Ruth Lewis

Risk-of-bias assessment (also known as the critical appraisal of internal validity) is a required component of systematic reviews. It evaluates how susceptible individual primary studies are to bias at the level of each effect estimate. The assessment results are then used in data synthesis, where subgroup analyses are conducted to draw overall conclusions about the effect. However, recent research has highlighted inadequate practices in risk-of-bias assessment in environmental evidence syntheses. The vast majority of these syntheses either omitted the critical appraisal step entirely or conducted it inappropriately. Additionally, there has been no standardised risk-of-bias assessment tool in the environmental sector. Although there are standardised tools in medicine, employing these tools in environmental evidence syntheses is not always appropriate. To address these issues and improve the standard of risk-of-bias assessment, we developed the first standardised risk-of-bias assessment tool in the sector: the Collaboration for Environmental Evidence Critical Appraisal Tool (environmentalevidence.org/cee-critical-appraisal-tool). Its prototype version was released in 2020, followed by real-world testing by environmental evidence synthesists, a survey to gather feedback from users, and the identification of action items for revision. All action items were addressed to produce a formal version, which this paper introduces. The tool can be used in quantitative evidence syntheses addressing causal questions in any environmental topic. It provides a standardised framework for risk-of-bias assessment, in which a study’s findings are first assessed within individual risk-of-bias criteria by answering a series of checklist questions. The results of these within-criteria assessments inform the overall judgement about risk of bias for the study’s findings. We hope that the release of this tool will lead to higher standards in risk-of-bias assessment. Future work is needed to further evaluate the tool and to create an external validity section to help evidence synthesists conduct critical appraisal of external validity objectively, comprehensively, and rigorously.

Background: Evaluating the methodological quality of primary studies is a crucial aspect of evidence syntheses, such as rapid reviews. Rapid reviews often include both randomised controlled trials (RCTs) and non-randomised studies (NRSIs) requiring multiple design-specific quality assessment tools. This can complicate workflows and reduce efficiency. Unified tools, designed to assess methodological quality across diverse study designs, may offer a more consistent and streamlined approach. This scoping review aimed to comprehensively identify and describe unified tools for assessing methodological quality across both RCTs and NRSIs. Methods: The review followed JBI scoping review methodology and was reported in line with PRISMA-ScR guidance. Searches were conducted in MEDLINE (Ovid), Embase (Ovid), and CINAHL (EBSCO) from 1998 to 2024, alongside grey literature searches, citation tracking, targeted website searches, and consultation with experts in evidence synthesis. Study selection was performed by two independent reviewers. A tool was defined as any structured instrument developed to support users in assessing methodological quality. Results: A total of 55 publications were included, identifying 29 unique unified tools. These were categorised by structure: scales ( n = 14), checklists with an additional summary judgement ( n = 7), simple checklists ( n = 5), domain-based tools ( n = 2), and other tools ( n = 1). All tools were designed to assess both RCTs and NRSIs, with many also applicable to additional study designs, including descriptive studies ( n = 15), case reports or series ( n = 9), qualitative research ( n = 7), and systematic reviews ( n = 3). Unified tools were developed using a mixture of approaches including literature reviewing ( n = 25), expert consensus ( n = 20), and stakeholder consultations ( n = 17) and pilot testing ( n = 17). Evaluation of psychometric properties was conducted to varying levels across different domains of validity and reliability. Conclusion: This review identified a diverse set of unified tools for assessing methodological quality across both RCTs and NRSIs. However, variation in tool structure, the availability of accompanying guidance, and the limited evaluation of psychometric properties, particularly inter-rater reliability and criterion validity, indicate potential issues for adoption in rapid reviews. Unified tools need further refinement and validation to be embedded in the rapid review process. Systematic review registration: https://osf.io/nyteu/

