Debra Fayter

Population tobacco control interventions and their effects on social inequalities in smoking: systematic review

Objective: To assess the effects of population tobacco control interventions on social inequalities in smoking. Data sources: Medical, nursing, psychological, social science and grey literature databases, bibliographies, hand-searches and contact with authors. Study selection: Studies were included (n = 84) if they reported the effects of any population-level tobacco control intervention on smoking behaviour or attitudes in individuals or groups with different demographic or socioeconomic characteristics. Data extraction: Data extraction and quality assessment for each study were conducted by one reviewer and checked by a second. Data synthesis: Data were synthesised using graphical (“harvest plot”) and narrative methods. No strong evidence of differential effects was found for smoking restrictions in workplaces and public places, although those in higher occupational groups may be more likely to change their attitudes or behaviour. Smoking restrictions in schools may be more effective in girls. Restrictions on sales to minors may be more effective in girls and younger children. Increasing the price of tobacco products may be more effective in reducing smoking among lower-income adults and those in manual occupations, although there was also some evidence to suggest that adults with higher levels of education may be more price-sensitive. Young people aged under 25 are also affected by price increases, with some evidence that boys and non-white young people may be more sensitive to price. Conclusions: Population-level tobacco control interventions have the potential to benefit more disadvantaged groups and thereby contribute to reducing health inequalities.

A systematic review of photodynamic therapy in the treatment of pre-cancerous skin conditions, Barrett's oesophagus and cancers of the biliary tract, brain, head and neck, lung, oesophagus and skin

BACKGROUND Photodynamic therapy (PDT) is the use of a light-sensitive drug, in combination with light of a visible wavelength, to destroy target cells. PDT is used either as a primary treatment or as an adjunctive treatment. It is fairly well accepted in clinical practice for some types of skin cancer but has yet to be fully explored as a treatment for other forms of cancer. OBJECTIVE To systematically review the clinical effectiveness and safety of PDT in the treatment of Barretts oesophagus, pre-cancerous skin conditions and the following cancers: biliary tract, brain, head and neck, lung, oesophageal and skin. DATA SOURCES The search strategy included searching electronic databases (between August and October 2008), followed by update searches in May 2009, along with relevant bibliographies, existing reviews, conference abstracts and contact with experts in the field. STUDY DESIGNS Randomised controlled trials (RCTs) in skin conditions and Barretts oesophagus, non-randomised trials for all other sites. PARTICIPANTS People with Barretts oesophagus, pre-cancerous skin conditions or primary cancer in the following sites: biliary tract, brain, head and neck, lung, oesophageal and skin. INTERVENTION Any type of PDT for either curative or palliative treatment. COMPARATORS Any comparator including differing applications of PDT treatments (relevant comparators varied according to the condition). MAIN OUTCOMES The outcomes measured were mortality, morbidity, quality of life, adverse events and resource use. REVIEW METHODS A standardised data extraction form was used. The quality of RCTs and non-randomised controlled studies was assessed using standard checklists. Data extracted from the studies were tabulated and discussed in a narrative synthesis, and the influence of study quality on results was discussed. Meta-analysis was used to estimate a summary measure of effect on relevant outcomes, with assessment of both clinical and statistical heterogeneity. Two reviewers independently screened all titles and abstracts, and data extracted and quality assessed the trials, with discrepancies resolved by discussion or referral to a third reviewer. A scoping review was also undertaken. RESULTS Overall, 88 trials reported in 141 publications were included, with some trials covering more than one condition. For actinic keratosis (AK), the only clear evidence of effectiveness was that PDT appeared to be superior to placebo. For Bowens disease, better outcomes with PDT were suggested when compared with cryotherapy or fluorouracil. For basal cell carcinoma (BCC), PDT may result in similar lesion response rates to surgery or cryotherapy but with better cosmetic outcomes. For nodular lesions, PDT appeared to be superior to placebo and less effective than surgery but suggestive of better cosmetic outcome. For Barretts oesophagus, PDT in addition to omeprazole appeared to be more effective than omeprazole alone at long-term ablation of high-grade dysplasia and slowing/preventing progression to cancer. No firm conclusions could be drawn for PDT in oesophageal cancer. Further research into the role of PDT in lung cancer is needed. For cholangiocarcinoma, PDT may improve survival when compared with stenting alone. There was limited evidence on PDT for brain cancer and cancers of the head and neck. A wide variety of photosensitisers were used and, overall, no serious adverse effects were linked to PDT. LIMITATIONS There were few well-conducted, adequately powered RCTs, and quality of life (QoL) and resource outcomes were under-reported. Problems were identified with reporting of key study features and quality parameters, making the reliability of some studies uncertain. Methodological limitations and gaps in the evidence base made it difficult to draw firm conclusions. CONCLUSIONS Evidence of effectiveness was found for PDT in the treatment of AK and nodular BCC in relation to placebo, and possibly for treating Barretts oesophagus. However, the effectiveness of PDT in relation to other treatments is not yet apparent. High-quality trials are needed to compare PDT with relevant comparators for all meaningful outcomes, including QoL and adverse effects. Further research is also needed on patient experience of PDT, as well as on the cost-effectiveness of PDT.

