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Rationale, aims and objective: Substituting outpatient hospital care with primary care is seen as a solution to decrease unnecessary referrals to outpatient hospital care and decrease rising healthcare costs. This systematic review aimed to evaluate the effects on quality of care, health and costs outcomes of substituting outpatient hospital care with primary care-based interventions, which are performed by medical specialists in face-to-face consultations in a primary care setting. Method: The systematic review was performed using the PICO framework. Original papers in which the premise of the intervention was to substitute outpatient hospital care with primary care through the involvement of a medical specialist in a primary care setting were eligible. Results: A total of 14 papers were included. A substitution intervention in general practitioner (GP) practices was described in 11 papers, three described a joint consultation intervention in which GPs see patients together with a medical specialist. This study showed that substitution initiatives result mostly in favourable outcomes compared to outpatient hospital care. The initiatives resulted mostly in shorter waiting lists, shorter clinic waiting times and higher patient satisfaction. Costs for treating one extra patient seemed to be higher in the intervention settings. This was mainly caused by inefficient planning of consultation hours and lower patient numbers. Conclusions: Despite the fact that internationally a lot has been written about the importance of performing substitution interventions in which preventing unnecessary referrals to outpatient hospital care was the aim, only 14 papers were included. Future systematic reviews should focus on the effects on the Triple Aim of substitution initiatives in which other healthcare professions than medical specialists are involved along with new technologies, such as e-consults. Additionally, to gain more insight into the effects of substitution initiatives operating in a dynamic healthcare context, it is important to keep evaluating the interventions in a longitudinal study design. [ABSTRACT FROM AUTHOR]

The vulnerability of deafblind people is considered axiomatic; they are seen not only as a vulnerable group but also as one of the most vulnerable. This paper aims to synthesise existing knowledge to determine what is known about such vulnerability. A comprehensive literature search was undertaken between April 2013 and May 2014. The review method was informed by systematic review principles. An approach based on a 'hierarchy of evidence' would have reduced the amount of literature reviewed significantly, to the point where synthesis would not be possible. Included material was appraised and an interpretative rather than aggregative approach to synthesis adopted. Drawing on principles of critical interpretive synthesis, rather than being a determiner of whether material should be included or excluded, a critique of the literature is offered within the synthesis. Twenty-eight references were identified for inclusion, originating from the UK, USA, Australia, Continental Europe and the Nordic Countries. No empirical studies specifically examining the experience of vulnerability of deafblind people were found. However, deafblind people describe feelings of vulnerability in studies exploring their experiences more generally, and in personal accounts of living with the impairment. Literature produced by practitioners and specialist organisations also explores the topic. Deafblind people are identified as a population 'at risk' of various adverse outcomes, particularly when compared to the non-deafblind majority, and deafblind people describe being and feeling vulnerable in various situations. The literature largely relates to negative outcomes and includes significantly less exploration of positive risk taking, coping capacity and resilience. Deafblind people do not appear to describe themselves as being vulnerable as a permanent state, suggesting a need for greater exploration of the experience among all sections of this heterogeneous population, with consideration of the concepts of resilience and coping capacity. [ABSTRACT FROM AUTHOR]

Introduction: Several forces are contributing to an increase in the number of people living with and surviving colorectal cancer (CRC). However, due to the lack of available data, little is known about the implications of these forces. In recent years, the use of administrative records to inform research has been increasing. The aim of this paper is to investigate the potential contribution that administrative data could have on the health economic research of CRC. Methods: To achieve this aim, we conducted a systematic review of the health economic CRC literature published in the United Kingdom and Europe within the last decade (2009–2019). Results: Thirty‐seven relevant studies were identified and divided into economic evaluations, cost of illness studies and cost consequence analyses. Conclusions: The use of administrative data, including cancer registry, screening and hospital records, within the health economic research of CRC is commonplace. However, we found that this data often come from regional databases, which reduces the generalisability of results. Further, administrative data appear less able to contribute towards understanding the wider and indirect costs associated with the disease. We explore several ways in which various sources of administrative data could enhance future research in this area. [ABSTRACT FROM AUTHOR]