Transition from children’s social care is a complex and often challenging process, and coordination between different agencies, such as health, education, and social care, is important to ensure effective communication, engagement, and continuity of care. This review focuses on young people’s experiences with multi-agency approaches to support transition from children’s social care to adults’ social care or support, their perceptions of success of such approaches, and barriers and facilitators of implementing multi-agency approaches to transition and to young people engaging with them. This review included 22 UK studies published between 2014 and 2025. Seven of the studies focused on care leavers, six on young people with learning disabilities (LD) or special educational needs or disabilities (SEND), five on young people in the justice system, and four on other groups of young people. Many of the multi-agency initiatives primarily focused on housing support. For young people in the justice system, the initiatives mainly focused on resettlement in community. There were also studies about broader planning for support needs when the young person transitioned to adulthood.The experiences and perceived success of multi-agency working: Care leavers’ experiences of transitions varied, with some young people experiencing anxiety and distress. Perceptions of the benefits of initiatives often related to the quality of their relationship with their transition worker. Some young people said their confidence, general skills, social relationships, and mental health improved during their involvement in multi-agency initiatives. Little evidence was identified about experiences of young people with LD/SEND. For young people in the justice system, mixed experiences were described. Little information was identified about success of multi-agency work as perceived by young people. Some positive experiences with multi-agency working were also described.Barriers and facilitators of implementing multi-agency work: Barriers included insufficient resources, structural issues and policy and strategy limitations. Shared practices, priorities, and vision as well as information sharing between agencies were important. A significant practitioner-related factor was staff expertise. Barriers and facilitators of young people engaging with multi-agency work: Awareness of the services and flexibility in how young people could engage with them were important factors. More support with engagement for young people could act as a facilitator. Personal factors that might act as barriers to engagement for young people were identified. Good relationships with staff and positive staff attitudes were important facilitators.The review identified evidence gaps and a need for further robust research.

Background: Evaluating the methodological quality of primary studies is a crucial aspect of evidence syntheses, such as rapid reviews. Rapid reviews often include both randomised controlled trials (RCTs) and non-randomised studies (NRSIs) requiring multiple design-specific methodological quality assessment tools. This can complicate workflows and reduce efficiency. Unified tools, designed to assess methodological quality across diverse study designs, may offer a more consistent and streamlined approach. This scoping review aimed to comprehensively identify and describe unified tools for assessing methodological quality across both RCTs and NRSIs. Methods: The review followed JBI scoping review methodology and was reported in line with PRISMA-ScR guidance. Searches were conducted in MEDLINE (Ovid), Embase (Ovid), and CINAHL (EBSCO) from 1998 to 2024, alongside grey literature searches, citation tracking, targeted website searches, and consultation with experts in evidence synthesis. Study selection was performed by two independent reviewers. A tool was defined as any structured instrument developed to support users in assessing methodological quality. Results: A total of 55 publications were included, identifying 29 unique unified tools. These were categorized by structure: scales (n=14), checklists with judgment (n=7), simple checklists (n=5), domain-based tools (n=2), and other tools (n=1). All tools were designed to assess both RCTs and NRSIs. Of these, 13 focused exclusively on RCTs and NRSIs, while others extended to descriptive studies (n=15), case reports or series (n=9), qualitative research (n=7), and systematic reviews (n=3). Unified tools were developed using a mixture of approaches including literature reviewing (n=25), expert consensus (n=20), and stakeholder consultations (n=17). Reports of pilot testing was identified for 17 unified tools, and evaluation of psychometric properties was conducted to varying levels across different domains of validity and reliability. Conclusion: This review identified a diverse set of unified tools for assessing methodological quality across both RCTs and NRSIs. However, variation in tool structure, the availability of accompanying guidance, and the limited evaluation of psychometric properties, particularly interrater reliability and criterion validity, indicate potential issues for adoption in rapid reviews. Unified tools need further refinement and validation to be embedded in the rapid review process. Systematic review registration: https://osf.io/nyteu/

