eLetters

711 e-Letters

  • Health and social care spending and mortality

    Further to my earlier response to this article, it is probably appropriate to add some further clarifying detail. The principal problem lies in the fact that the detailed trends in deaths do not conform to the assumed calendar year breaks assumed in this study. The international evidence indicates that deaths (and medical admissions) have for many years shown on/off switching along with single-year-of-age specific changes.

    Indeed deaths and medical admissions are not the only health factors to be affected and the gender ratio at birth along with admissions for certain conditions during pregnancy and childbirth also simultaneously change. The ratio of female to male admissions also show unexplained and simultaneous changes (and have done so for many years). It is difficult to pin these changes on a simple spending explanation.

    Hospital bed occupancy likewise undergoes unexplained changes. It has also been my experience from a 25-year career in healthcare analysis that delayed discharges of care always increase during these unexplained periods of higher deaths and medical admissions.

    Rather than citing all the individual studies can I refer the reader to over 200 studies on this topic published over the past 9 years. These can be found at http://www.hcaf.biz/2010/Publications_Full.pdf

    I hope this will lead to the further fruitful investigation of this enigmatic and recurring phenomena....

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  • Strong claims based on questionable methods

    I do not refute the hypothesis that spending constraints had adverse health impacts. However, the authors do not provide convincing evidence to support their hypothesis. For example, it does not seems sensible to investigate separately the association between spending and number of deaths by place of deaths. Surely, what we care about is the total number of deaths? If we find more deaths at home and in care homes and fewer deaths in hospital, this could be a good thing, since hospital is not most people's preferred place of death. Since the authors do not present results for all deaths, we do not know if the main effect is shifting deaths from hospitals to other places.

    Table 1 reports the number of observations as 28. So there are 14 data points for male mortality and 14 data points for female mortality. But the explanatory variables, expenditure on health and social care, are not reported separately for males and females. So the same values of these variables are used twice!

    The associations between spending and mortality reported in the paper are clearly not causal relationships. Nevertheless, the authors claim that around £25 to £30 billion additional spending are required to close the gap.

    The description of the methods are misleading. The authors describe their models as fixed effects regression models but what they actually do is a long way from a fixed effects model traditionally used by economists to control for area-specific unobserved e...

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  • Private finance initiative and sustainability and transformation partnerships are not working

    There can be no doubt that constraints on healthcare spending has an adverse effect upon mortality.
    If we analyse several key areas required for the safe and effective functioning of a hospital then it is clear to see that the reduction in real term funding has had a multifactorial effect upon some of the following:
    • Staffing: There are now record numbers of rota gaps. Shortages of doctors across all medical specialties is the norm. Trusts are routinely staffing rota gaps with internal locums or leaving posts vacant, resulting in certain services being dangerously understaffed or closing down. Rota gaps save trusts thousands of pounds, relying on the goodwill of the remaining staff to fill the void.
    • Equipment: Essential equipment is frequently defective, out of date or unsafe. Operating theatres have to contend with instruments that are ill maintained (owing to outsourcing) leading to increased operating time and putting lives at risk.
    • Medications: Health care authorities are rationing oncological medications despite NICE guidelines. We have a post code lottery for cancer and reproductive services.
    • Buildings and maintenance: Hospitals are ill maintained. Heating and ventilation failures are common in theatre. Money spent on PFI repayments could be used for building maintenance.
    • Study budgets: Cuts in study budgets have a negative impact upon training and education. Maintaining up to date skills is essential. Cutting study budget...

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  • Non Genetic Associated Factors in Obeisty, Reflection of Genetic Makeup

    A very nice study with focused vision for future. Read it and appreciate with acknowledgement to bring this entire study to us. Would like to highlight a follow up of the said subjects as per their genetic makeup in this era of personalised medicine. Hypoxia and level of venous hypoxia as a key factor is missing to be aligned with calories intake and other factors which will define change the entire scope of study beside its implementation. The genes associated with obesity and involved in energy hemostasis must be considered at least as per study performed.

  • Comparing spending to mortality rates

    This study appears to be flawed. This is due to the fact that although spending may have gone down, the number of nurses and care workers may have gone up. The rate of care may also have increased within a year that had less spending, factors which do not appear to have been addressed.

    The government ONS also predicted in 2004 that due to the ageing population and steadily declining mortality rate, this would lead to an increase, expected to start within 2010/2011.
    http://webarchive.nationalarchives.gov.uk/20160108034023/http://www.ons....

    Change in population also doesn't appear to have been taken into consideration as well as reasons for death.

  • Social care spending and mortality

    The increase in mortality since 2011 has been an intriguing area of inquiry. I have already published several papers on this topic which suggest that social care spending is not the major contributory factor [1-18]. Several other papers are in press [19-24]. The issues raised in these papers have sadly been missed in this study. It would appear that further research is required on this important topic to disentangle cause and effect.