Acupuncture and other physical treatments for the relief of pain due to osteoarthritis of the knee: network meta-analysis.

Summary Objective To compare the effectiveness of acupuncture with other relevant physical treatments for alleviating pain due to knee osteoarthritis. Design Systematic review with network meta-analysis, to allow comparison of treatments within a coherent framework. Comprehensive searches were undertaken up to January 2013 to identify randomised controlled trials in patients with osteoarthritis of the knee, which reported pain. Results Of 156 eligible studies, 114 trials (covering 22 treatments and 9,709 patients) provided data suitable for analysis. Most trials studied short-term effects and many were classed as being of poor quality with high risk of bias, commonly associated with lack of blinding (which was sometimes impossible to achieve). End of treatment results showed that eight interventions: interferential therapy, acupuncture, TENS, pulsed electrical stimulation, balneotherapy, aerobic exercise, sham acupuncture, and muscle-strengthening exercise produced a statistically significant reduction in pain when compared with standard care. In a sensitivity analysis of satisfactory and good quality studies, most studies were of acupuncture (11 trials) or muscle-strengthening exercise (9 trials); both interventions were statistically significantly better than standard care, with acupuncture being statistically significantly better than muscle-strengthening exercise (standardised mean difference: 0.49, 95% credible interval 0.00–0.98). Conclusions As a summary of the current available research, the network meta-analysis results indicate that acupuncture can be considered as one of the more effective physical treatments for alleviating osteoarthritis knee pain in the short-term. However, much of the evidence in this area of research is of poor quality, meaning there is uncertainty about the efficacy of many physical treatments.

Increasing participation of cancer patients in randomised controlled trials: a systematic review

BackgroundThere are many barriers to patient participation in randomised controlled trials of cancer treatments. To increase participation in trials, strategies need to be identified to overcome these barriers. Our aim was to assess the effectiveness of interventions to overcome barriers to patient participation in randomised controlled trials (RCTs) of cancer treatments.MethodsA systematic review was conducted. Published and unpublished studies in any language were searched for in fifteen electronic databases, including MEDLINE, EMBASE, CINAHL and PsycINFO, from inception to the end of 2004.Studies of any interventions to improve cancer patient participation in RCTs, which reported the change in recruitment rates, were eligible for inclusion. RCTs and non-randomised controlled trials as well as before and after studies reporting baseline rates specific to the population being investigated were included. Data were extracted by one reviewer into structured summary tables and checked for accuracy by a second reviewer. Each included study was assessed against a checklist for methodological quality by one reviewer and checked by a second reviewer. A narrative synthesis was conducted.ResultsEight studies were identified that met the inclusion criteria: three RCTs, two non-randomised controlled trials and three observational studies. Six of the studies had an intervention that had some relevance to the UK. There was no robust evidence that any of the interventions investigated led to an increase in cancer patient participation in RCTs, though one good quality RCT found that urologists and nurses were equally effective at recruiting participants to a treatment trial for prostate cancer. Although there was no evidence of an effect in any of the studies, the evidence was not of sufficient quality to be able to conclude that these interventions therefore do not work.ConclusionThere is not a strong evidence-base for interventions that increase cancer patient participation in randomised trials. Further research is required to evaluate the effectiveness of strategies to increase participation in cancer treatment trials.

Childhood obesity: should primary school children be routinely screened? A systematic review and discussion of the evidence

Background: Population monitoring has been introduced in UK primary schools in an effort to track the growing obesity epidemic. It has been argued that parents should be informed of their child’s results, but is there evidence that moving from monitoring to screening would be effective? We describe what is known about the effectiveness of monitoring and screening for overweight and obesity in primary school children and highlight areas where evidence is lacking and research should be prioritised. Design: Systematic review with discussion of evidence gaps and future research. Data sources: Published and unpublished studies (any language) from electronic databases (inception to July 2005), clinical experts, Primary Care Trusts and Strategic Health Authorities, and reference lists of retrieved studies. Review methods: We included any study that evaluated measures of overweight and obesity as part of a population-level assessment and excluded studies whose primary outcome measure was prevalence. Results: There were no trials assessing the effectiveness of monitoring or screening for overweight and obesity. Studies focussed on the diagnostic accuracy of measurements. Information on the attitudes of children, parents and health professionals to monitoring was extremely sparse. Conclusions: Our review found a lack of data on the potential impact of population monitoring or screening for obesity and more research is indicated. Identification of effective weight reduction strategies for children and clarification of the role of preventative measures are priorities. It is difficult to see how screening to identify individual children can be justified without effective interventions.

