadol dose evaluated and the treatment duration does not permit any assessment of a safe and effective minimum daily dose. The long-term effects and side effects, including addiction potential, for men with PE have not been evaluated in the current evidence base. TRIAL REGISTRATION: The review is registered on PROSPERO 2013: CRD42013005289 .

The state of the art in non-pharmacological interventions for developmental stuttering. Part 1: a systematic review of effectiveness.

BACKGROUND: The growing range of available treatment options for people who stutter presents a challenge for clinicians, service managers and commissioners, who need to have access to the best available treatment evidence to guide them in providing the most appropriate interventions. While a number of reviews of interventions for specific populations or a specific type of intervention have been carried out, a broad-based systematic review across all forms of intervention for adults and children was needed to provide evidence to underpin future guidelines, inform the implementation of effective treatments and identify future research priorities. AIMS: To identify and synthesize the published research evidence on the clinical effectiveness of the broad range of non-pharmacological interventions for the management of developmental stuttering. METHODS & PROCEDURES: A systematic review of the literature reporting interventions for developmental stuttering was carried out between August 2013 and April 2014. Searches were not limited by language or location, but were restricted by date to studies published from 1990 onwards. Methods for the identification of relevant studies included electronic database searching, reference list checking, citation searching and hand searching of key journals. Appraisal of study quality was performed using a tool based on established criteria for considering risk of bias. Due to heterogeneity in intervention content and outcomes, a narrative synthesis was completed. MAIN CONTRIBUTION: The review included all available types of intervention and found that most may be of benefit to at least some people who stutter. There was evidence, however, of considerable individual variation in response to these interventions. The review indicated that effects could be maintained following all types of interventions (although this was weakest with regard to feedback and technology interventions). CONCLUSIONS: This review highlights a need for greater consensus with regard to the key outcomes used to evaluate stuttering interventions, and also a need for enhanced understanding of the process whereby interventions effect change. Further analysis of the variation in effectiveness for different individuals or groups is needed in order to identify who may benefit most from which intervention.

Validation of surrogate endpoints in advanced solid tumors: systematic review of statistical methods, results, and implications for policy makers.

OBJECTIVES: Licensing of, and coverage decisions on, new therapies should rely on evidence from patient-relevant endpoints such as overall survival (OS). Nevertheless, evidence from surrogate endpoints may also be useful, as it may not only expedite the regulatory approval of new therapies but also inform coverage decisions. It is, therefore, essential that candidate surrogate endpoints be properly validated. However, there is no consensus on statistical methods for such validation and on how the evidence thus derived should be applied by policy makers. METHODS: We review current statistical approaches to surrogate-endpoint validation based on meta-analysis in various advanced-tumor settings. We assessed the suitability of two surrogates (progression-free survival [PFS] and time-to-progression [TTP]) using three current validation frameworks: Elston and Taylor's framework, the German Institute of Quality and Efficiency in Health Care's (IQWiG) framework and the Biomarker-Surrogacy Evaluation Schema (BSES3). RESULTS: A wide variety of statistical methods have been used to assess surrogacy. The strength of the association between the two surrogates and OS was generally low. The level of evidence (observation-level versus treatment-level) available varied considerably by cancer type, by evaluation tools and was not always consistent even within one specific cancer type. CONCLUSIONS: Not in all solid tumors the treatment-level association between PFS or TTP and OS has been investigated. According to IQWiG's framework, only PFS achieved acceptable evidence of surrogacy in metastatic colorectal and ovarian cancer treated with cytotoxic agents. Our study emphasizes the challenges of surrogate-endpoint validation and the importance of building consensus on the development of evaluation frameworks.

Interventions to minimise hospital winter pressures related to discharge planning and integrated care: a rapid mapping review of UK evidence.

