Maxwell S. Barnish

Objectives: To identify and map health-related services and interventions that support Armed Forces transitioning to veteran status, and to synthesise evidence on their potential effectiveness. Design: Scoping review. Data sources: Medline (Ovid), Embase (Ovid), APA PsycInfo (Ovid), Cochrane (Wiley), Web of Science (Clarivate), ASSIA (ProQuest) and PTSD Pubs (Proquest), citation chasing and web searches. Participants: Armed Forces members, veterans, family members and service providers from the UK, Europe, Canada, Australia or New Zealand. Interventions: Health-related services and interventions intended to support military to civilian transition. Primary and secondary outcome measures: Health and wellbeing outcomes (eg, mental health symptoms, quality of life), broader transition-related outcomes (eg, employment, housing, social connection), acceptability, barriers and facilitators to intervention or service engagement. Analytical methods: Tabulation and narrative synthesis (using thematic analysis for qualitative studies). Results: Thirty-four unique studies were included, reporting data on 10 040 veterans and transitioning service personnel. Twenty-two distinct interventions were identified and grouped into five categories: (1) art-based, (2) sport or outdoor-based, (3) peer- or group-based, (4) employment, skills or education training and (5) digital technology interventions. Most evidence originated from the UK, with additional studies from Canada, Australia, New Zealand and Israel. While no critical appraisal of study quality was performed within this review, quantitative evaluations suggested benefits for mental health, wellbeing and reintegration outcomes for some intervention types; however, evidence was heterogeneous and variable in outcome measurement. Qualitative evidence highlighted value in social connection, identity and purpose, and identified barriers related to awareness, access, acceptability and the need for tailored provision. Conclusions: A diverse range of services and interventions are available to support transition to civilian life, but the strength and consistency of the evidence varied considerably, meaning findings should be interpreted as identifying potentially valuable approaches rather than established best practices. Future research should prioritise robust evaluation designs, consistent outcome reporting and attention to implementation and equity. Service planners may benefit from improved signposting and better integration across health, social care and third-sector pathways to support veterans during transition. Study registration: Zenodo record 17630661.

Objectives: To assess the evidence for a benefit of music-based therapies (MBTs) on rehabilitation outcomes in adults with multiple sclerosis (MS). Setting: Scholarly literature (published in English) from any country. This systematic review received no specific funding and was registered on PROSPERO as CRD420251083656. Data sources: Six bibliographic databases: AMED (Ebsco), APA PsycINFO (Ovid), CINAHL (Ebsco), Cochrane CENTRAL, EMBASE (Ovid) and MEDLINE (Ovid), plus supplementary searches and citation chasing (search date July 2025). Primary and secondary outcome measures: Eligible studies used a clinical trial or controlled quantitative observational study design to assess the benefit of MBTs on rehabilitation outcomes in adults with MS. Risk of bias was assessed using Critical Appraisal Skills Programme checklists. Data were synthesised using narrative synthesis. Results: 23 studies were included (955 participants, of whom 880 people had MS and 691 received MBTs). The most frequently assessed outcome was motor function (16 studies), followed by quality of life (12 studies). Evidence suggests potential benefits for MBTs, particularly rhythmic auditory stimulation and music-cued motor imagery, on gait and mobility outcomes, including walking speed, walking distance, cadence, stride length and gait symmetry. Findings for other outcomes were less clear. Conclusions: MBTs may benefit people with MS, with the most consistent evidence observed for gait and mobility outcomes. However, heterogeneity in intervention type, study design and outcome measurement limits the strength of conclusions. Higher-quality, adequately powered trials with standardised outcomes and direct comparisons between MBTs are needed to clarify effectiveness and inform clinical implementation. PROSPERO registration number: CRD420251083656.

