Showing papers in "BMJ in 2000"
TL;DR: The proposed cut off points, which are less arbitrary and more internationally based than current alternatives, should help to provide internationally comparable prevalence rates of overweight and obesity in children.
Abstract: Objective To develop an internationally acceptable definition of child overweight and obesity, specifying the measurement, the reference population, and the age and sex specific cut off points. Design International survey of six large nationally representative cross sectional growth studies. Setting Brazil, Great Britain, Hong Kong, the Netherlands, Singapore, and the United States. Subjects 97 876 males and 94 851 females from birth to 25 years of age. Main outcome measure Body mass index (weight/height 2 ). Results For each of the surveys, centile curves were drawn that at age 18 years passed through the widely used cut off points of 25 and 30 kg/m 2 for adult overweight and obesity. The resulting curves were averaged to provide age and sex specific cut off points from 2›18 years. Conclusions The proposed cut off points, which are less arbitrary and more internationally based than current alternatives, should help to provide internationally comparable prevalence rates of overweight and obesity in children.
14,792 citations
TL;DR: In patients with type 2 diabetes the risk of diabetic complications was strongly associated with previous hyperglycaemia, with the lowest risk being in those with HbA1c values in the normal range (<6.0%).
Abstract: Objective: To determine the relation between exposure to glycaemia over time and the risk of macrovascular or microvascular complications in patients with type 2 diabetes. Design: Prospective observational study. Setting: 23 hospital based clinics in England, Scotland, and Northern Ireland. Participants: 4585 white, Asian Indian, and Afro-Caribbean UKPDS patients, whether randomised or not to treatment, were included in analyses of incidence; of these, 3642 were included in analyses of relative risk. Outcome measures: Primary predefined aggregate clinical outcomes: any end point or deaths related to diabetes and all cause mortality. Secondary aggregate outcomes: myocardial infarction, stroke, amputation (including death from peripheral vascular disease), and microvascular disease (predominantly retinal photo-coagulation). Single end points: non-fatal heart failure and cataract extraction. Risk reduction associated with a 1% reduction in updated mean HbA 1c adjusted for possible confounders at diagnosis of diabetes. Results: The incidence of clinical complications was significantly associated with glycaemia. Each 1% reduction in updated mean HbA 1c was associated with reductions in risk of 21% for any end point related to diabetes (95% confidence interval 17% to 24%, P Conclusions: In patients with type 2 diabetes the risk of diabetic complications was strongly associated with previous hyperglycaemia. Any reduction in HbA 1c is likely to reduce the risk of complications, with the lowest risk being in those with HbA 1c values in the normal range (
8,102 citations
TL;DR: Qualitative research produces large amounts of textual data in the form of transcripts and observational fieldnotes, and the systematic and rigorous preparation and analysis of these data is time consuming and labour intensive.
Abstract: This is the second in a series of three articles
Contrary to popular perception, qualitative research can produce vast amounts of data. These may include verbatim notes or transcribed recordings of interviews or focus groups, jotted notes and more detailed “fieldnotes” of observational research, a diary or chronological account, and the researcher's reflective notes made during the research. These data are not necessarily small scale: transcribing a typical single interview takes several hours and can generate 20–40 pages of single spaced text. Transcripts and notes are the raw data of the research. They provide a descriptive record of the research, but they cannot provide explanations. The researcher has to make sense of the data by sifting and interpreting them.
#### Summary points
Qualitative research produces large amounts of textual data in the form of transcripts and observational fieldnotes
The systematic and rigorous preparation and analysis of these data is time consuming and labour intensive
Data analysis often takes place alongside data collection to allow questions to be refined and new avenues of inquiry to develop
Textual data are typically explored inductively using content analysis to generate categories and explanations; software packages can help with analysis but should not be viewed as short cuts to rigorous and systematic analysis
High quality analysis of qualitative data depends on the skill, vision, and integrity of the researcher; it should not be left to the novice
In much qualitative research the analytical process begins during data collection as the data already gathered are analysed and shape the ongoing data collection. This sequential analysis1 or interim analysis2 has the advantage of allowing the researcher to go back and refine questions, develop hypotheses, and pursue emerging avenues of inquiry in further depth. Crucially, it also enables the researcher to look for deviant or negative cases; that is, …
7,637 citations
TL;DR: The longstanding and widespread tradition of the person approach focuses on the unsafe acts—errors and procedural violations—of people at the sharp end: nurses, physicians, surgeons, anaesthetists, pharmacists, and the like.
Abstract: The longstanding and widespread tradition of the person approach focuses on the unsafe acts—errors and procedural violations—of people at the sharp end: nurses, physicians, surgeons, anaesthetists, pharmacists, and the like. It views these unsafe acts as arising primarily from aberrant mental processes such as forgetfulness, inattention, poor motivation, carelessness, negligence, and recklessness. Naturally enough, the associated countermeasures are directed mainly at reducing unwanted variability in human behaviour. These methods include poster campaigns that appeal to people’s sense of fear, writing another procedure (or adding to existing ones), disciplinary measures, threat of litigation, retraining, naming, blaming, and shaming. Followers of this approach tend to treat errors as moral issues, assuming that bad things happen to bad people—what psychologists have called the just world hypothesis.
4,710 citations
TL;DR: The design and execution of research required to address the additional problems resulting from evaluation of complex interventions, those “made up of various interconnecting parts,” are examined.