Background: Winter pressures are a familiar phenomenon within the National Health Service and represent the most extreme of many regular demands placed on health and social care service provision. This review focuses on a part of the pathway that is particularly problematic: the discharge process from hospital to social care and the community. Although studies of discharge are plentiful, we identified a need to focus on identifying interventions and initiatives that are a specific response to 'winter pressures'. This mapping review focuses on interventions or initiatives in relation to hospital winter pressures in the United Kingdom with either discharge planning to increase smart discharge (both a reduction in patients waiting to be discharged and patients being discharged to the most appropriate place) and/or integrated care. Methods: We conducted a mapping review of United Kingdom evidence published 2018-22. Initially, we searched MEDLINE, Health Management Information Consortium, Social Care Online, Social Sciences Citation Index and the King's Fund Library to find relevant interventions in conjunction with winter pressures. From these interventions we created a taxonomy of intervention types and a draft map. A second broader stage of searching was then undertaken for named candidate interventions on Google Scholar (Google Inc., Mountain View, CA, USA). For each taxonomy heading, we produced a table with definitions, findings from research studies, local initiatives and systematic reviews and evidence gaps. Results: The taxonomy developed was split into structural, changing staff behaviour, changing community provision, integrated care, targeting carers, modelling and workforce planning. The last two categories were excluded from the scope. Within the different taxonomy sections we generated a total of 41 headings. These headings were further organised into the different stages of the patient pathway: hospital avoidance, alternative delivery site, facilitated discharge and cross-cutting. The evidence for each heading was summarised in tables and evidence gaps were identified. Conclusions: Few initiatives identified were specifically identified as a response to winter pressures. Discharge to assess and hospital at home interventions are heavily used and well supported by the evidence but other responses, while also heavily used, were based on limited evidence. There is a lack of studies considering patient, family and provider needs when developing interventions aimed at improving delayed discharge. Additionally, there is a shortage of studies that measure the longer-term impact of interventions. Hospital avoidance and discharge planning are whole-system approaches. Considering the whole health and social care system is imperative to ensure that implementing an initiative in one setting does not just move the problem to another setting. Limitations: Time limitations for completing the review constrained the period available for additional searches. This may carry implications for the completeness of the evidence base identified. Future work: Further research to consider a realist review that views approaches across the different sectors within a whole system evaluation frame. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130588) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 31. See the NIHR Funding and Awards website for further award information.

Every year, the National Health Service struggles with huge care demands from people with heart and lung problems. This 'mapping review' aimed to chart the evidence around what has been done to minimise winter pressures related to discharge planning, by helping people leaving hospital sooner, and by optimising integrated care (also known as 'collaborative care') and to make suggestions for future research. Good research evidence was identified for three specific approaches: Acute medical units: these units provide rapid assessment, diagnosis and treatment for adults referred by their general practitioner or the emergency department. Discharge to assess: this involves discharging patients who need care services but not an acute hospital bed. Patients are either discharged home or are transferred to an appropriate community setting with short-term funded support while their future care needs are assessed. Hospital at home: this approach provides patients with the care they need at home instead of in hospital (also known as virtual wards). The evidence for many other activities to reduce winter pressures was weaker, coming from case studies, conference presentations or small, low methodological quality (poorly designed or executed) research studies. The review identified many different initiatives with diverse names or labels and it is also important to consider how implementing an initiative in one setting might affect another setting. Further research is recommended around what works best for which patient groups, under what circumstances and why, based on common processes within the different initiatives and across the whole health and social care system.

Signposting services for people with health and care needs: a rapid realist review.

