Rare diseases are diseases which affect fewer than 1 in 2000 people. The England 2023 Rare Disease Action Plan is committed to addressing health inequities associated with rare diseases, i.e. systematic, avoidable and unfair differences in health between the rare disease community and the general population, or between different rare diseases communities. This commitment builds on the UK Rare Diseases Framework, which sets out four priorities including: ensuring patients get the right diagnosis faster; increasing awareness of rare diseases among healthcare professionals; better coordination of care; and improving access to specialist care, treatments and drugs.

Although there is evidence that health inequity is experienced by specific groups within the rare disease community, there is no overall understanding of the extent of the evidence across the rare disease community. This includes whether there is evidence of health inequity within the rare disease community, and also between the rare disease community and the general population. We have been commissioned by the NIHR Policy Research Programme to identify and summarise evidence on health inequities experienced by the rare disease community, with a specific focus on inequities related to receipt of a diagnosis or access to health and social care services. We will fulfil this aim by carrying out a scoping review which will systematically identify and describe the available evidence which addresses our research aim. In particular, we will draw out findings relevant to the UK context. The project is being carried out in response to a request for evidence in this area by the UK Department of Health and Social Care (DHSC) Rare Diseases and Emerging Therapies policy team.

We began the project in February 2024 and expect the work to take several months, depending on how many studies we identify for inclusion in the review. We plan to write up the findings in a report which will be submitted to the Rare Diseases and Emerging Therapies policy team.

The protocol for this project can be found here: http://hdl.handle.net/10871/135276

In 2008, the Climate Change Act set national targets for the reduction of carbon emissions in England. The National Health Service (NHS) has an important role to help achieve these targets, as the organisation accounts for 4% of England’s carbon-footprint. The Exeter PRP Evidence Review Facility have been asked by the government Greener NHS team from NHS England to carry out a systematic review looking at different ways the NHS could reduce its carbon emissions.

This systematic review will bring together existing research which evaluates how well strategies such as waste management, online clinics and using different surgical techniques work to reduce carbon-emissions. We are particularly interested in strategies delivered in secondary-healthcare settings, such as hospitals or clinics. We will separate the research we find into groups to analyse and report them. These groups will be based on the type of strategy being tested and/or where it is delivered. We will summarise the main messages from each group of research and consider how the quality of the research may affect how it can be used to inform future research, clinical practice and government policy.

We began the project in June 2023 and expect the work to take about 7.5 months if all members of the team work on it full-time. We plan to write-up our findings in a report which we will give to people in the Greener NHS team. We aim to work closely with people working in the NHS and members of the public to make sense of our findings and decide how best to share them.

The protocol can be found here: https://ore.exeter.ac.uk/repository/handle/10871/133658

Hearing loss is prevalent across the world, including in the UK. The negative effects of hearing loss on quality of life are associated with socio-economic inequalities, including more limited employment opportunities and social isolation. Furthermore, risk factors for hearing loss are stratified by socio-economic inequalities, such as working in noisy environments, and due to some population sub-groups’ low take up of hearing screening programmes, including ethnic minorities. We were asked to identify risk factors for hearing loss and to describe how they are related to socio-economic inequalities. This could help with more effectively targeted hearing screening programmes.

Status: Complete

Background: In the UK, 12 million adults live with hearing loss greater than 25 dBHL, or one in five adults. This includes more than 40% of people over 50 years old, rising to more than 70 percent over the age of 70. Hearing loss is often associated with socio-economic inequalities, including more limited employment opportunities and social isolation. Furthermore, risk factors for hearing loss are stratified by socio-economic inequalities, such as working in noisy environments and smoking, and due to some population sub-groups’ low take up of hearing screening programmes, such as ethnic minorities. Improving the identification of groups at risk of hearing loss could lead to more effectively targeted screening programmes, and alleviate harms which are associated with socio-economic inequalities.