Background: The National Institute for Health and Care Excellence is piloting a new approach to evaluating health technologies, which takes into consideration the full treatment pathway for a condition. This report describes the first pilot topic for the pathways process, which evaluated systemic treatments for advanced renal cell carcinoma. Objectives: This pilot aimed to develop a decision model representing the treatment pathway that will be used to evaluate new technologies for advanced renal cell carcinoma. The pilot also evaluated a new treatment for renal cell carcinoma: cabozantinib (Cabometyx®; Ipsen, Slough, UK) plus nivolumab (Opdivo®; Bristol Myers Squibb, Princeton, NJ, USA). Review methods: A systematic literature review was conducted to identify evidence to inform effectiveness, safety and economic model development, including systematic literature reviews, randomised controlled trials, economic evaluations, utility studies and cost and resource use data. Real-world evidence was sought following the recommendations of the National Institute for Health and Care Excellence real-world evidence framework. Structured expert elicitation informed assumptions about overall survival and progression-free survival. Network meta-analyses were conducted to evaluate the clinical effectiveness of treatments. A de novo state transition model that was constructed with a partitioned survival analysis structure was also presented. The cost perspective of the model was that of the National Health Service and Personal Social Services; the time horizon was 40 years, costs and outcomes were discounted at 3.5% per annum and a 2022 price year was used. The model allowed sequences of up to four active lines of treatment. Information sources: The review included 118 systematic literature reviews, 30 randomised controlled trials, 122 economic evaluations, 82 studies reporting utility data and 13 studies reporting cost and/or resource use data. A total of 21 real-world evidence sources were identified. Unpublished data were provided by the manufacturer and other stakeholders (competitor companies, patient and clinical organisations). The expert elicitation recruited nine United Kingdom-based oncologists. Results: Cabozantinib plus nivolumab was associated with better progression-free survival and overall survival than existing tyrosine kinase inhibitors as first-line treatment in the all-risk group. Using the list price of the evaluated interventions, the incremental cost-effectiveness ratio for cabozantinib plus nivolumab compared to the next non-dominated tyrosine kinase inhibitor monotherapy (pazopanib [Votrient®; Novartis, Slough, UK]) was £275,106 per quality-adjusted life-year in the all-risk population and was £379,222 in the favourable-risk population. Incremental cost-effectiveness ratios were relatively consistent across the base-case and scenario analyses. In the intermediate-/poor-risk population, the incremental cost-effectiveness ratio for pembrolizumab (Keytruda®; Merck Sharp & Dohme, London, UK) plus lenvatinib (Lenvima®; Eisai, Hatfield, UK) was £450,638 compared to cabozantinib; cabozantinib plus nivolumab and nivolumab plus ipilimumab were both dominated by cabozantinib and pazopanib monotherapy, respectively, in the base-case analysis. Quality-adjusted life-year gains were similar for cabozantinib plus nivolumab, pembrolizumab plus lenvatinib and nivolumab plus ipilimumab (Yervoy®; Bristol-Myers Squibb, Princeton, NJ, USA). Cabozantinib plus nivolumab was shown to be less effective and less expensive than pembrolizumab plus lenvatinib in most scenarios. Limitations: Most interventions were supported by only one trial and data quality was poor. Outcomes reported in clinical trials were generally more favourable than those reported in real-world evidence, suggesting that trials may overestimate treatment benefits. Conclusions: This pilot demonstrated the feasibility of producing a reference model, which is open source and available to relevant stakeholders without restriction. This will improve consistency in the National Institute for Health and Care Excellence’s decision-making and allow for the evaluation of optimum treatment sequences for advanced renal cell carcinoma. Future work: Future research is needed to resolve uncertainties in clinical effectiveness estimates for treatments for advanced renal cell carcinoma, including long-term effectiveness of combination treatments and their effectiveness in the favourable-risk subgroup. This would also inform further evaluation of optimal treatment sequences for advanced renal cell carcinoma. This evaluation included the use of confidential data, including commercially sensitive data provided by the manufacturers of treatments for renal cell carcinoma. Where feasible, references to confidential data have been removed from this monograph. Any remaining instances of confidential data have been redacted. Study registration: A final review protocol was submitted to National Institute for Health and Care Excellence in advance. Due to confidentiality issues surrounding the analysis plan, this was not deposited with PROSPERO. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: NIHR136008) and is published in full in Health Technology Assessment ; Vol. 30, No. 1. See the NIHR Funding and Awards website for further award information.

The National Institute for Health and Care Excellence (NICE) early value assessment (EVA) was launched in 2022 as a process to assess new technologies that have the potential to meet an unmet need or demand. The recommendations that result from the process are best viewed as a type of managed entry agreement – that is, time-limited and conditional on further evidence being generated. This commentary, from authors in PenTAG (an external assessment group involved in assessing medical technologies for NICE, based at the University of Exeter), explores the challenges that have arisen during 3 years of performing EVAs, offers some thoughts on EVA’s role in evidence generation, and their fit in NICE’s wider evidence landscape. The commentary identifies areas for potential improvement in terms of timelines, scoping and protocol development, searching, reviewing, and economic modeling. Many of the suggested changes are relatively minor tweaks to the process, or requests for clearer guidance or expectation management. We conclude that, with some changes to the EVA process and its accompanying guidance, the assessments could become more efficient. In summary, the EVA represents NICE’s life cycle approach in their HealthTech program, wherein evidence is collected along the life cycle to help monitor initial assumptions and recommendations made. The process is designed to continuously capture incremental innovation over the lifetime of a medical device. As such, EVAs reflect a small but important shift in how health technology assessment is practiced.