Background: Signposting typically refers to an informal process that involves giving information to patients to enable them to access external services and support. It is perceived to reduce demand on primary care and other urgent care services. Methods: This focused realist review was conducted rapidly within time constraints. Searches to identify theory were undertaken on MEDLINE, Cumulative Index to Nursing and Allied Health Literature and Social Sciences Citation Index in June 2022 for research published in English from 2016. We selected 22 publications and extracted programme theories from these to develop three priority questions: Question 1: What do people with health and social care needs require from a signposting service to believe it is valuable? Question 2: What resources do providers require to confidently deliver an effective signposting service? Question 3: Under what circumstances should commissioners commission generic or specialist signposting services? Purposive searching was conducted to find a rich sample of studies. UK studies were prioritised to optimise the applicability of synthesis findings. Results: The review included 27 items, 4 reviews and 23 studies, a mix of qualitative, evaluations and case studies. Service users value a joined-up response that helps them to navigate the available resources. Key features include an understanding of their needs, suggestion of different options and a summary of recommended actions. Only a small number of service user needs are met by signposting services alone; people with complex health and social care needs often require extended input and time. Front-line providers of signposting services require appropriate training, ongoing support and supervision, good knowledge of relevant and available activities and an ability to match service users to appropriate resources. Front-line providers need to offer a flexible response targeted at user needs. Commissioned signposting services in England (no studies from Scotland, Wales and Northern Ireland) are highly diverse in terms of client groups, staff delivering the service, referral routes and role descriptions. A lack of service evaluation poses a potential barrier to effective commissioning. A shortage of available services in the voluntary and community sector may limit the effectiveness of signposting services. Commissioners should ensure that referrals target intensive support at patients most likely to benefit in the longer term. Conclusions: Signposting services need greater clarity of roles and service expectations to facilitate evaluation. Users with complex health and social care needs require intensive, repeat support from specialist services equipped with specific knowledge and situational understanding. A tension persists between efficient (transactional) service provision with brief referral and effective (relational) service provision, underpinned by competing narratives. Do signposting services represent 'diversion of unwanted demand from primary care/urgent care services' or 'improved quality of care through a joined-up response by health, social care and community/voluntary services'? Limitations: This realist review was conducted within a tight time frame with a potential impact on methodology; for example, the use of purposive searching may have resulted in omission of relevant evidence. Future work: Signposting services require service evaluation and consideration of the issue of diversity. Study registration: This study is registered as PROSPERO CRD42022348200. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130588) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 26. See the NIHR Funding and Awards website for further award information.

Signposting points people to information, help or advice that they should find useful. Signposting can be delivered face to face, by phone, or virtually, by technology. This review of research brings together what is already known. We have not collected any data ourselves. The review uses realist synthesis. This method tries to understand the whys and ways (the mechanisms and theories) of how things work (or do not work!). It goes beyond whether something works (is effective). It tries to explain why something might work for some people but not others. For example, why an approach may not be helpful for people with disabilities, why it might work in some places but not others and exactly what leads to what effects (what are the 'key ingredients'). The report answers the following three questions: What do people with health and social care needs require from a signposting service to enable them to believe it is a valuable and useful service? What resources do people providing signposting services require to ensure that they can confidently provide effective signposting services? How can commissioners/funders specify, monitor and evaluate signposting services (generic or specific) to optimise value for money and outcomes for service users? Specifically, do any factors favour funding general over specialist services and vice versa? The diversity of signposting services within health or across social and community services, including voluntary services, makes them difficult to evaluate and compare. Within each service, different people undertake signposting roles: from general practitioners, practice nurses or receptionist to a standalone signposting role, each for a different purpose and intensity. Only a small number of service users potentially benefit from signposting-only services. Many service users have complex health and social care needs and, therefore, need different support extended over a longer time.

Relationships between sodium, fats and carbohydrates on blood pressure, cholesterol and HbA1c: an umbrella review of systematic reviews.

Background: The relationship between nutrition and health is complex and the evidence to describe it broad and diffuse. This review brings together evidence for the effect of nutrients on cardiometabolic risk factors. Methods: An umbrella review identified systematic reviews of randomised controlled trials and meta-analyses estimating the effects of fats, carbohydrates and sodium on blood pressure, cholesterol and haemoglobin A1c (HbA1c). Medline, Embase, Cochrane Library and Science Citation Index were search through 26 May 2020, with supplementary searches of grey literature and websites. English language systematic reviews and meta-analyses were included that assessed the effect of sodium, carbohydrates or fat on blood pressure, cholesterol and HbA1c. Reviews were purposively selected using a sampling framework matrix. The quality of evidence was assessed with A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR2) checklist, evidence synthesised in a narrative review and causal pathways diagram. Results: Forty-three systematic reviews were included. Blood pressure was significantly associated with sodium, fibre and fat. Sodium, fats and carbohydrates were significantly associated with cholesterol. Monounsaturated fat, fibre and sugars were associated with HbA1c. Conclusion: Multiple relationships between nutrients and cardiometabolic risk factors were identified and summarised in an accessible way for public health researchers. The review identifies associations, inconsistencies and gaps in evidence linking nutrition to cardiometabolic health.