Background/objectives: Sedentary behavior (SB), defined as sitting (nonexercising), reclining, and lying down (posture), or by low energy expenditure, is a public health risk independent to physical activity. The objective of this systematic literature review was to synthesize the available evidence on amount of SB reported by and measured in older adults. Data source: Studies published between 1981 and 2014 were identified from electronic databases and manual searching. Large-scale population studies/surveys reporting the amount of SB (objective/ subjective) in older adults aged ≥ 60 years of age were included. Appraisal and synthesis was completed using MOOSE guidelines. Results: 349,698 adults aged ≥ 60 within 22 studies (10 countries and 1 EU-wide) were included. Objective measurement of SB shows that older adults spend an average of 9.4 hr a day sedentary, equating to 65-80% of their waking day. Self-report of SB is lower, with average weighted self-reports being 5.3 hr daily. Within specific domains of SB, older adults report 3.3 hr in leisure sitting time and 3.3 hr watching TV. There is an association with more time spent in SB as age advances and a trend for older men to spend more time in SB than women. Conclusion/ implications: Time spent sedentary ranges from 5.3-9.4 hr per waking day in older adults. With recent studies suggesting a link between SB, health, and well-being, independent of physical activity, this is an area important for successful aging. Limitations: Different methodologies of measurement and different reporting methods of SB made synthesis difficult. Estimated SB time from self-report is half of that measured objectively; suggesting that most self-report surveys of SB will vastly underestimate the actual time spent in SB. [ABSTRACT FROM AUTHOR]

Background: Patient and public involvement (PPI) is a requirement for UK health and social care research funding. Evidence for how best to implement PPI in research programmes, such as National Institute for Health Research (NIHR) Collaborations for Applied Health Research and Care (CLAHRCs), remains limited. This paper reports findings from an action research (AR) project called IMPRESS, which aims to strengthen PPI within CLAHRC East of England (EoE). IMPRESS combines AR with Normalisation Process Theory (NPT) to explore PPI within diverse case study projects, identifying actions to implement, test and refine to further embed PPI. Methods: We purposively selected CLAHRC EoE case study projects for in-depth analysis of PPI using NPT. Data were generated from project PPI documentation, semi-structured qualitative interviews with researchers and PPI contributors and focus groups. Transcripts and documents were subjected to abductive thematic analysis and triangulation within case. Systematic across case comparison of themes was undertaken with findings and implications refined through stakeholder consultation. Results: We interviewed 24 researchers and 13 PPI contributors and analysed 28 documents from 10 case studies. Three focus groups were held: two with researchers (n = 4 and n = 6) and one with PPI contributors (n = 5). Findings detail to what extent projects made sense of PPI, bought in to PPI, operationalised PPI and appraised it, thus identifying barriers and enablers to fully embedded PPI. Conclusion: Combining NPT with AR allows us to assess the embeddedness of PPI within projects and programme, to inform specific local action and report broader conceptual lessons for PPI knowledge and practice informing the development of an action framework for embedding PPI in research programmes. To embed PPI within similar programmes teams, professionals, disciplines and institutions should be recognised as variably networked into existing PPI support. Further focus and research is needed on sharing PPI learning and supporting innovation in PPI. [ABSTRACT FROM AUTHOR]