Abstract: Randomised controlled trials are widely accepted as the most reliable method of determining effectiveness, but most trials have evaluated the effects of a single intervention such as a drug. Recognition is increasing that other, non-pharmacological interventions should also be rigorously evaluated.1-3 This paper examines the design and execution of research required to address the additional problems resulting from evaluation of complex interventions—that is, those “made up of various interconnecting parts.”4 The issues dealt with are discussed in a longer Medical Research Council paper (www.mrc.ac.uk/complex_packages.html). We focus on randomised trials but believe that this approach could be adapted to other designs when they are more appropriate.
#### Summary points
Complex interventions are those that include several components
The evaluation of complex interventions is difficult because of problems of developing, identifying, documenting, and reproducing the intervention
A phased approach to the development and evaluation of complex interventions is proposed to help researchers define clearly where they are in the research process
Evaluation of complex interventions requires use of qualitative and quantitative evidence
There are specific difficulties in defining, developing, documenting, and reproducing complex interventions that are subject to more variation than a drug. A typical example would be the design of a trial to evaluate the benefits of specialist stroke units. Such a trial would have to consider the expertise of various health professionals as well as investigations, drugs, treatment guidelines, and arrangements for discharge and follow up. Stroke units may also vary in terms of organisation, management, and skill mix. The active components of the stroke unit may be difficult to specify, making it difficult to replicate the intervention. The box gives other examples of complex interventions.
#### Examples of complex interventions
Service delivery and organisation:
Stroke units
Hospital at home
Interventions directed at health professionals' behaviour:
Strategies for implementing guidelines
Computerised decision support
Community interventions:
Community …
3,235 citations
TL;DR: Two views of how qualitative methods might be judged are outlined and it is argued that qualitative research can be assessed according to two broad criteria: validity and relevance.
Abstract: This is the first in a series of three articles
In the past decade, qualitative methods have become more commonplace in areas such as health services research and health technology assessment, and there has been a corresponding rise in the reporting of qualitative research studies in medical and related journals.1 Interest in these methods and their wider exposure in health research has led to necessary scrutiny of qualitative research. Researchers from other traditions are increasingly concerned to understand qualitative methods and, most importantly, to examine the claims researchers make about the findings obtained from these methods.
The status of all forms of research depends on the quality of the methods used. In qualitative research, concern about assessing quality has manifested itself recently in the proliferation of guidelines for doing and judging qualitative work.2–5 Users and funders of research have had an important role in developing these guidelines as they become increasingly familiar with qualitative methods, but require some means of assessing their quality and of distinguishing “good” and “poor” quality research. However, the issue of “quality” in qualitative research is part of a much larger and contested debate about the nature of the knowledge produced by qualitative research, whether its quality can legitimately be judged, and, if so, how. This paper cannot do full justice to this wider epistemological debate. Rather it outlines two views of how qualitative methods might be judged and argues that qualitative research can be assessed according to two broad criteria: validity and relevance.
#### Summary points
Qualitative methods are now widely used and increasingly accepted in health research, but quality in qualitative research is a mystery to many health services researchers
There is considerable debate over the nature of the knowledge produced by such methods and how such research should be judged
Antirealists argue …
3,075 citations
TL;DR: Neuraxial blockade reduces postoperative mortality and other serious complications, and the size of some of these benefits remains uncertain, and further research is required to determine whether these effects are due solely to benefits of neuraxia blockade or partly to avoidance of general anaesthesia.
Abstract: Objectives: To obtain reliable estimates of the effects of neuraxial blockade with epidural or spinal anaesthesia on postoperative morbidity and mortality. Design: Systematic review of all trials with randomisation to intraoperative neuraxial blockade or not. Studies: 141 trials including 9559 patients for which data were available before 1 January 1997. Trials were eligible irrespective of their primary aims, concomitant use of general anaesthesia, publication status, or language. Trials were identified by extensive search methods, and substantial amounts of data were obtained or confirmed by correspondence with trialists. Main outcome measures: All cause mortality, deep vein thrombosis, pulmonary embolism, myocardial infarction, transfusion requirements, pneumonia, other infections, respiratory depression, and renal failure. Results: Overall mortality was reduced by about a third in patients allocated to neuraxial blockade (103 deaths/4871 patients versus 144/4688 patients, odds ratio=0.70, 95% confidence interval 0.54 to 0.90, P=0.006). Neuraxial blockade reduced the odds of deep vein thrombosis by 44%, pulmonary embolism by 55%, transfusion requirements by 50%, pneumonia by 39%, and respiratory depression by 59% (all P Conclusions: Neuraxial blockade reduces postoperative mortality and other serious complications. The size of some of these benefits remains uncertain, and further research is required to determine whether these effects are due solely to benefits of neuraxial blockade or partly to avoidance of general anaesthesia. Nevertheless, these findings support more widespread use of neuraxial blockade.
2,087 citations
TL;DR: In patients with type 2 diabetes the risk of diabetic complications was strongly associated with raised blood pressure, with the lowest risk being in those with systolic blood pressure less than 120 mm Hg.