Aims of our project: We were asked to identify risk factors for hearing loss and to describe how they are related to socio-economic inequalities. To this end, our project included the following two objectives:

1. To create an annotated bibliography of systematic reviews which evaluate potential risk factors for hearing loss.
2. To describe how the identified risk factors within individual systematic reviews are related to socio-economic inequalities wherever relevant data are reported.

What did we do? We carried out a systematic search for systematic reviews on risk factors for hearing loss and presented the findings as an annotated bibliography. This involved searching a selection of bibliographic databases for relevant systematic reviews, and using supplementary search methods including checking the reference lists of relevant systematic reviews, and searching topically relevant websites. Identified records were independently screened by two reviewers using pre-defined inclusion criteria. This included a five-year historical date limit (2018-to date of search, 2022). Full-texts of relevant records were sought and screened in the same way.

We used a bespoke data-extraction form to extract relevant data on risk factors for hearing loss and socio-economic inequalities from the included systematic reviews. The PROGRESS-Plus checklist was used to identify socio-economic inequalities. Risk factors for hearing loss were categorised as physiological, behavioural, demographic or environmental. Key characteristics of relevant systematic reviews were tabulated. In addition, we produced an annotated list of systematic reviews organised by type of risk factor, including a brief summary of socio-economic inequalities reported in each systematic review where relevant. Some types of systematic review, including scoping reviews, were listed but not annotated, as their findings were not synthesised.

What did we find? We identified 64 systematic reviews (including scoping reviews) which evaluated potential risk factors for hearing loss published 2018 to date of search. Of these, 50 were included in the annotated list. This included 35 systematic reviews relating to physiological risk factors, including four which addressed socio-economic inequalities. Two systematic reviews considered behavioural risk factors, including one which addressed socio-economic inequalities. Six systematic reviews considered demographic risk factors, including five which addressed socio-economic inequalities. Seven systematic reviews considered environmental risk factors, including three which addressed socio-economic inequalities.

Overall, a minority of systematic reviews addressed factors associated with socio-economic inequalities. The most commonly addressed socio-economic inequality was gender (n=8 reviews), followed by occupation (n=4 reviews) and personal characteristics, mainly age (n=3 reviews).

Plans for sharing our findings: The final report is available on the University of Exeter Open Repository. We have also written a follow up paper which addresses the finding that only a minority of systematic reviews reported data relating to socio-economic inequalities. Given that the systematic reviews were published in the last five years, we found this finding surprising in view of recent efforts to encourage more reporting of socio-economic inequalities, such as the PRISMA-Equity statement. Our follow up paper has involved retrieving the primary studies included in a sub-sample of the most recently published systematic reviews, and assessing whether more data associated with socio-economic inequalities was reported in the primary studies than was subsequently reported in the systematic reviews. We hope to be able to share this paper as a published journal article in the near future.

Status: Complete

Background
Key stakeholders, including bereaved families and public figures, are calling for a process that investigates historically unresolved cases of suspected National Health Service (NHS) care failures, going back as far as 20 years or more. Consequently, the Department of Health and Social Care (DHSC) is keen to understand options for a proportionate, time-limited, mechanism to address those cases where legitimate questions or grievances remain, and it is in the public interest to do so.

Creating a system to address unresolved historical patient safety cases in the NHS is a complex issue.  These cases have often been subject to multiple reviews, but families feel that justice has not yet been achieved and remain traumatised and angry. Ministers have considered these calls to “establish a process that addresses unresolved cases, aimed at providing truth, justice and reconciliation, to address the concerns of patients, families and staff affected”.  They have concluded that, rather than establish a process or separate inquiry, the need to investigate such cases should be considered on a case-by-case basis and that the DHSC should commission a review to understand and how to address this issue from the perspective of achieving resolution and/or reconciliation for individuals and/or their families who have experienced a medical adverse event. This gives rise to the following policy questions:

• What are the issues for the health system to consider on how to respond on a case-by-case basis to historical patient safety cases?
• How can the way the health system currently supports and responds to bereaved families, particularly those whose cases are historic (non-recent), be improved?

To address these questions, we first need to understand how the current investigation process is experienced and the features that seem to lead to perceptions of “truth, justice and/or reconciliation” among those affected.