Epidemiological evidence suggests that regular physical activity (PA) positively impacts individuals' mental health (MH). The PA-MH relationship may be critical among immigrants owing to psycho-social-cultural influences. This scoping review of 61 studies employed a holistic bio-psycho-socio-cultural framework to thoroughly investigate the complex relationship between PA (across life domains) and immigrants' MH in Western countries. A systematic search of five electronic databases (Medline, PubMed, Embase, PsycINFO and Anthropology Plus) was conducted to locate relevant articles. No limitations were applied to study design, age, gender, home country, MH condition or PA type. A bio-psycho-socio-cultural-informed conceptual model guided the analysis of the multi-domain PA-MH relationship. Immigrant PA-MH studies were conducted and reported most commonly in the USA (38%), Australia (18%), and Canada (11%). Overall, PA was positively related to MH. Each domain-specific PA appeared to be associated with unique MH-promoting pathways/mechanisms. Leisure-related PA may support MH by enhancing self-agency and minimizing risky behaviors, whilst travel- and domestic-related PA may promote self-accomplishment and physical engagement. Ethnic sports appeared to enhance resilience. Occupational-related PA was associated with either positive or negative MH, depending on the type of occupation. A bio-psycho-socio-cultural-informed model is required to gain an encompassing and integrated understanding of immigrants' health. The first iteration of such a model is presented here, along with an illustration of how the model may be used to deepen analysis and understanding of the multi-domain PA-MH relationship among immigrants and inform public health planners and practitioners. [ABSTRACT FROM AUTHOR]

Context North American medical students are more depressed and anxious than their peers. In the UK, the regulator now has responsibility for medical students, which may potentially increase scrutiny of their health. This may either help or hinder medical students in accessing appropriate care. The prevalences of anxiety, depression and psychological distress in medical students outside North America are not clear. A better understanding of the prevalence of, risk factors for and results of psychological distress will guide the configuration of support services, increasingly available for doctors, for medical students too. Objectives The aim of this study was to examine the prevalences of depression, anxiety and psychological distress in students in medical schools in the UK, Europe and elsewhere in the English-speaking world outside North America. Methods A systematic review was conducted using search terms encompassing psychological distress amongst medical students. Ovid SP was used to search the following databases: Ovid MEDLINE (R) from 1948 to October 2013; Psyc INFO from 1806 to October 2013, and EMBASE from 1980 to October 2013. Results were restricted to medical schools in Europe and the English-speaking world outside North America, and were evaluated against a set of inclusion criteria including the use of validated assessment tools. Results The searches identified 29 eligible studies. Prevalences of 7.7-65.5% for anxiety, 6.0-66.5% for depression and 12.2-96.7% for psychological distress were recorded. The wide range of results reflects the variable quality of the studies. Almost all were cross-sectional and many did not mention ethical approval. Better-quality studies found lower prevalences. There was little information on the causes or consequences of depression or anxiety. Conclusions Prevalences of psychological distress amongst medical students outside North America are substantial. Future research should move on from simple cross-sectional studies to better-quality longitudinal work which can identify both predictors for and outcomes of poor mental health in medical students. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To study the drop-out rates in trials of selective serotonin and serotonin-norepinephrine reuptake inhibitors (SSRIs and SNRIs). METHODS: This study is a systematic review and meta-analysis of trials. The main outcome measure: Overall drop-out rate. Secondary outcomes were drop-outs due to adverse events and lack of effect. We obtained clinical study reports (CSRs) of five antidepressant drugs from the European Medicines Agency and the UK's Medicines and Healthcare products Regulatory Agency. The eligibility criteria for selecting studies: double-blind randomised, placebo-controlled trials for any indication. Data extraction and analysis: The primary outcome was extracted by two researchers independently and meta-analysed using the Mantel-Haenszel method (fixed effect model). The secondary outcomes were extracted by one researcher and checked by another. Sensitivity analyses were performed using Peto's odds ratio and beta binomial methods, due to presence of null events, and by excluding unreliable trials. RESULTS: We included 71 CSRs (67,319 pages) with information on 73 trials (11,057 patients on SSRI or SNRI drugs, and 7,369 on placebo). There were minor discrepancies within the CSRs when a modified intention to treat principle was used and patients lost to follow up early in the trial were not accounted for. Significantly more patients dropped out on active drug than on placebo, risk ratio 1.08 (95% CI 1.03 to 1.13), with no difference between adults and children/ adolescents, RR = 1.08 (1.03 to 1.13) and 1.07 (0.95 to 1.21), respectively. When three trials with a prior single-blind phase on active drug were removed, the difference was a risk ratio of 1.12 (1.07 to 1.18), whereas the result was the same after removal of three trials with fraudulent data or other issues with data validity, risk ratio 1.08 (1.03 to 1.13). There were more drop-outs due to adverse events on active drug than on placebo, risk ratio 2.63 (2.33 to 2.96). There were fewer drop-outs due to lack of effect, risk ratio 0.47 (0.43 to 0.53). However, this result is biased; when more people drop out due to adverse effects, fewer can drop out because of lack of effect. CONCLUSIONS: By using CSRs, we were able to demonstrate for the first time that more patients dropped out on active drug than on placebo. As it can be argued that the drop-out rate reflects the patients' overall assessment of the balance between benefits and harms, our review adds to the growing concern that SSRIs and SNRIs might not have the desired effect. Our review also highlights the importance of using CSRs for undertaking reviews of drugs. [ABSTRACT FROM AUTHOR]