Abstract: OBJECTIVE: To determine the relation between systolic blood pressure over time and the risk of macrovascular or microvascular complications in patients with type 2 diabetes. DESIGN: Prospective observational study. SETTING: 23 hospital based clinics in England, Scotland, and Northern Ireland. PARTICIPANTS: 4801 white, Asian Indian, and Afro-Caribbean UKPDS patients, whether randomised or not to treatment, were included in analyses of incidence; of these, 3642 were included in analyses of relative risk. OUTCOME MEASURES: Primary predefined aggregate clinical outcomes: any complications or deaths related to diabetes and all cause mortality. Secondary aggregate outcomes: myocardial infarction, stroke, lower extremity amputation (including death from peripheral vascular disease), and microvascular disease (predominantly retinal photocoagulation). Single end points: non-fatal heart failure and cataract extraction. Risk reduction associated with a 10 mm Hg decrease in updated mean systolic blood pressure adjusted for specific confounders. RESULTS: The incidence of clinical complications was significantly associated with systolic blood pressure, except for cataract extraction. Each 10 mm Hg decrease in updated mean systolic blood pressure was associated with reductions in risk of 12% for any complication related to diabetes (95% confidence interval 10% to 14%, P<0.0001), 15% for deaths related to diabetes (12% to 18%, P<0.0001), 11% for myocardial infarction (7% to 14%, P<0.0001), and 13% for microvascular complications (10% to 16%, P<0.0001). No threshold of risk was observed for any end point. CONCLUSIONS: In patients with type 2 diabetes the risk of diabetic complications was strongly associated with raised blood pressure. Any reduction in blood pressure is likely to reduce the risk of complications, with the lowest risk being in those with systolic blood pressure less than 120 mm Hg.
2,021 citations
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TL;DR: In the trinity of births, marriages, and deaths, only death does not have glossy magazines devoted to stylish consumption at the attendant ceremonies.
Abstract: Death is the new sex, last great taboo in Western society and Western medicine, as Richard Smith discusses in his editorial (p 129). In the trinity of births, marriages, and deaths, only death does not have glossy magazines devoted to stylish consumption at the attendant ceremonies. On the web, of course, …
1,764 citations
TL;DR: Findings suggest that some inflammatory processes, unrelated to the chronic infections studied here, are likely to be involved in coronary heart disease.
Abstract: Objective: To assess associations between baseline values of four different circulating markers of inflammation and future risk of coronary heart disease, potential triggers of systemic inflammation (such as persistent infection), and other markers of inflammation. Design: Nested case-control comparisons in a prospective, population based cohort. Setting: General practices in 18 towns in Britain. Participants: 506 men who died from coronary heart disease or had a non-fatal myocardial infarction and 1025 men who remained free of such disease until 1996 selected from 5661 men aged 40–59 years who provided blood samples in 1978-1980. Main outcome measures: Plasma concentrations of C reactive protein, serum amyloid A protein, and serum albumin and leucocyte count. Information on fatal and non-fatal coronary heart disease was obtained from medical records and death certificates. Results: Compared with men in the bottom third of baseline measurements of C reactive protein, men in the top third had an odds ratio for coronary heart disease of 2.13 (95% confidence interval 1.38 to 3.28) after age, town, smoking, vascular risk factors, and indicators of socioeconomic status were adjusted for. Similar adjusted odds ratios were 1.65 (1.07 to 2.55) for serum amyloid A protein; 1.12 (0.71 to 1.77) for leucocyte count; and 0.67 (0.43 to 1.04) for albumin. No strong associations were observed of these factors with Helicobacter pylori seropositivity, Chlamydia pneumoniae IgG titres, or plasma total homocysteine concentrations. Baseline values of the acute phase reactants were significantly associated with one another (P Conclusion: In the context of results from other relevant studies these findings suggest that some inflammatory processes, unrelated to the chronic infections studied here, are likely to be involved in coronary heart disease.
1,667 citations
TL;DR: In this contemporary well nourished cohort, catch-up growth was predicted by factors relating to intrauterine restraint of fetal growth, and children who showed catch- up growth between zero and two years were fatter and had more central fat distribution at five years than other children.
Abstract: Objective: To identify predictors of postnatal catch-up growth from birth to two years and its relation to size and obesity at five years. Design: Regional prospective cohort study. Setting: Avon longitudinal study of pregnancy and childhood, United Kingdom. Subjects: 848 full term singletons from a 10% random sample of the Avon longitudinal study of pregnancy and childhood. Main outcome measures: Maternal birth weight, prepregnancy weight, pregnancy weight gain, height, smoking, and parity, and paternal height. Weight and length of infants at birth, two years, and five years expressed as standard deviation (SD) scores from the UK reference scores for 1990. Percentage fat mass and total fat mass (estimated from skinfolds) and waist circumference at five years. Results: Size at birth was representative of the national reference. Overall, 30.7% (260 of 848) of infants showed a gain in SD score for weight greater than 0.67 SD scores between zero and two years, indicating clinically significant catch-up growth. These children had lower weight, length, and ponderal index at birth than other children, and were more often from primiparous pregnancies. They also had taller fathers than other children, and their mothers had lower birth weights and were more likely to smoke during pregnancy. Children who showed catch-up growth between zero and two years were heavier, taller, and fatter (body mass index, percentage body fat, and waist circumference) at five years than other children. Conclusions: In this contemporary well nourished cohort, catch-up growth was predicted by factors relating to intrauterine restraint of fetal growth. Children who showed catch-up growth between zero and two years were fatter and had more central fat distribution at five years than other children. Mechanisms that signal and regulate early catch-up growth in the postnatal period may influence associations between small size at birth and risks for disease in adulthood.
TL;DR: Medical staff reported that error is important but difficult to discuss and not handled well in their hospital and barriers to discussing error are more important since medical staff seem to deny the effect of stress and fatigue on performance.