Research Questions:

1. What aspects of the processes and outcomes of redress and reconciliation following a life changing event lead the individual and/or family to feel that they were/were not treated fairly and appropriately?  
2. How do these perceptions vary over time following the initial event?

What we did
We conducted a systematic review of qualitative evidence to improve understanding of the processes and outcomes of redress and reconciliation following a life-changing event from the perspectives of individuals experiencing the event and their families. This is with a view to developing a framework or typology to help the Department of Health and Social Care identify historical patient cases for which management has been perceived to be procedurally unjust and for which some further intervention might be indicated.

Our review protocol was prospectively registered on PROSPERO. The methods used to conduct and report the findings of this review were consistent with the best practice approach for the conduct of systematic reviews and reporting of qualitative evidence synthesis.

We sought primary studies about individuals who have experienced a life-changing event and/or family or carers seeking justice on behalf of the person who experienced the event regarding their experiences and/or views of redress and reconciliation processes following this event. Studies were conducted in high-income countries and the redress process occurred within health/social care systems, child protection or sudden death investigations, homicide reviews or any other service or professional context identified by our searches where findings could provide useful insights for the health care context. No limits to the age of participants or date of publication were set.

Potentially relevant studies were found through searching bibliographic databases with search terms derived from relevant journal articles identified in our scoping searches. This search strategy was supplemented with forward citation searches, backwards citation chasing and targeted bibliographic database searches. To identify grey literature, we searched Google Scholar and topically relevant websites.

We appraised the quality of all studies prioritised for inclusion in the framework synthesis using the Wallace Checklist (2004). Studies were prioritised on the basis of their relevance to the health field. A sample of studies from outside of the health field were included in the synthesis if they provided data to support weaker subthemes.

We used NVivio software to synthesise the prioritised studies using a ‘Best-Fit’ framework synthesis approach based on the work of Daniels and Sabin (1997;1998; 2000), which highlight key aspects of a procedurally fair redress-reconciliation process. This framework was revised in a series of stages, using a process of iterative coding to ensure the final themes and subthemes best represented the extracted data.

We worked alongside a variety of stakeholders and advisors to ensure our findings reflect the needs of individuals who will use them, including representatives from the DHSC and two individuals with lived experience of medically life-changing events.

What did we find?

Overview
Fifty-three studies (61 papers) met the criteria for inclusion in this review. The types of life-changing event included in these papers included medical(n=31), homicide(n=5), work-related death(n=4), suicide(n=3), missing person (n=1), death in police custody/following contact with police(n=3) and child sexual abuse (CSA)(n=6).

Forty-one studies (47 papers) were included in the synthesis. None of these studies reported experiences of individuals who were still actively seeking justice following a non-recent, or “historical”, medical event. All of the studies representing the views of individuals seeking redress and reconciliation following a medically life-changing event were included in the synthesis. Other life-changing events represented within the synthesis included homicide (n=3), CSA (n=2), employment/work-related death (n=2), death in custody (n=1) and suicide (n=2). The majority of these studies scored positively on at least 8 of the 14 items on the Wallace checklist (range 2 to 13).

Main findings
Four themes were identified by the framework synthesis; 1) Transparency, 2) Person-centred, 3) Trustworthy and 4) Restorative justice.

The three themes ‘Transparency’, ‘Person-centred’ and ‘Trustworthy’ represent the procedural elements of redress-reconciliation which should be established to support a fair and objective process. The elements within these three themes are interdependent with each another, with each element influencing others within the redress-reconciliation process. For example, it is likely that if the process is conducted using a person-centred approach that this will increase the transparency and trustworthiness of the process.