Background: The Healthy Living Pharmacy (HLP) project, launched in England, UK in 2009 was a novel approach of introducing public health services within community pharmacy to tackle local health inequalities. A national roll-out followed a reported successful pilot; subsequent local evaluations ensued. Objectives: To summarise reported outcomes and investigate contextual factors that indicate the presence, absence and maturity of implementation determinants, thus offering useful lessons to stakeholders in implementing future initiatives to achieve successful outcomes. Methods: A systematic review was conducted to identify all publications reporting on the HLP project. All HLP articles and conference abstracts were considered for inclusion and were assessed for methodological quality. The Consolidated Framework for Implementation Research (CFIR) was utilised to identify potential implementation determinants reported. Each article was then analysed to identify reported economic, humanistic or clinical outcomes. Results: The review included six peer-reviewed journal articles and 12 conference abstracts. Joanna Briggs Institute Qualitative Assessment and Review Instrument indicated deficiencies in methodological quality. Through adoption of the CFIR framework, the implementation determinants relevant to the implementation of HLP into community pharmacy were identified. A resonating issue emerged in that the absence of adopting an evidence-based implementation process limited the ability to capture meaningful outcome data. This resulted in a lack of evidence to support sustainability and the failure to address many of the well cited barriers, e.g. lack of awareness amongst patients, public and other healthcare professionals, and weak support for future investment in resource for training and dissemination. Conclusions: Healthcare systems are increasingly called on to adopt evidence-based interventions that improve quality, control costs, and maximize value, thus offering opportunity to accelerate the implementation of clinical pharmacy services and programs aimed at improving patient care. Interventions, such as the HLP project require focused efforts on implementation and evaluation of those implementation efforts to produce effective and lasting changes in complex health care systems. [ABSTRACT FROM AUTHOR]