Abstract: OBJECTIVES: To survey operating theatre and intensive care unit staff about attitudes concerning error, stress, and teamwork and to compare these attitudes with those of airline cockpit crew. DESIGN:: Cross sectional surveys. SETTING:: Urban teaching and non-teaching hospitals in the United States, Israel, Germany, Switzerland, and Italy. Major airlines around the world. PARTICIPANTS:: 1033 doctors, nurses, fellows, and residents working in operating theatres and intensive care units and over 30 000 cockpit crew members (captains, first officers, and second officers). MAIN OUTCOME MEASURES:: Perceptions of error, stress, and teamwork. RESULTS:: Pilots were least likely to deny the effects of fatigue on performance (26% v 70% of consultant surgeons and 47% of consultant anaesthetists). Most pilots (97%) and intensive care staff (94%) rejected steep hierarchies (in which senior team members are not open to input from junior members), but only 55% of consultant surgeons rejected such hierarchies. High levels of teamwork with consultant surgeons were reported by 73% of surgical residents, 64% of consultant surgeons, 39% of anaesthesia consultants, 28% of surgical nurses, 25% of anaesthetic nurses, and 10% of anaesthetic residents. Only a third of staff reported that errors are handled appropriately at their hospital. A third of intensive care staff did not acknowledge that they make errors. Over half of intensive care staff reported that they find it difficult to discuss mistakes. CONCLUSIONS: Medical staff reported that error is important but difficult to discuss and not handled well in their hospital. Barriers to discussing error are more important since medical staff seem to deny the effect of stress and fatigue on performance. Further problems include differing perceptions of teamwork among team members and reluctance of senior theatre staff to accept input from junior members.
TL;DR: Improvements in clinical outcomes support the use of this treatment in patients with moderate to severe chronic obstructive pulmonary disease as patients on fluticasone propionate had fewer exacerbations and a slower decline in health status.
Abstract: Objectives: To determine the effect of long term inhaled corticosteroids on lung function, exacerbations, and health status in patients with moderate to severe chronic obstructive pulmonary disease. Design: Double blind, placebo controlled study. Setting: Eighteen UK hospitals. Participants: 751 men and women aged between 40 and 75 years with mean forced expiratory volume in one second (FEV 1 ) 50% of predicted normal. Interventions: Inhaled fluticasone propionate 500 μg twice daily from a metered dose inhaler or identical placebo. Main outcome measures: Efficacy measures: rate of decline in FEV 1 after the bronchodilator and in health status, frequency of exacerbations, respiratory withdrawals. Safety measures: morning serum cortisol concentration, incidence of adverse events. Results: There was no significant difference in the annual rate of decline in FEV 1 (P=0.16). Mean FEV 1 after bronchodilator remained significantly higher throughout the study with fluticasone propionate compared with placebo (P v 19%, P=0.034). Conclusions: Fluticasone propionate 500 μg twice daily did not affect the rate of decline in FEV 1 but did produce a small increase in FEV 1 . Patients on fluticasone propionate had fewer exacerbations and a slower decline in health status. These improvements in clinical outcomes support the use of this treatment in patients with moderate to severe chronic obstructive pulmonary disease.
TL;DR: The literature was reviewed through traditional and electronic means and correlational analyses of gross domestic product and life expectancy and of income inequality and mortality trends based on data from the World Bank, the World Health Organization, and two British sources were supplemented.
Abstract: Studies on the health effects of income inequality have generated great interest. The evidence on this association between countries is mixed,1–4 but income inequality and health have been linked within the United States,5–11 Britain,12 and Brazil.13 Questions remain over how to interpret these findings and the mechanisms involved. We discuss three interpretations of the association between income inequality and health: the individual income interpretation, the psychosocial environment interpretation, and the neo-material interpretation.
#### Summary points
Income inequality has generally been associated with differences in health
A psychosocial interpretation of health inequalities, in terms of perceptions of relative disadvantage and the psychological consequences of inequality, raises several conceptual and empirical problems
Income inequality is accompanied by many differences in conditions of life at the individual and population levels, which may adversely influence health
Interpretation of links between income inequality and health must begin with the structural causes of inequalities, and not just focus on perceptions of that inequality
Reducing health inequalities and improving public health in the 21st century requires strategic investment in neo-material conditions via more equitable distribution of public and private resources
We reviewed the literature through traditional and electronic means and supplemented this with correlational analyses of gross domestic product and life expectancy and of income inequality and mortality trends based on data from the World Bank,14 the World Health Organization,15 and two British sources.16 17
According to the individual income interpretation, aggregate level associations between income inequality and health reflect only the individual level association between income and health. The curvilinear relation between income and health at the individual level 18 19 is a sufficient condition to produce health differences between populations with the same average income but different distributions of income.3 20 This interpretation assumes that determinants …
TL;DR: Fetal loss is high in women in their late 30s or older, irrespective of reproductive history, and should be taken into consideration in pregnancy planning and counselling.