Pharmacist-led primary care interventions to promote medicines optimisation and reduce overprescribing: a systematic review of UK studies and initiatives.

OBJECTIVES: To systematically review and synthesise evidence on the effectiveness and implementation barriers/facilitators of pharmacist-led interventions to promote medicines optimisation and reduce overprescribing in UK primary care. DESIGN: Systematic review. SETTING: UK primary care. METHODS: We searched MEDLINE, Embase, CINAHL PsycINFO and The Cochrane Library for UK-based studies published between January 2013 and February 2023. Targeted searches for grey literature were conducted in May 2023. Quantitative and qualitative studies (including conference abstracts and grey literature) that addressed a relevant intervention and reported a primary outcome related to changes in prescribing were eligible for inclusion. Quality of included studies was assessed using the Multiple Methods Appraisal Tool. We performed a narrative synthesis, grouping studies by publication status, setting and type of data reported (effectiveness or implementation). RESULTS: We included 14 peer-reviewed journal articles and 11 conference abstracts, together with 4 case study reports. The journal articles reported 10 different interventions, 5 delivered in general practice, 4 in care homes and 1 in community pharmacy. The quality of evidence was higher in general practice than in care home settings. It was consistently reported that the intervention improved outcomes related to prescribing, although the limited number of studies and wide range of outcomes reported made it difficult to estimate the size of any effect. Implementation was strongly influenced by relationships between pharmacists and other health and care professionals, especially general practitioners. Implementation in care homes appeared to be more complex than in general practice because of differences in systems and 'culture' between health and social care. CONCLUSIONS: Pharmacist-led interventions have been reported to reduce overprescribing in primary care settings in the UK but a shortage of high-quality evidence means that more rigorous studies using high-quality designs are needed. More research is also needed in community pharmacy settings; to assess intervention effects on patient outcomes other than prescribing and to investigate how reducing overprescribing can impact health inequalities. PROSPERO REGISTRATION NUMBER: CRD42023396366.

Factors within the clinical encounter that impact upon risk assessment within child and adolescent mental health services: a rapid realist synthesis.