If the redress-reconciliation process is conducted in a way which is consistent with the procedural elements identified by this synthesis, it may support the development of a supportive, empathic relationship between justice-seekers and individuals seen as responsible for the harm. This relationship may support those seeking redress and reconciliation to develop a coherent narrative about the trauma they have lived. This presents the opportunity for justice-seekers to express their emotions whilst telling their own story and receive acknowledgement for the hurt they have experienced. During this process, those seeking redress and reconciliation can be supported to take part in action which gives meaning to their loss. The combination of experience arising from a humanising process and the opportunity to develop a cathartic narrative and participate in meaningful action provides the foundation for the final theme, ‘Restorative justice’ which encapsulates how a fair process feels to those who have experienced a life-changing event.

It is within the context of the humanising and cathartic relationship between these stakeholders that the procedural elements of the redress and reconciliation process can be worked through, the harm and the impact on the individual can be explored, meaningful outcomes agreed upon and the emotional impact diffused, as people accept what has happened and learn how to incorporate the consequences of the event into their lives going forward. Thus, we propose that a fair process is dependent on both its procedural elements and the quality of the relationship developed between the different stakeholders. The latter has important implications for how those seeking redress reconciliations are made to feel, the extent to which they feel heard, and the degree to which their experiences can inform the process. This in turn can influence how fair they perceive the redress and reconciliation process and its outcomes to be.

We then considered how the key elements identified by the framework synthesis could be applied retrospectively to appraise if those seeking redress and reconciliation following a historical medical life-changing event have experienced a fair process. Thirteen elements of a fair redress and reconciliation process which could be applied to historical life-changing events were identified:

1. Opportunity to develop a comprehensive account of the life-changing event and redress-reconciliation process
2. Key information made available
3. Joint reflection on systemic factors which may have influenced the redress-reconciliation process
4. Assessment of needs and provision of ongoing support
5. An apology
6. Identification and implementation of points of learning
7. Achievement of other meaningful outcomes
8. Access to a reasonable and consistent process
9. Mechanisms in place to support the challenge of institutional accounts and/or decisions made
10. Opportunity for objective oversight or input
11. Opportunity to meet those perceived to be responsible for harm
12. Validation of experiences
13. Meaningful action for those who have experienced harm

What are the implications?

The features of a fair redress and reconciliation process support professionals involved with the investigation/inquest system to establish if those seeking redress-reconciliation following both a recent or historical medically life-changing event have experienced a fair process, or not.

Our findings may help patients and/or their families who are seeking redress-reconciliation know what to expect in terms of a fair process and could be used to help them articulate their needs at different stages throughout their journey.

It would be useful to establish to what extent the findings of this review reflect the experiences and needs of patients and families seeking redress and reconciliation following a historical medical event. This could be achieved through sharing the findings of this review with a greater number of individuals who have experienced medical harm, or other individuals, groups and organisations who represent them. Alternatively, a separate work of qualitative primary research could be commissioned to explore the experiences and needs of this group, with particular emphasis on their reflections on the need for a clear rationale for decisions made and their views on the resources available to support them to challenge findings/processes or resolve disputes.

Once work has been completed to validate the findings of this review, primary research to evaluate the extent to which existing structures and processes utilised within the NHS to promote redress-reconciliation reflect the components of the fair process as outlined within this report could be beneficial. This would provide insight into whether the processes currently being used are perceived as fair, with a view to reducing the number of people whose needs remain unmet for prolonged periods of time.

This review and any subsequent primary research have the potential for identifying areas in current practice which are not meeting the needs of people seeking redress and reconciliation and where changes need to be made. Some of these changes may initially be challenging to incorporate into the procedure-based systems used within healthcare settings and by other organisations supporting the redress-reconciliation process. Thus, further research regarding the most effective way to implement any proposed changes may be beneficial.

To see the protocol for this review, please click here.

Please click here to see the final report. We have also produced a Briefing paper and Illustration.