Abstract: Objective: To estimate the association between maternal age and fetal death (spontaneous abortion, ectopic pregnancy, stillbirth), taking into account a woman9s reproductive history. Design: Prospective register linkage study. Subjects: All women with a reproductive outcome (live birth, stillbirth, spontaneous abortion leading to admission to hospital, induced abortion, ectopic pregnancy, or hydatidiform mole) in Denmark from 1978 to 1992; a total of 634 272 women and 1 221 546 pregnancy outcomes. Main outcome measures: Age related risk of fetal loss, ectopic pregnancy, and stillbirth, and age related risk of spontaneous abortion stratified according to parity and previous spontaneous abortions. Results: Overall, 13.5% of the pregnancies intended to be carried to term ended with fetal loss. At age 42 years, more than half of such pregnancies resulted in fetal loss. The risk of a spontaneous abortion was 8.9% in women aged 20–24 years and 74.7% in those aged 45 years or more. High maternal age was a significant risk factor for spontaneous abortion irrespective of the number of previous miscarriages, parity, or calendar period. The risk of an ectopic pregnancy and stillbirth also increased with increasing maternal age. Conclusions: Fetal loss is high in women in their late 30s or older, irrespective of reproductive history. This should be taken into consideration in pregnancy planning and counselling.
TL;DR: People who stop smoking, even well into middle age, avoid most of their subsequent risk of lung cancer, and stopping before middle age avoids more than 90% of the risk attributable to tobacco.
Abstract: Objective and design: To relate UK national trends since 1950 in smoking, in smoking cessation, and in lung cancer to the contrasting results from two large case-control studies centred around 1950 and 1990. Setting: United Kingdom. Participants: Hospital patients under 75 years of age with and without lung cancer in 1950 and 1990, plus, in 1990, a matched sample of the local population: 1465 case-control pairs in the 1950 study, and 982 cases plus 3185 controls in the 1990 study. Main outcome measures: Smoking prevalence and lung cancer. Results: For men in early middle age in the United Kingdom the prevalence of smoking halved between 1950 and 1990 but the death rate from lung cancer at ages 35–54 fell even more rapidly, indicating some reduction in the risk among continuing smokers. In contrast, women and older men who were still current smokers in 1990 were more likely than those in 1950 to have been persistent cigarette smokers throughout adult life and so had higher lung cancer rates than current smokers in 1950. The cumulative risk of death from lung cancer by age 75 (in the absence of other causes of death) rose from 6% at 1950 rates to 16% at 1990 rates in male cigarette smokers, and from 1% to 10% in female cigarette smokers. Among both men and women in 1990, however, the former smokers had only a fraction of the lung cancer rate of continuing smokers, and this fraction fell steeply with time since stopping. By 1990 cessation had almost halved the number of lung cancers that would have been expected if the former smokers had continued. For men who stopped at ages 60, 50, 40, and 30 the cumulative risks of lung cancer by age 75 were 10%, 6%, 3%, and 2%. Conclusions: People who stop smoking, even well into middle age, avoid most of their subsequent risk of lung cancer, and stopping before middle age avoids more than 90% of the risk attributable to tobacco. Mortality in the near future and throughout the first half of the 21st century could be substantially reduced by current smokers giving up the habit. In contrast, the extent to which young people henceforth become persistent smokers will affect mortality rates chiefly in the middle or second half of the 21st century.
TL;DR: Doctors are inaccurate in their prognoses for terminally ill patients and the error is systematically optimistic, which may be adversely affecting the quality of care given to patients near the end of life.
Abstract: Objective To describe doctors’ prognostic accuracy in terminally ill patients and to evaluate the determinants of that accuracy. Design Prospective cohort study. Setting Five outpatient hospice programmes in Chicago.
TL;DR: Although operating theatres are not cockpits, medicine could learn from aviation and aviation has developed standardised methods of investigating, documenting, and disseminating errors and their lessons.
Abstract: Pilots and doctors operate in complex environments where teams interact with technology. In both domains, risk varies from low to high with threats coming from a variety of sources in the environment. Safety is paramount for both professions, but cost issues can influence the commitment of resources for safety efforts. Aircraft accidents are infrequent, highly visible, and often involve massive loss of life, resulting in exhaustive investigation into causal factors, public reports, and remedial action. Research by the National Aeronautics and Space Administration into aviation accidents has found that 70% involve human error.1
In contrast, medical adverse events happen to individual patients and seldom receive national publicity. More importantly, there is no standardised method of investigation, documentation, and dissemination. The US Institute of Medicine estimates that each year between 44 000 and 98 000 people die as a result of medical errors. When error is suspected, litigation and new regulations are threats in both medicine and aviation.
#### Summary points
In aviation, accidents are usually highly visible, and as a result aviation has developed standardised methods of investigating, documenting, and disseminating errors and their lessons
Although operating theatres are not cockpits, medicine could learn from aviation
Observation of flights in operation has identified failures of compliance, communication, procedures, proficiency, and decision making in contributing to errors
Surveys in operating theatres have confirmed that pilots and doctors have common interpersonal problem areas and similarities in professional culture
Accepting the inevitability of error and the importance of reliable data on error and its management will allow systematic efforts to reduce the frequency and severity of adverse events
Error results from physiological and psychological limitations of humans.2 Causes of error include fatigue, workload, and fear as well as cognitive overload, poor interpersonal communications, imperfect information processing, and flawed decision making.3 In both aviation …
TL;DR: In this paper, the effect of publication bias on the results and conclusions of systematic reviews and meta-analyses was assessed using the trim and fill fixed effects analysis method, and the results showed that publication bias was common within the sample of meta-annalyses assessed.