Background: ‘Paediatric bipolar disorder’ (PBD) is a controversial diagnosis where often prepubertal children as well as adolescents, who may have a range of psychiatric disorders or symptoms, are diagnosed with a severe mental illness requiring lifelong medication. Clinically, it has often been applied in the United States but rarely in most other countries. A meta‐analysis (Van Meter et al., Journal of Clinical Psychiatry, , 72, 1250) claimed that the prevalence of PBD was similar to adults at 1.8% with no difference between the United States and other countries. This conclusion has been highly cited. Methods: The heterogeneous nature of the original 12 epidemiological surveys warrants a qualitative analysis, rather than statistical meta‐analysis as performed by Van Meter et al. (Journal of Clinical Psychiatry, 2011, 72, 1250). Thus, the meta‐analysis and each of the 12 studies (six from the United States; six from other countries) were reexamined. Results: Most of the 12 surveys predated the emergence of the PBD hypothesis. The 12 surveys were mainly of adolescents and at times young adults with few prepubertal children. Prevalence rates in the 12 studies suggest a lower rate of bipolar disorder, especially in non‐US samples. For example, the Van Meter et al. (Journal of Clinical Psychiatry, 2011, 72, 1250) meta‐analysis chose a rate of 2.8% by summation of adolescent and parent responses in a Dutch survey, however the rate fell to 0% if requiring concordance of adolescent and parent responses. Indeed, it could be argued that four of the non‐US studies show 0% rates of PBD. Conclusions: Rates of PBD were generally substantially lower than 1.8%, particularly in non‐US surveys, and if both parent and adolescent reports were required to meet the diagnostic threshold they fell to close to zero. The reanalysis suggests that bipolar disorder is rare before the expected age of onset in later adolescence. [ABSTRACT FROM AUTHOR]

Background Ageing is a multifaceted and inevitable process involving a decline in health and well-being that could be ameliorated by dietary modification. We review and discuss the evidence for nutritional interventions that may support healthy ageing. Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analyses ( PRISMA) guidelines were used to identify randomised controlled trials investigating the role(s) of fatty acids and micronutrients in relation to markers of healthy ageing. Results European dietary surveys suggest that diets in elderly people are generally high in saturated fat, whereas intakes of vitamin D, magnesium, potassium, zinc and copper are below recommended levels. Thirty-four studies meeting the criteria were found, with 12 of these investigating the role of fatty acids and 22 considering intakes of micronutrients in relation to healthy ageing. Overall, these studies suggested that certain nutrients were consistent with healthy ageing; for example, omega-3 fatty acids were helpful for cognitive health, whereas combinations of calcium, vitamin D and K were linked with better bone health. Conclusions Vitamin, mineral and fatty acid intakes are in need of improvement to help elderly populations achieve optimal diet quality and support healthy ageing. This could involve the judicious use of supplements alongside dietary advice. Additional research is needed to determine optimal nutrient doses, combinations and forms in relation to desired health outcomes. [ABSTRACT FROM AUTHOR]

BackgroundThere is an increasing interest in cognitive–behavioural therapy (CBT) interventions targeting negative symptoms in schizophrenia. To date, CBT trials primarily focused on positive symptoms and investigated change in negative symptoms only as a secondary outcome. To enhance insight into factors contributing to improvement of negative symptoms, and to identify subgroups of patients that may benefit most from CBT directed at ameliorating negative symptoms, we reviewed all available evidence on these outcomes.MethodA systematic search of the literature was conducted in PsychInfo, PubMed and the Cochrane register to identify randomized controlled trials reporting on the impact of CBT interventions on negative symptoms in schizophrenia. Random-effects meta-analyses were performed on end-of-treatment, short-term and long-term changes in negative symptoms.ResultsA total of 35 publications covering 30 trials in 2312 patients, published between 1993 and 2013, were included. Our results showed studies’ pooled effect on symptom alleviation to be small [Hedges’ g = 0.093, 95% confidence interval (CI) −0.028 to 0.214, p = 0.130] and heterogeneous (Q = 73.067, degrees of freedom = 29, p < 0.001, τ2 = 0.081, I2 = 60.31) in studies with negative symptoms as a secondary outcome. Similar results were found for studies focused on negative symptom reduction (Hedges’ g = 0.157, 95% CI −0.10 to 0.409, p = 0.225). Meta-regression revealed that stronger treatment effects were associated with earlier year of publication, lower study quality and with CBT provided individually (as compared with group-based).ConclusionsThe co-occurring beneficial effect of conventional CBT on negative symptoms found in older studies was not supported by more recent studies. It is now necessary to further disentangle effective treatment ingredients of older studies in order to guide the development of future CBT interventions aimed at negative symptom reduction. [ABSTRACT FROM PUBLISHER]