An emerging evidence base for PET-CT in the management of childhood rhabdomyosarcoma: systematic review

Introduction Rhabdomyosarcoma (RMS) management depends on risk stratification at diagnosis and treatment response. Assessment methods include CT, MRI, bone scintigraphy, histological analysis and bone marrow biopsy. Advanced functional imaging (FI) has potential to improve staging accuracy and management strategies. Methods and analysis We conducted a systematic review (PROSPERO 2013:CRD42013006128) of diagnostic accuracy and clinical effectiveness of FI in histologically proven paediatric RMS. PRISMA guidance was followed. We searched 10 databases to November 2013. Studies with ≥10 patients with RMS which compared positron emission tomography (PET), PET-CT or diffusion-weighted imaging (DWI) MRI to conventional imaging at any treatment stage were included. Study quality was assessed. Limited, heterogeneous effectiveness data required narrative synthesis, illustrated by plotting sensitivity and specificity in receiver operating curve (ROC) space. Results Eight studies (six PET-CT, two PET) with 272 RMS patients in total were included. No DWI-MRI studies met inclusion criteria. Pooled estimates were not calculated due to sparseness of data. Limited evidence indicated initial PET-CT results were predictive of survival. PET-CT changed management of 7/40 patients. Nodal involvement PET-CT: sensitivity ranged from 80% to 100%; specificity from 89% to 100%. Distant metastatic involvement: PET-CT sensitivity ranged from 95% to 100%; specificity from 80% to100%. Data on metastases in different sites were sparse. Limited data were found on outcome prediction by PET-CT response. Dissemination and ethics PET/PET-CT may increase initial staging accuracy in paediatric RMS, specifically in the detection of nodal involvement and distant metastatic spread. There is a need to further assess PET-CT for this population, ideally in a representative, unbiased and transparently selected cohort of patients.

Interventions for reducing alcohol consumption among general hospital inpatient heavy alcohol users: a systematic review

BACKGROUND There is growing interest in pro-active detection and provision of interventions for heavy alcohol use in the general hospital inpatient population. We aimed to determine, from the available evidence, the effectiveness of interventions in reducing alcohol consumption among general hospital inpatient heavy alcohol users. METHODS The following databases were searched for completed and on-going randomised and non-randomised controlled studies published up to November 2012: MEDLINE; C2-SPECTR; CINAHL; The Cochrane Library; Conference Proceedings Citation Index: Science; EMBASE; HMIC; PsycInfo; Public Health Interventions Cost Effectiveness Database (PHICED); and ClinicalTrials.gov. Studies were screened independently by two reviewers. Data extraction was performed by one reviewer and independently checked by a second. RESULTS Twenty-two studies which met the inclusion criteria enrolled 5307 participants in total. All interventions were non-pharmacological and alcohol focused. Results from single session brief interventions and self-help literature showed no clear benefit on alcohol consumption outcomes, with indications of benefit from some studies but not others. However, results suggest brief interventions of more than one session could be beneficial on reducing alcohol consumption, especially for non-dependent patients. No active intervention was found superior over another on alcohol consumption and other outcomes. CONCLUSIONS Brief interventions of more than one session could be beneficial on reducing alcohol consumption among hospital inpatients, especially for non-dependent patients. However, additional evidence is still needed before more definitive conclusions can be reached.

Effectiveness and cost-effectiveness of height screening programmes during the primary school years: a systematic review

Objective: To determine the effectiveness and cost-effectiveness of height screening (of children aged 4 to 11) to identify height-related conditions. Design: Systematic review and economic modelling. Setting and intervention: We included published and unpublished screening studies of any design, except case reports, conducted in any setting that measured children’s height as part of a population-level assessment. Studies were identified by electronic database searches, contact with experts and from bibliographies of retrieved studies. Participants: Children aged between 4 and 11 years. Outcome measures: Diagnostic yield of height-related conditions and change in quality of life, as measured by quality-adjusted life years (QALYs), for early versus late treatment of underlying conditions. Results: Twelve studies described a height-screening programme and provided data on the diagnostic yield of newly diagnosed height-related conditions. Where reported, yield for growth-hormone deficiency (per 1000 children screened) ranged from 0.05 (1 in 20 000) to 0.62 (approximately 1 in 1500) and for Turner syndrome (per 1000 children screened) was between 0.02 (1 in 50 000) and 0.07 (approximately 1 in 14 000). As a secondary gain, children with other potentially treatable conditions were identified; diagnostic yields ranged from 0.22 to 1.84 per 1000 children screened. Three studies did not detect any new cases, but all of these studies had methodological limitations. Economic modelling suggested that height screening is associated with health improvements and is cost effective for a willingness to pay threshold of £30 000 per QALY. Conclusions: This review indicates the utility and acceptable cost-effectiveness of height screening arising from increased detection of height-related disorders and secondary pick-up of other undiagnosed conditions. Further research is needed to obtain more reliable data on quality of life gains and costs associated with early interventions for height-related conditions. The exact role of height-screening programmes in improving child health remains to be determined.