Community-based interventions are designed to address the needs of individuals living in the community, and particularly those with or at risk of frailty. Their primary aim is to support individuals to live independently in their homes. The aim of this rapid review is to identify and assess evidence on the clinical effectiveness of community-based interventions, led by nurses, for individuals with or at risk of frailty. The review includes 23 eligible studies conducted in the UK and Europe, which were published between 1984 and 2023. These studies included 16 distinct nurse-led interventions. The interventions differed considerably in factors including the procedures they used, how they were delivered and how tailored this was to individual needs, and their duration/intensity. 17 studies reported changes in activities of daily living (ADLs). One study suggested that a nurse-led rehabilitation programme for people with frailty was more likely to improve independence in personal ADLs compared to usual care. In eight studies reporting falls incidence, one study found that a nurse-led health consultation programme reduced falls incidence compared to usual care, while seven studies of other interventions found no conclusive evidence for this outcome. 13 studies reported hospital admission rates in people receiving nurse-led interventions. One study found that a nurse-led consultation programme reduced the proportion of participants experiencing hospital admissions compared to usual care, and one study found that a nurse-led surveillance programme for people with frailty was associated with fewer individuals admitted to hospital compared to usual care. We found no conclusive evidence on how any nurse-led interventions affect frailty status or progression, instrumental activities of daily living, mortality, and long-term care needs. Whilst the evidence suggests some specific types of interventions may be beneficial, the evidence is insufficient to conclude that these interventions would offer benefit if deployed. The findings could be used to explore how these interventions fit into the wider context of community care. We found no evidence suggesting that the use of nurse-led community-based interventions was detrimental when compared with usual care. Therefore, such interventions may offer added value by reducing the demand for, and/or the costs associated with, care delivered by other health care professionals. This review only studied interventions led specifically by nurses. It may be helpful to consider our findings alongside new (or existing) research into interventions delivered by wider teams of healthcare professionals.

Allied Health Professionals (AHPs) play a key role in delivering rehabilitation across Wales, but service-access and evaluation vary. To improve consistency, a national framework is being developed to measure how much care is delivered, its quality, and its impact on quality of life, wellbeing, agency, activity and participation. This review focuses on identifying the best person-reported outcome measures (PROMs) for tracking goal achievement and functional improvement. The review included evidence available up until August 2025. 101 systematic reviews, covering 19 free-of-charge PROMs with evidence of content validity, were included in the rapid evidence map (REM). The REM provides a description of the PROM’s purpose, ease of use, relevance to AHP rehabilitation, and the number of reviews that evaluated the quality and performance of the PROM - and in which populations. It does not summarise the findings. Based on the REM, eight PROMs were selected for detailed analysis. 47 reviews examined the measurement properties of these eight PROMs. The approximate time taken to complete the PROM was five minutes or less for 14 PROMs. Two PROMs had potential administration times of 60 minutes or more. The number of questions included in the PROMs ranged from one to 135. Most systematic reviews included people with general (or mixed) conditions. Many reviews in the REM included populations with neurological and neuromuscular conditions, and musculoskeletal and pain conditions. Few reviews focusing on other specific conditions were identified. Content validity, construct validity and test-retest reliability were the only measurement properties that were investigated in systematic reviews for all 19 PROMs. Face validity was reported for the fewest number of PROMs. Seven PROMs had reviews investigating all measurement properties. The eight PROMs prioritised for detailed analysis were the Goal Attainment Scale (GAS), Lawton-Brody Instrumental Activities of Daily Living (IADL), International Classification of Functioning, Disability and Health Measure of Participation and Activities Screener (IMPACT-S), Keele Assessment of Participation (KAP), Patient-Specific Functional Scale (PSFS), Reintegration to Normal Living Index (RLI/RLNI), Utrecht Scale for Evaluation of Rehabilitation – Participation (USER-P) and World Health Organization Disability Assessment Schedule version 2.0 - 12 items (WHODAS 2 -12). Most of the systematic reviews aimed to evaluate the quality and performance of the PROMs in a general population receiving rehabilitation. For each PROM, an overall quality rating was assigned for each measurement property. Four of the PROMs (GAS, IADL, IMPACT-S and RLI/RNLI) were rated as sufficient for three or more measurement properties in the general conditions category, and one PROM (PSFS) was rated as sufficient for two measurement properties in this category. GAS, IADL, IMPACT-S, PSFS, RLI/RNLI and WHODAS 2-12 also had some sufficient measurement properties in the more specific population categories. All the ratings of KAP and USER-P scales were either indeterminate, inconsistent or insufficient. GAS, IADL and RNI/RNLI were the only PROMs identified as having sufficient content validity, considered the most important measurement property as it ensures the outcome measurement instrument accurately and completely captures what it is intended to measure before other types of validity or reliability are assessed. Only GAS and PSFS had evidence of good responsiveness, a crucial property to detect change in function. We also summarise the evidence gaps in this review. While some PROMs (GAS, IADL, IMPACT-S, PSFS, RLI/RNLI and WHODAS 2-12) show promise for the planned shortlist of measures suitable for assessing rehabilitation services across Wales, the choice of PROM will also depend on other things, such as feasibility, population fit and practical considerations.