    References

    1. Jones R (2014) Infectious-like Spread of an Agent Leading to Increased Medical Admissions and Deaths in Wigan (England), during 2011 and 2012. British Journal of Medicine and Medical Research 4(28): 4723-4741. doi: 10.9734/BJMMR/2014/10807
    2. Jones R, Beauchant S (2015) Spread of a new type of infectious condition across Berkshire in England between June 2011 and March 2013: Effect on medical emergency admissions. British Journal of Medicine and Medical Research 6(1): 126-148. doi: 10.9734/BJMMR/2015/14223
    3. Jones R (2015) Unexpected and Disruptive Changes in Admissions Associated with an Infectious-like Event Experienced at a Hospital in Berkshire, England around May of 2012. British Journal of Medicine and Medical Research 6(1): 56-76. doi: 10.9734/BJMMR/2015/13938
    4. Jones R (2015) A previously uncharacterized infectious-like event leading to spatial spread of deaths across England and Wales: Characteristics of the most recent event and a time series for past events. Brit J Medicine and...

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  • Letter to the Editor: Emergency Medicine is a recognized specialty in Kenya

    Dear Editor,

    In the recent article by Myers, et al., the authors stated that Emergency Medicine (EM) was not a recognized specialty in Kenya, which was highlighted as a key step for the development of acute care in Kenya. During the review process for publication of this paper, the Kenya Medical Practitioners and Dentists Board (KMPDB) formally recognized EM as a new “medical specialty” in May 2017.(1) The paper also highlights the volume and diversity of patient presentations to Kenyatta National Hospital, the national referral hospital. The majority of patient complaints were either undifferentiated, or were due to trauma and non-communicable diseases. These high acuity, multi-disciplinary patients represent a case mix that an EM residency– trained practitioner is ideally suited to manage. Although Kenya currently lacks EM residency training programs, the recognition of the specialty is a step forward for the development of EM care in Kenya.

    (1)Gazetted Specialties [Internet]. Kenya Medical Practitioners and Dentists Board. 2017. Available from: http://medicalboard.co.ke/resources_page/gazetted-specialties/

  • Decreased risk of dementia in patients with non-haemorrhagic stroke using acupuncturetreatment: benefit or time-related and residual compounding biases ?

    Corresponding author:
    Ju-Young Shin, PhD
    Professor of Pharmacy
    School of Pharmacy
    Sungkyunkwan University

    Dear Sir

    We read with great interest the study by Chun-Chuan Shin et al1 assessing the effects of acupuncture treatment on the risk of dementia in patients with stroke. They conducted a retrospective cohort study with 5,610 patients in acupuncture group and 5,610 in the non-acupuncture group using data from the National Health Insurance (NHI) system. The authors found that acupuncture treatment reduces the risk of dementia (hazard ratio [HR]: 0.73, 95% confidence interval [CI]: 0.66 to 0.80) compared with the non-treatment group. However, we are concerned that these observed beneficial effects of acupuncture treatment are the results of immortal time bias.

    In the study, cohort entry was defined as patients with no records of stroke within 5 years before the index date and patients who received at least five (5) courses of acupuncture treatment after stroke admission (exclude patients with stroke with only one (1) to four (4) courses of acupuncture treatment). The index date for both groups was defined by the discharge date following stroke admission, and the follow-up for the acupuncture group started from the first date of receiving acupuncture treatment after the index dateuntil 31 December 2009 or until the dementia event occurred. The authors calculatedthe follow-up time, in person-years, for each patients with s...

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  • Authors’ response to Dhillon and Sahu

    Thank you for your ELetter. We agree with you, this is why we took issue with the misleading media coverage and made our best efforts to rectify the message where we felt it had been distorted (both in print and in radio interviews). See our rebuttal to the (London) Times for an example of this:

    "Sir
    In relation to “Light drinking does no harm in pregnancy”, The Times 12/09/2017
    We write to you to complain about the highly misleading front page coverage that your paper dedicated yesterday to our scientific study, and to rectify the wrong messages you have propagated.
    Frustratingly, in today’s paper your columnist has said: “Alcohol […] drinking in pregnancy, which many health professionals considered a crime only a month ago, now appears to be acceptable in moderation” (from “Take health advice with a big pinch of salt” The Times 13/09/2017). This continues the misinformation that yesterday’s article started. To say that “light drinking does no harm in pregnancy” is a gross misrepresentation of our findings – detailed in the scientific paper, summarised in the press release, and distilled and interpreted in plain language by one of our lead authors in conversation with your journalist.

    We went to great lengths to stress that ‘little or no evidence does not mean little or no effect’. In other words, we have little evidence that light drinking in pregnancy is harmful, but we also have little evidence that it is safe! Conversely, your bol...

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  • The problem is 'insurance'

    Physicians would happily spend more time with patients, just as restaurants happily serve appetizers, sides, and desserts, IF they were reimbursed for the extra time, but the insurance system was set up to deal with big, unexpected, single-diagnoses events, so doesn't address the complexity and time of a non-procedural primary-care visit.
    Direct-pay environments, where the physician can make $20/hr after expenses, encourage proper allocation of time, but the 'co-pay' environment, where the insurer caps everything at a 99214 (which one can perform in 4 minutes) so the patient with 9 interacting problems who you spend 40 minutes with and try to bill a 99215 (which may pay $100/40min versus $50/4 minutes, so you don't even meet overhead), you get a kangaroo-court "audit" where your services are deemed 'not medically necessary' and you are threatened with fines (or jail, in the case of Anthem/Medicare).

    So doctors do what they are paid to do, which is 4 minute visits.

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