The aging UK population accompanied by the removal of default retirement age and increased prevalence of chronic conditions means there is an increased demand for workforce based support to enable individuals to continue their productive working lives for as long as they choose.  Occupational Health (OH) services have been identified as being key to ensuring that workplaces meet the physical and mental health needs of their employees.  Understanding the relative effectiveness of OH delivered interventions on return-to work outcomes, including intervention content and delivery mechanisms, will help inform the needs of those commissioning future OH services.  Whilst there is an abundance of systematic review evidence which seeks to evaluate single and multi-component OH interventions which aim to improve work and employment based outcomes, it is difficult to identify which aspects of the content and/or delivery of these interventions may be associated with success. In February 2021, we were asked to review the effectiveness and cost-effectiveness systematic review evidence that evaluates multi-disciplinary OH interventions aiming to improve work outcomes including return to work and reduced sickness absence.

Status: Complete

Background: In the UK, tens of millions of working days are lost due to work-related ill health every year, costing billions of pounds. Prior to the COVID-19 pandemic, around 8 million working-age people were registered disabled and about half of these were in employment.

The role of Occupational Health (OH) services is vital in helping workers to maintain employment when they encounter injury or illness. Part of this role is to advise on prevention of illness and injury at work, but a large part of it is to manage the recovery, rehabilitation and return to work (RTW) of sick-listed employees. The combination of an ageing population, increasing levels of chronic illness, mental health difficulties and disability, and the removal of the default retirement age, means that the demand for occupational health (OH) services is ever increasing.

OH providers traditionally rely on a clinical workforce to deliver these services, particularly doctors and nurses with OH qualifications. However, the increasing demand for OH services is unlikely to be met in future using this traditional model, as the number of OH-trained doctors and nurses in the UK is declining. Experts suggest multi-disciplinary models of OH delivery, including a more varied range of healthcare and non-healthcare professionals, can be highly effective. Moving to a more multidisciplinary workforce could also enable OH market capacity to significantly increase to meet new demand with less reliance on OH-trained doctors and nurses.

There is a therefore a pressing need to identify effective collaborative models of occupational health service delivery that involve a variety of healthcare and non-healthcare professionals.

Aims of our project: To review the effectiveness and cost-effectiveness systematic review evidence that evaluates multi-disciplinary OH interventions aiming to improve work outcomes including return to work and reduced sickness absence.

Research question:

1. What multi-disciplinary delivery models for OH services are effective, and for whom?
2. What are the characteristics of effective multi-disciplinary delivery models for OH?
3. Which multi-disciplinary models of OH service delivery are cost-effective?

What did we do?

We carried out systematic searches to identify, critically appraise, and narratively summarise systematic review evidence regarding:

1. The effectiveness of multi-disciplinary interventions intended to improve work outcomes following illness or injury, such as return to work and reduced sickness absence;
2. The cost-effectiveness of multi-disciplinary interventions intended to improve work outcomes following illness or injury.

We sought systematic reviews about adults (16 or over) in employment who have had absence or are absent from work for any medical reason and were receiving an intervention to get them back to work or help them retain work. Interventions needed to be multi-disciplinary (including professionals from different backgrounds in clinical and non-clinical professions) and designed to support employees and employers to manage health conditions in the workplace and/or to help employees with health conditions retain work and/or return to work following medical absence. Effectiveness needed to be measured in terms of return to work, work retention or measures of absence, or economic evaluation outcomes.

We worked alongside a variety of stakeholders and advisors to ensure our umbrella review reflects the needs of individuals who will use it. Stakeholders included commissioners and policy makers from DHSC and DWP, OH personnel and people with lived experience of accessing OH services themselves and/or supporting employees to access OH services.

What did we find?

We identified 89 systematic reviews that contained relevant interventions which involved a variety of professionals and the workplace, and which measured effectiveness in terms of RTW. Of these, we focused on the 24 where the population and intervention characteristics within the systematic reviews were the most relevant to our research questions. The 24 reviews were of varying quality, split evenly between High/Moderate quality and Low/Critically Low-quality ratings.

We mapped these 24 reviews in an evidence and gap map providing a visual representation of the evidence. Due to the heterogeneity of the interventions included within the systematic reviews, we were unable to structure the map according to the different types of intervention being evaluated. Instead, using the evidence and gap map, it is possible to view i) the quality and quantity of systematic review evidence for a given health condition, ii) how the review authors rated the effectiveness or cost-effectiveness of the interventions included. Furthermore, by navigating the evidence and gap map, one can see the relevant primary studies within each review.