Objectives: Outward medical tourism is when people seek medical treatment in a different country to the one they live in. We aimed to identify all studies that describe the impact on the UK National Health Service (NHS) of patients who require treatment due to outward medical tourism for elective surgery and report on complications, costs and benefits. Design: A rapid literature review. Medical and grey literature databases were searched, limited to literature published between 2012 and 2024. Selection criteria: Studies published in the English language, conducted in any NHS setting, describing complications, costs or benefits due to outward medical tourism for elective surgery were included. We excluded emergency and semi-urgent surgery, dental and transplant surgery, cancer treatment and fertility treatment. Outcome measures: Primary outcomes were costs and savings to the NHS. Secondary outcomes were type and frequency, demographics, procedures, complications, treatment, follow-up care and use of NHS resources. Results were summarised narratively. Study quality was assessed using JBI critical appraisal tools and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used for certainty of evidence for costs. Results: Some 35 case series and case reports and two surveys of NHS plastic surgeons were identified. Case studies described 655 patients treated in specific NHS hospitals between 2006 and 2024 for postoperative complications due to metabolic/bariatric surgery (n=385), cosmetic (n=265) and ophthalmic (n=5) surgery tourism. No cases relating to other surgical specialities were identified in the literature. Most patients were women (90%), with an average age of 38 (range 14–69) years. The most common destination for surgery was Turkey (61%). Complications were not well described for metabolic/bariatric surgery tourism; but for cosmetic surgery tourism, infection and wound dehiscence were most commonly reported. There was evidence that some patients needed complex treatment involving long hospital stays and multiple surgical interventions. Very low certainty evidence indicated that costs to the NHS from outward medical tourism for elective surgery ranged from £1058 to £19 549 per patient in 2024 prices. We found no studies that reported on the benefits of outward medical tourism. Conclusions: A systematic approach is needed to collecting information on the number of people who travel abroad for elective surgery and the frequency and impact on the UK NHS of treating complications. Without these data, we cannot fully understand the risk of seeking surgery abroad.

This review examines international evidence on how changes to active travel infrastructure affect disabled people. It explores the impact of infrastructure changes on accessibility and identifies the barriers and facilitators experienced by disabled people. The review included 11 primary research studies and 8 reviews published between 2015 and July 2025. Populations represented across the studies included: People with visual impairments; People with mobility impairments; Neurodivergent people; People with mobility, hearing, or vision impairments; People with mobility, hearing, vision impairments and neurodivergence; People using mobility assistive devices; and older adults with motor, visual, hearing impairments, or orientation difficulties. Design changes to bus stop infrastructure, were consistently associated with reduced accessibility, subjective feelings of safety, and confidence among disabled people getting on and off buses. Uneven pavements and surface defects reduced perceived safety and confidence for people with visual and mobility impairments, with tactile paving aiding navigation for blind users but creating instability for mobility aid users. The review also describes the impact of kerb level changes, continuous footways, low traffic neighbourhoods, barrier removal, and the development of shared spaces. Raised trapezoidal designs were most effective in providing clear, detectable boundaries and supporting confidence among visually impaired users. Some design features, such as kerb-free layouts, clear tactile paving, and well-marked crossings, acted as facilitators that improved accessibility, perceived safety, and confidence, while other features introduced barriers. Some barriers were consistent across all disability groups, whereas others were impairment-specific. Vehicles parked on pavements created barriers to navigation for neurodivergent people and blocked movement for guide dog users. Tactile paving aided navigation for people with visual impairments but was perceived to create a barrier to wheelchair stability, whereas kerb removal reduced barriers for wheelchair users but created orientation barriers for people with visual impairments. Meeting conflicting accessibility needs of different groups of disabled people can be challenging when planning and implementing change in active travel infrastructure. Inconsistent infrastructure designs across different spaces and regions can create confusion among disabled people and lead to them feeling unsafe or potentially being directed to harm’s way.