Abstract: Objective: To assess the effect of publication bias on the results and conclusions of systematic reviews and meta-analyses. Design: Analysis of published meta-analyses by trim and fill method. Studies: 48 reviews in Cochrane Database of Systematic Reviews that considered a binary endpoint and contained 10 or more individual studies. Main outcome measures: Number of reviews with missing studies and effect on conclusions of meta-analyses. Results: The trim and fill fixed effects analysis method estimated that 26 (54%) of reviews had missing studies and in 10 the number missing was significant. The corresponding figures with a random effects model were 23 (48%) and eight. In four cases, statistical inferences regarding the effect of the intervention were changed after the overall estimate for publication bias was adjusted for. Conclusions: Publication or related biases were common within the sample of meta-analyses assessed. In most cases these biases did not affect the conclusions. Nevertheless, researchers should check routinely whether conclusions of systematic reviews are robust to possible non-random selection mechanisms.
TL;DR: If the journal does publish papers for education and debate it follows that they should be understandable to all of the readers of the journal, including such lowly students as surgeons, and that it has to be remembered by educators that an essential part of the educational process is good communication.
Abstract: Editor—The first Education and debate section of the new millennium was very educational in a way that was almost certainly not anticipated or intended by either the staff of the journal (unless they were being very mischievous) or the authors of the papers concerned.1,2 In the paper by Lilford et al1 the study under discussion was clearly defined, but unfortunately in the paper by Mays et al2 I was not able, after reading the paper three times, to find a definition of the type of research being discussed anywhere.
The style of the paper by Lilford et al allowed an easy understanding of the thesis being developed, but the same could not be said of the paper by Mays et al, which seemed to lack a clearly discernible logic in relation to the case being made. The paper was replete with jargon and many strangely unscientific terms, which made it difficult to read—such as “epistemological,” “extreme relativists,” “antirealist,” “reflexivity,” “inductive inquiries,” and “subtle realism.” No such problem seemed to exist in relation to the paper by Lilford et al. As one of the “researchers from other traditions,” I was appalled to read of research trying to “derive . . . unequivocal insights.” I thought in my “naive realism” that we sought facts. Should not all research “be concerned to develop theory?” The need to develop a hypothesis to be tested is surely not “arguable.” I was taught by my research mentors that the truth, rather than subtle realism, was what we were trying to attain. It would have been unthinkable to omit a clear account of the process of data collection and analysis.
In this double blind (I had no idea prior to publication of the content or style), randomised (by chance I chose to read the “unintelligible paper” first) controlled (the papers were controls for each other) trial, not intended by the journal (?), I found a significant difference (I could not even understand one of the papers) in favour of tracker studies. Perhaps this was because of my only admitted bias or conflict of interest, that of being a surgeon and an educator. I am not really sure what all of this means except that if the journal does publish papers for education and debate it follows that they should be understandable to all of the readers of the journal, including such lowly students as surgeons, and that it has to be remembered by educators that an essential part of the educational process is good communication. Quality in qualitative research is a mystery to many health services researchers, and, sadly, it is an even greater mystery to me now. I am left pondering the simple question “Who should be responsible for educating the educators?”
TL;DR: The odds are a way of representing probability, especially familiar for betting, and enable us to examine the effects of other variables on that relationship, using logistic regression.
Abstract: In recent years odds ratios have become widely used in medical reports—almost certainly some will appear in today's BMJ . There are three reasons for this. Firstly, they provide an estimate (with confidence interval) for the relationship between two binary (“yes or no”) variables. Secondly, they enable us to examine the effects of other variables on that relationship, using logistic regression. Thirdly, they have a special and very convenient interpretation in case-control studies (dealt with in a future note).
The odds are a way of representing probability, especially familiar for betting. For example, the odds that a single throw of a die will produce a six are 1 to 5, or 1/5. The odds is the ratio of the probability that the event of interest occurs to the probability that it does not. This is often estimated by the ratio of the number of times that the event of interest occurs to …
TL;DR: Focusing on data for near misses may add noticeably more value to quality improvement than a sole focus on adverse events, and an environment fostering a rich reporting culture must be created to capture accurate and detailed data about nuances of care.
Abstract: Reducing mishaps from medical management is central to efforts to improve quality and lower costs in health care. Nearly 100 000 patients are estimated to die preventable deaths annually in hospitals in the United States, with many more incurring injuries at an annual cost of $9 billion. Underreporting of adverse events is estimated to range from 50%-96% annually.1–3 This annual toll exceeds the combined number of deaths and injuries from motor and air crashes, suicides, falls, poisonings, and drownings.4 Many stakeholders in health care have begun to work together to resolve the moral, scientific, legal, and practical dilemmas of medical mishaps. To achieve this goal, an environment fostering a rich reporting culture must be created to capture accurate and detailed data about nuances of care.
Outcomes in complex work depend on the integration of individual, team, technical, and organisational factors. 5 6 A continuum of cascade effects exists from apparently trivial incidents to near misses and full blown adverse events. 7 8 Consequently, the same patterns of causes of failure and their relations precede both adverse events and near misses. Only the presence or absence of recovery mechanisms determines the actual outcome.9 The National Research Council defines a safety “incident” as an event that, under slightly different circumstances, could have been an accident.10 Focusing on data for near misses may add noticeably more value to quality improvement than a sole focus on adverse events.