Growth monitoring for short stature: update of a systematic review and economic model.

OBJECTIVES The aim of the project was to compare different screening rules and/or referral cut-offs for the identification of children with disorders of short stature. We undertook an update of a previous systematic review and economic model that addressed the same question. DATA SOURCES Sources searched included MEDLINE, EMBASE, Science Citation Index, Social Science Citation Index, Conference Proceedings Citation Index - Science/Social Science & Humanities, Cochrane Library 2009 Issue 4, Office of Health Economics Health Economic Evaluations Database, and the NHS Economic Evaluation Database. REVIEW METHODS The review was conducted as an update to our previous assessment in 2007. Searching covered January 2005 to November 2009 with no language or publication restrictions. Two reviewers examined full papers for relevance. Data extraction was conducted by one reviewer and independently checked by a second. In addition, searches were conducted to identify quality of life or utility papers to inform the economic evaluation. We developed a probabilistic decision analytic model to estimate the costs and quality-adjusted life-year (QALY) gains from the perspective of the UK NHS and personal social services. The model was a cohort model, assuming a homogeneous population of 5-year-olds at baseline. RESULTS One study was included in the systematic review. The study was not UK based, but had been identified in the brief as relevant to the UK setting. The studys authors examined the performance of a number of rules to determine sensitivity and specificity of referral for short stature in four patient groups and three reference groups in the Netherlands. They derived an algorithm for referral based on the optimal rules. No new studies were located that provided appropriate quality of life or utilities data for the economic model. The model was based on the previous assessment which was updated to better reflect current UK clinical practice. We compared two alternative monitoring strategies, one of which was based on the study identified in our systematic review (Grote strategy); the other was based on UK consensus (UK strategy). We identified that the UK strategy was the least effective and least costly, with a mean gain of 0.001 QALYs at a mean cost of £21. The Grote strategy was both more expensive and more effective, with a mean cost of £68 and a mean QALY gain of 0.042. The incremental cost-effectiveness ratio was £1144 per QALY gained. CONCLUSIONS This assessment contributes further knowledge, but does not provide definitive answers on how to deliver growth monitoring. In particular, we were unable to ascertain current practice in the UK for growth screening. Further, we were unable to evaluate through the use of identified studies and modelling an optimal referral cut-off and age at which to screen. We identified a number of research questions that would further inform referral strategies, which in summary would involve further primary and secondary data collection. FUNDING The National Institute for Health Research Health Technology Assessment programme.

Interventions for alcohol and drug problems in outpatient settings: a systematic review.

ISSUES Research evidence indicates a high prevalence of substance abuse among patients presenting in general hospital settings. Such misuse of alcohol and illicit drugs has a major impact on population health and on costs to health services and to society at large. This review aimed to identify the interventions for alcohol or illicit drug misuse problems that have been evaluated for hospital outpatient populations. APPROACH Thirteen electronic databases including MEDLINE, EMBASE and PsycInfo were searched for published and unpublished studies in any language up to August 2011. Reference lists of included studies and reviews were also hand-searched. We included randomised and controlled clinical trials of any intervention for adult participants identified as having alcohol and/or drug problems presenting to hospital outpatient settings other than addiction or psychiatric units. Participants could be attending hospital for any reason other than treatment for substance abuse. A narrative synthesis was conducted. KEY FINDINGS There is some evidence to suggest that interventions based on motivational techniques might be effective in treatment of alcohol misuse in oral-maxillofacial clinics but not in general outpatient departments. The evidence is insufficient to allow any conclusions to be derived on the effectiveness of interventions in the treatment of drug misuse and combined alcohol-drug misuse in outpatient settings. CONCLUSIONS Further research is needed to investigate interventions for alcohol and drug misuse in outpatient settings. Additionally, problems remain in terms of study quality. Procedures to ensure the rigour of a study were often poorly reported.