Objectives: To assess the evidence for active group-based performing arts interventions for people with Parkinson’s disease (PD). Setting: Scholarly literature (published in English) from any country or countries (last search February 2025). This systematic review was not registered and received no funding. Data sources: Five bibliographic databases: AMED (Ebsco), APA PsycINFO (Ovid), CINAHL (Ebsco), EMBASE (Ovid) and MEDLINE (Ovid), plus supplementary searches. Primary and secondary outcome measures: Eligible studies used a quantitative design to assess the benefit of active group-based performing arts interventions on quality of life, functional communication, speech, motor function and cognitive status in PD. The risk of bias was assessed using the SURE, University of York Centre for Reviews and Dissemination and Newcastle-Ottawa Scale checklists. Data were synthesised using narrative synthesis and random-effects meta-analysis. Results: A total of 94 studies were included: 2453 people with PD (mean age 68 years, 55% male) from 18 countries. Narrative synthesis supported nine combinations of performing arts modalities and outcome domains, including a benefit for dance on motor function (supported by 50 out of 54 studies), dance on quality of life (supported by 24 out of 37 studies) and singing on speech (supported by 17 out of 20 studies). Meta-analysis supported five combinations of performing art modalities, comparators and outcomes, including a clinically significant benefit for PD-specific dance versus usual care PDQ-39, MD −7.81, 95% CI −11.87 to −3.75 and tango-based dance versus usual care on UPDRS-III, MD −9.89, 95% CI −16.65 to −3.13. Conclusions: Evidence from both the narrative synthesis and the meta-analysis supports a benefit for some combinations of performing arts modalities and outcomes. Limitations of the evidence base included differences in comparators and outcomes, heterogeneity, lack of control arms and male underrepresentation. Future studies should compare the effectiveness of different performing arts modalities, assess functional communication and consider clinical significance.

Objectives This systematic review examined the potential benefit of all group-based performing arts interventions for primary anxiety and/or depression. Setting Scholarly literature from any country or countries globally. Data sources Three key bibliographic databases, Google Scholar and relevant citation chasing. Primary and secondary outcome measures Depression and/or anxiety symptom severity, well-being, quality of life, functional communication or social participation. Results Database searches returned a total of 63 678 records, of which 56 059 remained following dededuplication. From these database searches, a total of 153 records proceeded to full-text screening. These were supplemented by 18 additional unique full-text screening records from Google Scholar searches and citation chasing (12% of total). From a total of 171 records at the full-text screening stage, 12 publications (7%) were eligible for inclusion in this systematic review, each reporting on a separate study. Published from 2004 to 2021, these studies involved a total of 669 participants with anxiety and/or depression from nine countries and covered five broad artistic modalities: dance, music therapy, art therapy, martial arts and theatre. Dance was the most studied artistic modality (five studies), while there were three studies on art therapy, two on music therapy and one each on martial arts and theatre. The evidence was clearest for a benefit of arts therapies on depression and/or anxiety symptoms. Conclusions This systematic review addresses all group-based active arts interventions in a focused population of primary anxiety and/or depression. The evidence suggests that the arts may be a useful therapeutic medium in this population. However, a substantial limitation of the evidence base is the lack of studies directly comparing different artistic modalities. Moreover, not all artistic modalities were assessed for all outcome domains. Therefore, it is not currently possible to determine which artistic modalities are most beneficial for which specific outcomes.