Background: Older adults make up the largest proportion of nonusers of the internet. With the increasing digitalization of services, it is important to identify what interventions are effective at reducing digital exclusion in older adults. Objective: We aimed to identify what evidence exists on the effectiveness of interventions to address digital exclusion in older adults. Methods: This rapid review assessed the effectiveness of interventions to address digital exclusion in older adults aged 60 years or older. Searches were conducted in November 2023 across a range of databases and used supplementary search methods. Searches were limited to comparative studies published from 2018 onward in English. Data were analyzed using a narrative synthesis approach. Results: A total of 21 studies were included that aimed to increase a range of digital literacy skills. Sample sizes ranged from 5 to 381. Intervention approaches varied considerably and were often multicomponent and undertaken in a variety of settings. There is evidence to suggest that a range of interventions can reduce physical, personal, and perceptual barriers and improve older adults’ skills, knowledge, digital literacy, and perceived self-efficacy, reduce technophobia, and increase use of technology. Importantly, findings indicated improvements among a range of subpopulations, including those living in rural areas, at risk of social isolation, who are homebound, of lower socioeconomic groups, and individuals with visual impairment. To achieve improved and sustained digital inclusion in older adults, evidence suggests it may be important to ensure structural barriers, such as access to the internet and affordability of devices, are removed. However, all studies contained methodological limitations and may not be adequately powered to determine effectiveness. Conclusions: The evidence shows the potential benefits of interventions aimed at improving a range of digital skills and increasing technology use in older adults, which could help to address digital exclusion. The findings of this rapid review can inform the development and delivery of future interventions. However, it is important to consider the context in which the included interventions were used and the lack of certainty of the findings. This review also identified a lack of high-quality evidence, as all studies identified contained methodological limitations and may not have been adequately powered to determine effectiveness. In addition, consideration should also be given to those who do not wish to engage with the online world to ensure they are not left behind.

Methods of economic evaluation, such as Cost-Effectiveness Analysis (CEA), and approaches to Value Based Health Care (VBHC) are both being used in Wales, UK. They have similar goals in terms of maximising benefit as described by costs and outcomes. However, these approaches serve separate aims and fulfil different needs in healthcare delivery. The aim of this review was to contrast, and where possible describe, the complementarity of CEA and VBHC approaches to maximising value to healthcare systems. The objective was to review published literature contrasting these approaches in terms of their aims, perspectives of analysis, mathematical approach, and strengths and limitations. Given that these two approaches are being used in Wales, we were interested in the most appropriate positioning of these approaches across the landscape of decision-making from Welsh Government down to seven health boards across Wales. The review was informed by input from health economists, VBHC leaders, and Welsh Government stakeholders, although no direct comparisons within the Welsh system were made. The review included evidence published between January 2004 and January 2024. Database searches were conducted on 10th January 2024. The study found that both CEA and VBHC aim to maximise value in healthcare; however, these approaches differ in their specific definitions of value and in their applications. An augmented approach to economic evaluation highlights multiple elements of value, showing how traditional CEA and broader value-based perspectives can complement each other to capture both efficiency and patient-centred outcomes.Most of the papers identified in this review have come from authors from US research institutions and therefore caution is required when considering the applicability of the findings to the UK healthcare system. The VBHC framework adopted in the UK focuses on improving patient outcomes relative to fixed and constrained resource use. More work is required to make the connection between CEA and VBHC approaches when developing policy initiatives that promote efficiency and equity. Open discussions among clinicians, researchers and policy-makers are required around the need for broader frameworks that capture the dynamic nature of value to present the changing preferences of individual patients and society over time. Further research is also needed to explore recent refinements or alternatives to the traditional cost per QALY framework.