Schemes for reporting near misses, “close calls,” or sentinel (“warning”) events have been institutionalised in aviation,w1 w2 nuclear power technology,w3 w4 petrochemical processing, steelw5 production,w6 military operations, and air transportation.w7-w11 In health care, efforts are now being made to create incident reporting systems for medical near misses 8 11–15 to supplement the limited …
TL;DR: Cadesartan 16 mg once daily is as effective as lisinopril 20 mgonce daily in reducing blood pressure and microalbuminuria in hypertensive patients with type 2 diabetes and combination treatment is well tolerated and more effective in reducingBlood pressure.
Abstract: Objectives: To assess and compare the effects of candesartan or lisinopril, or both, on blood pressure and urinary albumin excretion in patients with microalbuminuria, hypertension, and type 2 diabetes. Design: Prospective, randomised, parallel group, double blind study with four week placebo run in period and 12 weeks9 monotherapy with candesartan or lisinopril followed by 12 weeks9 monotherapy or combination treatment. Setting: Tertiary hospitals and primary care centres in four countries (37 centres). Participants: 199 patients aged 30-75 years. Interventions: Candesartan 16 mg once daily, lisinopril 20 mg once daily. Main outcome measures: Blood pressure and urinary albumin:creatinine ratio. Results: At 12 weeks mean (95% confidence interval) reductions in diastolic blood pressure were 9.5 mm Hg (7.7 mm Hg to 11.2 mm Hg, P Conclusion: Candesartan 16 mg once daily is as effective as lisinopril 20 mg once daily in reducing blood pressure and microalbuminuria in hypertensive patients with type 2 diabetes. Combination treatment is well tolerated and more effective in reducing blood pressure.
TL;DR: Patients, who have an understandable need to consider their doctors infallible, have colluded with doctors to deny the existence of error.
Abstract: Personal view p 812
When I was a house officer another resident failed to identify the electrocardiographic signs of the pericardial tamponade that would rush the patient to the operating room late that night. The news spread rapidly, the case tried repeatedly before an incredulous jury of peers, who returned a summary judgment of incompetence. I was dismayed by the lack of sympathy and wondered secretly if I could have made the same mistake—and, like the hapless resident, become the second victim of the error.
Strangely, there is no place for mistakes in modern medicine. Society has entrusted physicians with the burden of understanding and dealing with illness. Although it is often said that “doctors are only human,” technological wonders, the apparent precision of laboratory tests, and innovations that present tangible images of illness have in fact created an expectation of perfection. Patients, who have an understandable need to consider their doctors infallible, have colluded with doctors to deny the existence of error. Hospitals react to every error as an anomaly, for which the solution is to ferret out and blame an individual, with a promise that “it will never happen again.” Paradoxically, this approach has diverted attention …
TL;DR: A Medline search for randomised controlled trials of team care using the MeSH heading “patient care team” considered the implications of these observations for the structure and functioning of patient care teams in primary care.
Abstract: > “In the gradual division of labor, by which civilization has emerged from barbarism, the doctor and nurse have been evolved”
>
> Sir William Osler (1891)
The delivery of health care by a coordinated team of individuals has always been assumed to be a good thing. Patients reap the benefits of more eyes and ears, the insights of different bodies of knowledge, and a wider range of skills. Thus team care has generally been embraced by most as a criterion for high quality care. Despite its appeal, team care, especially in the primary care setting, remains a source of confusion and some scepticism.1 Which disciplines are essential on the team? What do the team members other than the doctor do to support patient care?
With the ageing of the population and the advances in the treatment of chronic diseases, teamwork in the context of chronic diseases needs to be re-examined. Successful chronic disease interventions usually involve a coordinated multidisciplinary care team.2–5
In this article I consider the implications of these observations for the structure and functioning of patient care teams in primary care. My work is rooted in US health care, and the references and roles described largely reflect that perspective. I performed a Medline search for randomised controlled trials of team care using the MeSH heading “patient care team.”
#### Summary points
Effective chronic illness interventions generally rely on multidisciplinary care teams
Successful teams often include nurses and pharmacists with clinical and behavioural skills
Such teams ensure that critical elements of care that doctors may not have the training or time to do well are competently performed
These elements include population management, protocol based regulation of medication, self management support, and intensive follow up
The participation of medical specialists in consultative and educational roles outside conventional referrals may contribute to …
TL;DR: There is no clear evidence that atypical antipsychotics are more effective or are better tolerated than conventional antipsychotic drugs.
Abstract: Objective To develop an evidence base for recommendations on the use of atypical antipsychotics for patients with schizophrenia.Design Systematic overview and meta-regression analyses of randomised controlled trials, as a basis for formal development of guidelines.Subjects 12 649 patients in 52 randomised trials comparing atypical antipsychotics (amisulpride, clozapine, olanzapine, quetiapine, risperidone, and sertindole) with conventional antipsychotics (usually haloperidol or chlorpromazine) or alternative atypical antipsychotics.Main outcome measures Overall symptom scores. Rate of drop out las a proxy for tolerability) and of side effects, notably extrapyramidal side effects.Results For both symptom reduction and drop out, there was substantial heterogeneity between the results of trials, including those evaluating the same atypical antipsychotic and comparator drugs. Meta-regression suggested that dose of conventional antipsychotic explained the heterogeneity. When the dose was less than or equal to 12 mg/day of haloperidol (or equivalent), atypical antipsychotics had no benefits in terms of efficacy or overall tolerability, but they still caused fewer extrapyramidal side effects.Conclusions There is no clear evidence that atypical antipsychotics are more effective or are better tolerated than conventional antipsychotics. Conventional antipsychotics should usually be used in the initial treatment of an episode of schizophrenia unless the patient has previously not responded to these drugs or has unacceptable extrapyramidal side effects.
