Care homes play a vital role in the provision of support for the frailest members of our society, and given the demographic trends their role will continue for the foreseeable future. However, there remain enduring concerns about the quality of care such homes provide. Training and education for staff are often seen as the key to raising standards and as such are widely promoted. This paper presents a conceptual review and synthesis of the literature on the role of education and training in initiating and supporting change in care homes. A systematic method to the identification of sources was adopted, and a rigorous three-stage approach to analysis applied. The review identifies the barriers and facilitators to change and concludes that education is a necessary but not a sufficient condition for success. Rather it is argued that the role and status of care homes needs to be raised, and that a relationship-centred approach to care adopted, which acknowledges the importance of attending to the needs of all those who live in, work in, or visit care homes.

Abstract. Pandor A, Ara RM, Tumur I, Wilkinson AJ, Paisley S, Duenas A, Durrington PN, Chilcott J (University of Sheffield, Sheffield; and University of Manchester, Manchester; UK). Ezetimibe monotherapy for cholesterol lowering in 2,722 people: systematic review and meta-analysis of randomized controlled trials. J Intern Med 2009; 265: 568-580.Objectives. To study the evidence on the efficacy and safety of ezetimibe monotherapy for the treatment of primary (heterozygous familial and non-familial) hypercholesterolaemia. Design. Systematic review and meta-analysis of randomized controlled trials (RCTs).Methods. Eleven electronic bibliographic databases covering the biomedical, scientific and grey literature were searched from inception and supplemented by contact with experts in the field. Two reviewers independently determined the eligibility of RCTs, with a minimum treatment duration of 12 weeks, which compared ezetimibe monotherapy (10 mg per day) with placebo.Results. In the absence of data from clinical outcome trials, surrogate endpoints such as changes in lipid concentrations were used as indicators of clinical outcomes. A meta-analysis of eight randomized, doubleblind, placebo-controlled trials (all 12 weeks) showed that ezetimibe monotherapy was associated with a statistically significant mean reduction in LDL cholesterol (from baseline to endpoint) of )18.58%, (95% CI: )19.67 to )17.48, P < 0.00001) compared with placebo. Significant (P < 0.00001) changes were also found in total cholesterol ()13.46%, 95% CI: )14.22 to )12.70), HDL cholesterol (3.00%, 95% CI: 2.06-3.94) and triglyceride levels ()8.06%, 95% CI: )10.92 to )5.20). Ezetimibe monotherapy appeared to be well tolerated with a safety profile similar to placebo.Conclusions. In a meta-analysis restricted to short-term trials in hypercholesterolaemia, significant potentially favourable changes in lipid and lipoprotein levels relative to baseline occurred with ezetimibe monotherapy. Further long-term studies with cardiovascular and other clinical outcome data are needed to assess the efficacy and safety of ezetimibe more fully.

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The short-term RCT clinical evidence demonstrated that ezetimibe was effective in reducing LDL-c when administered as monotherapy or in combination with a statin. However, when used as a monotherapy, ezetimibe is less effective than statins in lowering LDL-c. Given the limitations in the effectiveness data, there is great uncertainty in the economic results. These suggest that ezetimibe could be a cost-effective treatment for individuals with high baseline LDL-c values, for patients with diabetes and for individuals with heterozygous familial hypercholesterolaemia. Long-term clinical outcome studies are needed to allow more precise cost-effectiveness estimates to be calculated.

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