Background: Risk assessment is a key process when a child or adolescent presents at risk for self-harm or suicide in a mental health crisis or emergency. Risk assessment by a healthcare professional should be included within a biopsychosocial assessment. However, the predictive value of risk-screening tools for self-harm and suicide in children and adolescents is consistently challenged. A review is needed to explore how best to undertake risk assessment and the appropriate role for tools/checklists within the assessment pathway. Aims: To map research relating to risk assessment for child and adolescent mental health and to identify features that relate to a successful risk assessment. Objectives: To review factors within the clinical encounter that impact upon risk assessments for self-harm and suicide in children and adolescents: i. to conduct a realist synthesis to understand mechanisms for risk assessment, why they occur and how they vary by context ii. to conduct a mapping review of primary studies/reviews to describe available tools of applicability to the UK. Data sources: Databases, including MEDLINE, PsycINFO®, EMBASE, CINAHL, HMIC, Science and Social Sciences Citation Index and the Cochrane Library, were searched (September 2021). Searches were also conducted for reports from websites. Review methods: A resource-constrained realist synthesis was conducted exploring factors that impact upon risk assessments for self-harm and suicide. This was accompanied by a mapping review of primary studies/reviews describing risk-assessment tools and approaches used in UK child and adolescent mental health. Following piloting, four reviewers screened retrieved records. Items were coded for the mapping and/or for inclusion in the realist synthesis. The review team examined the validity and limitations of risk-screening tools. In addition, the team identified structured approaches to risk assessment. Reporting of the realist synthesis followed RAMESES guidelines. Results: From 4084 unique citations, 249 papers were reviewed and 41 studies (49 tools) were included in the mapping review. Eight reviews were identified following full-text screening. Fifty-seven papers were identified for the realist review. Findings highlight 14 explanations (programme theories) for a successful risk assessment for self-harm and suicide. Forty-nine individual assessment tools/approaches were identified. Few tools were developed in the UK, specifically for children and adolescents. These lacked formal independent evaluation. No risk-screening tool is suitable for risk prediction; optimal approaches incorporate a relationship of trust, involvement of the family, where appropriate, and a patient-centred holistic approach. The objective of risk assessment should be elicitation of information to direct a risk formulation and care plan. Limitations: Many identified tools are well-established but lack scientific validity, particularly predictive validity, or clinical utility. Programme theories were generated rapidly from a survey of risk assessment. Conclusions: No single checklist/approach meets the needs of risk assessment for self-harm and suicide. A whole-system approach is required, informed by structured clinical judgement. Useful components include a holistic assessment within a climate of trust, facilitated by family involvement. Study registration: This study is registered as PROSPERO CRD42021276671. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR135079) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 1. See the NIHR Funding and Awards website for further award information.

When young people up to 18 years of age present to health services, having tried to poison themselves, take an overdose or injure themselves, a health professional needs to work out whether this is likely to happen again (risk assessment). Lists of questions or things to look for (risk screening) have proved unreliable. Thorough discussion with the child or teenager may be helpful but takes much time. How can a health professional best use time spent with a young person to prevent further harm and make sure that they get the treatment that they need? This review focuses on young persons who use health services in the UK. Included studies report how health professionals work out whether young people are likely to harm themselves; either how to handle the overall discussion or to use memory aids or checklists (known as tools) to help the discussion. Tools developed in the USA many years ago have not been tested well enough with UK populations. Recent approaches within the UK are used inconsistently. Young persons do not like how they are assessed. Health professionals may use methods that have not been shown to work or use tools differently from how they were designed. This review identified 14 ways to help a young person have valued discussions with a health professional. Health professionals should not simply 'tick boxes'; tools should help them gain a full picture, including input from other family members. Health professionals should create a trusted relationship where the young person feels respected and heard. Tools should not label someone 'at risk' but should support care that reduces the risk of further harm. Health professionals should gather good-quality information that includes asking about thoughts of suicide. Staff should be supported by training, guidance and feedback from experienced colleagues.

Minimally invasive oesophagectomy versus open surgery: is there an advantage?

BACKGROUND: Oesophageal resection is the main method of curative treatment for cancer of the oesophagus. Despite advances in surgical technology and postoperative care, the survival rate and prognosis of people undergoing oesophagectomy is still poor. The use of minimally invasive techniques in oesophageal surgery offers hope of reduced recovery time due to a reduction in surgical trauma. Although the first reports of thoracoscopy- and laparoscopy-assisted oesophagectomy emerged some 20 years ago, there is still no consensus that the outcomes are clearly superior to outcomes following conventional open surgery. Increasingly, some surgeons promote the use of minimally invasive techniques for oesophagectomy but questions remain over its safety and efficacy compared with open surgery. METHODS: We conducted a systematic review of the literature to compare minimally invasive techniques for oesophagectomy to open surgery. The outcomes of interest for efficacy and safety included mortality, operative complications, recurrence, and quality of life. RESULTS: There were 28 included comparative studies. No randomised controlled studies (RCTs) were available and therefore the data need to be interpreted with caution. CONCLUSION: Recommendations for future research are discussed. We argue that it is difficult to conduct an RCT for this procedure due to ethical considerations and suggest ways that future nonrandomised studies could be improved.