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TL;DR: The single most important part of the NHS plan is the cash injection to boost capacity, which to anyone who has worked in frontline care, is manna (leaving aside for the moment questions of how and when).
Abstract: News p 317
This is probably as good as it gets: a significant injection of money for the NHS sustained over five years1 coupled with a comprehensive national plan for the NHS, announced last week.2 The plan is true to the NHS's founding principles and has been drawn up by all the NHS's major stakeholders—who have signed up to help make it a reality.2 The plan is impressive in scope and clearly reflects messages coming from staff and the public in the recent public consultation exercise3—from “bring back matron,” to improving hospital food, to reducing micro-management of the service from Whitehall. It is a plan for the medium, not the short, term.
Four headlines stand out: capacity; standards and targets; delivery; partnership. Years of lower growth in expenditure compared with other European countries have left the NHS looking worthy but relatively clapped out. The single most important part of the NHS plan is the cash injection to boost capacity: 7500 more consultants; 2000 more general practitioners, 20 000 more nurses; 7000 more beds (particularly to boost intermediate care), investment in NHS facilities—the list goes on. To anyone who has worked in frontline care, this is manna (leaving aside for the moment questions of how and when). The disappointment for many was …
TL;DR: Sleep apnoea syndrome is profoundly associated with hypertension independent of all relevant risk factors, and is a significant predictor of both systolic and diastolic blood pressure after adjustment for age, body mass index, and sex.
Abstract: Objective: To assess whether sleep apnoea syndrome is an independent risk factor for hypertension Design: Population study Setting: Sleep clinic in Toronto Participants: 2677 adults, aged 20-85 years, referred to the sleep clinic with suspected sleep apnoea syndrome Outcome measures: Medical history, demographic data, morning and evening blood pressure, and whole night polysomnography Results: Blood pressure and number of patients with hypertension increased linearly with severity of sleep apnoea, as shown by the apnoea-hypopnoea index Multiple regression analysis of blood pressure levels of all patients not taking antihypertensives showed that apnoea was a significant predictor of both systolic and diastolic blood pressure after adjustment for age, body mass index, and sex Multiple logistic regression showed that each additional apnoeic event per hour of sleep increased the odds of hypertension by about 1%, whereas each 10% decrease in nocturnal oxygen saturation increased the odds by 13% Conclusion: Sleep apnoea syndrome is profoundly associated with hypertension independent of all relevant risk factors
TL;DR: This paper explains conjoint analysis, provides examples of applications in health care which were obtained from a systematic review of databases between 1989 and 1999, and uses a study in orthodontic care to show the uses and pitfalls of the technique.
Abstract: Traditionally the extent of patients' involvement in medical decision making has been minimal. This has been true at both the micro level of the patient consultation with a doctor and the macro level of planning and developing healthcare services. Since 1989, however, greater involvement of patients and the community in these processes has been advocated.1–5 In principle, the elicitation of patients' and the community's values represents a big step forward in terms of enhancing the benefits from the provision of health care. For the exercise to be worth while, however, the information obtained must be useful and scientifically defensible.6 During the 1990s, conjoint analysis was developed to elicit patients' and the community's views on health care.
#### Summary points
Conjoint analysis is a rigorous method of eliciting preferences
It allows estimation of the relative importance of different aspects of care, the trade-offs between these aspects, and the total satisfaction or utility that respondents derive from healthcare services
The technique can help with decision making for some of the issues facing the NHS
Though further applications of conjoint analysis are encouraged, methodological issues need further consideration
This paper explains conjoint analysis, provides examples of applications in health care which were obtained from a systematic review of databases between 1989 and 1999 (Medline, Embase, HealthSTAR, PsychLIT, EconLIT), and uses a study in orthodontic care to show the uses and pitfalls of the technique.
The survey method of data collection and analysis known as conjoint analysis was developed in mathematical psychology and has a strong theoretical basis.7–9 It has been successfully used in market research,10 transport economics,11 and environmental economics 12 13 and was recommended to the UK Treasury for valuing quality in the provision of public services.14 Within these areas it has been well received …
TL;DR: Cancer patients' attitudes to cancer and their strategies for coping with their illness can constrain their wish for information and their efforts to obtain it, and the government's cancer information strategy should attend to variations in patients' desires for Information and the reasons for them.
Abstract: Objectives: To explore why cancer patients do not want or seek information about their condition beyond that volunteered by their physicians at times during their illness. Design: Qualitative study based on in-depth interviews. Setting: Outpatient oncology clinics at a London cancer centre. Participants: 17 patients with cancer diagnosed in previous 6 months. Main outcome measures: Analysis of patients9 narratives to identify key themes and categories. Results: While all patients wanted basic information on diagnosis and treatment, not all wanted further information at all stages of their illness. Three overarching attitudes to their management of cancer limited patients9 deon with life as normal and could be maintained through silence and avoiding information, especially too detailed or “unsafe” information. Charity to fellow patients, especially those seen as more needy than themselves, was expressed in the recognition that scarce resources—including information and explanations—had to be shared and meant that limited information was accepted as inevitable. Conclusions: Cancer patients9 attitudes to cancer and their strategies for coping with their illness can constrain their wish for information and their efforts to obtain it. In developing recommendations, the government9s cancer information strategy should attend to variations in patients9 desires for information and the reasons for them.