Introduction: Computer simulation games are increasingly being used in agriculture as a promising tool to study, support and influence real-life farming practices. We explored the potential of using simulation games to engage with sheep farmers on the ongoing challenge of reducing lameness. Working with UK stakeholders, we developed a game in which players are challenged with identifying all the lame sheep in a simulated flock. Here, we evaluate the game’s potential to act as a tool for to help assess, train and understand farmers’ ability to recognise the early signs of lameness. Methods: Participants in the UK were invited to play the game in an online study, sharing with us their in-game scores alongside information relating to their real-life farming experience, how they played the game, and feedback on the game. Mixed methods were used to analyse this information in order to evaluate the game. Quantitative analyses consisted of linear modelling to test for statistical relationships between participants’ in-game recall (% of the total number of lame sheep that were marked as lame), and the additional information they provided. Qualitative analyses of participants’ feedback on the game consisted of thematic analysis and a Likert Scale questionnaire to contextualise the quantitative results and identify additional insights from the study. Results: Quantitative analyses identified no relationships between participants’ (n = 63) recall scores and their real life farming experience, or the lameness signs they looked for when playing the game. The only relationship identified was a relationship between participants’ recall score and time spent playing the game. Qualitative analyses identified that participants did not find the game sufficiently realistic or engaging, though several enjoyed playing it and saw potential for future development. Qualitative analyses also identified several interesting and less-expected insights about real-life lameness recognition practices that participants shared after playing the game. Discussion: Simulation games have potential as a tool in livestock husbandry education and research, but achieving the desired levels of realism and/or engagingness may be an obstacle to realising this. Future research should explore this potential further, aided by larger budgets and closer collaboration with farmers, stockpeople and veterinarians.

Background: Conceptual and theoretical links between politics and public health are longstanding. Internationally comparative systematic review evidence has shown links between four key political exposures – the welfare state, political tradition, democracy and globalisation – on population health outcomes. However, the pathways through which these influences may operate have not been systematically appraised. Therefore, focusing on child and maternal health outcomes, we present a realist re-analysis of the dataset from a recent systematic review.Methods: The database from a recent systematic review on the political determinants of health was used as the data source for this realist review. Included studies from the systematic review were re-evaluated and those relating to child and/or maternal health outcomes were included in the realist synthesis. Initial programme theories were generated through realist engagement with the prior systematic review. These programme theories were adjudicated and refined through detailed engagement with the evidence base using a realist re-synthesis involving two independent reviewers. The revised theories that best corresponded to the evidence base formed the final programme theories.Results: Out of the 176 included studies from the systematic review, a total of 67 included child and/or maternal health outcomes and were included in the realist re-analysis. Sixty-three of these studies were ecological and data were collected between 1950 and 2014. Six initial programme theories were generated. Following theory adjudication, three theories in revised form were supported and formed the final programme theories. These related to a more generous welfare state leading to better child and maternal health especially in developed countries through progressive social welfare policies, left-of-centre political tradition leading to lower child mortality and low birth weight especially in developed countries through greater focus on welfare measures, and increased globalisation leading to greater child and infant mortality and youth smoking rates in LMECs through greater influence of multinational corporations and neoliberal trade organisations.Conclusion: We present a realist re-analysis of a large systematically identified body of evidence on how four key political exposures – the welfare state, democracy, political tradition and globalisation – relate to child and maternal health outcomes. Three final programme theories were supported.

Background: Parkinson’s disease (PD) is a common neurodegenerative condition associated with a wide range of motor and non-motor symptoms. There has been increasing interest in the potential benefit of performing arts as a therapeutic medium in PD. While there have been previous reviews, none have considered all performing arts modalities and most have focused on dance. This systematic review examined the potential benefit of all active group-based performing arts interventions for quality of life, functional communication, speech, motor function and cognitive status. Methods: Searches were conducted in February 2020 on five scholarly databases. Supplementary searches were conducted. Included studies were quantitative in design, and assessed the potential benefit of any active group-based performing arts intervention for quality of life, functional communication, speech, motor function or cognitive status in people with PD. Full text papers were eligible for inclusion, as were conference abstracts since January 2018. Screening, data extraction, narrative synthesis and quality assessment were conducted independently by two reviewers. Quality assessment used the SURE checklists. Results: Fifty-six studies were eligible for inclusion in this systematic review, reported in 67 publications. Published from 1989 to 2020, these studies included a total of 1531 people with PD from 12 countries, and covered four broad performing arts modalities: dance, singing, music therapy and theatre. Dance remains the most commonly studied performing arts modality for PD (38 studies), while there were 12 studies on singing interventions, four on music therapy, and only two on theatrical interventions. There was evidence for a beneficial effect of all four performing arts modalities on at least some outcome domains. Conclusions: This is the first systematic review to assess the potential benefit of all active group-based performing arts interventions in PD. The evidence suggests that performing arts may be a useful therapeutic medium in PD. However, a substantial limitation of the evidence base is that no studies compared interventions from different performing arts modalities. Moreover, not all performing arts modalities were assessed for all outcome domains. Therefore it is not currently possible to determine which performing arts modalities are most beneficial for which specific outcomes.