Our umbrella review provides the first point of reference for interventions under the broad remit of multidisciplinary OH services involving the workplace, across any health condition leading to sick leave. However, the body of systematic review evidence about multidisciplinary models of OH services is highly heterogeneous in terms of intervention, health condition, size and quality and we were unable to draw conclusions about the relative effectiveness of different interventions across health conditions from this body of evidence.

Plans for sharing our findings: The final report is available on the University of Exeter Open Repository. We will share the report and Briefing Paper with the Occupational Health Teams who formed part of our project advisory group and other OH colleagues via social media. Please follow us on Twitter for updates.

Several recent reports have found that women do not feel listened to either by clinicians or at the system level when discussing health care concerns. Some women perceive that they are treated dismissively and that their symptoms are not taken seriously. Reports that have investigated how the health and social care system listens as a whole have also found that women have been disproportionately affected. In June 2021, we were asked to review the evidence on on primary care clinicians’ views on listening to and, more broadly, interacting with female patients, including with specific groups of female patients such as BAME, LGBTQ, older/younger and disabled women.

Status: Complete

Background: Evidence suggests that women do not feel listened to by primary care clinicians when discussing their health care concerns. In particular, women perceive that they are treated dismissively and that their symptoms are not taken seriously. What is less clear is why this occurs and in what circumstances, or indeed to what extent primary care clinicians perceive that there are problems around listening to women patients.

Aims of our project: We were asked to carry out a scoping review of evidence relating to primary care clinicians’ views on listening to and, more broadly, interacting with women patients. We focused on primary care clinicians’ views on listening to and interacting with women patients with gynaecological conditions or symptoms suggestive of gynaecological conditions, as background reading and survey data suggested that this was a particular area of concern for women patients.

Research questions:

1. What evidence is there about primary care clinicians’ perspectives on interacting with patients with gynaecological conditions or symptoms suggestive of gynaecological conditions?
2. What key themes have been raised about challenges of interacting with patients with gynaecological conditions or symptoms suggestive of gynaecological conditions?

What did we do? We developed and carried out searches for relevant studies using bibliographic databases and a variety of supplementary search methods. The search results were screened against pre-defined inclusion and exclusion criteria. In order to present and summarise the findings of the identified studies, we selected an ‘index paper’ to provide the initial framework against which findings of the other papers were coded. In addition, an interpretive discussion was written with a focus on how the findings might relate to the issues of listening to and communicating with women. Stakeholder engagement involved meetings with primary care clinicians to discuss their perspectives on interacting with women patients with gynaecological conditions or symptoms suggestive of gynaecological conditions.  

What did we find? Twenty-three papers, from 18 unique studies, were included in the qualitative scoping review. These covered clinicians’ experiences with diagnosing and managing endometriosis, menopause, menorrhagia, polycystic ovary syndrome, chronic pelvic pain, infertility disease, menstrual disorders and premenstrual symptoms. Issues relating to listening to and interacting with women patients with gynaecological conditions or symptoms suggestive of gynaecological conditions were organised under four thematic ‘levels’:

• the individual clinician;
• structural and organisational factors;
• community and external factors; and
• factors specific to gynaecological conditions and symptoms.

Plans for sharing our findings:The final report is available on the University of Exeter Open Respository. We have also produced a briefing paper and submitted a paper for peer reviewed publication. Please visit our blog and follow us on Twitter for updates.

Evidence suggests that both the prescribing of statins and the taking of prescribed statins are not at optimal levels.  There is also evidence that many patients take drugs that cause dependency beyond the short periods for which they are licensed.  Furthermore, addiction to DCD is a priority area for reform, with a required focus on prescribing (and de-prescribing) practices.  In order to achieve optimal prescribing, it is essential to first understand the factors influencing the prescription and taking of drugs throughout the patient pathway. Scoping of the literature in this area reveals an array of systematic reviews covering aspects of the overarching topic of interest.  Prior to conducting further research, there is a need to clarify the state of the evidence in the area.

In April 2020, we were asked to map the quantitative and qualitative systematic review evidence available to inform the optimal prescribing of statins, anti-hypertensives and drugs which can cause dependency (DCD) and the point at which this evidence could be used to inform decision making in the patient care pathway for each type of medication.

Status: Complete

Background: Evidence suggests the prescribing and taking of, or adherence to, certain types of medication is not at optimal levels. This review focused on two areas of challenge:

• the under-prescribing and poor adherence to medications to prevent cardiovascular disease (CVD), specifically statins and antihypertensives, and
• the over-prescribing of drugs that may cause dependency (DCD, which includes opioids, benzodiazepines, gabapentinoids and non-benzodiazepine hypnotics) and antidepressants.

Scoping of the evidence base revealed an abundance of relevant primary research and evidence syntheses.  

Aims of our project:  We, therefore, aimed to identify, categorise and map the existing systematic review evidence, identifying both abundant and scarce areas of research.

Research question: What is known about how to achieve optimal prescribing of statins, anti-hypertensives and drugs which may cause dependency from the perspectives of patients and their families, prescribers, policy makers and other relevant professionals within the health care system?

What did we do? Systematic reviews published since 2010 were sought from bibliographic databases, websites and author contact and included if they brought together quantitative and/or qualitative evidence on:

• The effectiveness or experiences of interventions intended to improve prescribing practices or patient adherence;
• The effectiveness or experiences of interventions intended to improve implementation of interventions intended to improve prescribing practices or patient adherence;
• Practitioner views or perceptions of making prescribing decisions;
• Guidelines intended to inform prescribing practise.

We worked with members of the public and clinical stakeholders to construct patient care pathways from the decision to access care through to the decision to maintain or discontinue medication.  Initially, the care pathways were based on NICE guidance for prescribing of relevant medication of interest (statins, anti-hypertensives, antidepressants), as well as NICE guidelines for optimal prescribing and shared decision making, but we also incorporated evidence from other publications and guidelines as well existing research which explored the patient experience of taking some of the medications of interest.  We used the care pathways to structure the evidence and gap map.

Systematic reviews which met our eligiblity criteria were organised within an evidence and gap map according to the medication of interest and the relevance to the patient care pathway.

For a more detailed description of our methods please see the protocol.

What did we find?

One hundred and thirty systematic reviews met the eligibility criteria for inclusion in the evidence-gap map.

The evidence and gap map highlights the available quantitative and qualitative systematic review evidence to inform the optimal prescribing of DCD, antidepressants, statins and antihypertensive medication. The map summarises key characteristics of these systematic reviews and identifies areas where no, or low-quality systematic reviews have been conducted. These gaps highlight areas which may benefit from further searches to identify if any primary research exists, which could be combined within further evidence synthesis. Consultation with policy and commissioning stakeholders is required to confirm in which areas further evidence syntheses or primary research could best inform government policy.

Below we provide links to two versions of the evidence and gap map which displays systematic review evidence which met the inclusion criteria for this review.  The first displays systematic reviews which met our inclusion criteria according to which part of the patient-care pathway they may inform regarding the prescription of drugs which may cause dependency or prevent cardiovascular disease. This pathway was informed by NICE guidelines on prescribing these medications, a qualitative evidence synthesis exploring patient experiences of taking medication and consultation with patients and members of the public with experience of taking one or more of the medications of interest: https://eppi.ioe.ac.uk/CMS/Portals/35/EGM%20University%20of%20Exeter%20July%202021.html

The second version of the evidence and gap map presents the included systematic reviews within a condensed version of this pathway, as requested by our government stakeholders:
https://eppi.ioe.ac.uk/CMS/Portals/35/EGM%20University%20of%20Exeter%20August%202021.html

Plans for sharing our findings:

The final report is available on the University of Exeter Open Respository and the Briefing Paper can be found here. We have a published journal article which can be found here with a further paper under peer review. Please follow us on Twitter for updates.