In the meta-analysis and systematic review by Qiao et al regarding the assessment of cardiac involvement in systemic sclerosis (SSc) using speckle tracking echocardiography the authors have reported that left ventricular (LV) global longitudinal strain (GLS) is lower in SSc patients than in healthy control subjects 1. While not specifically stated by the authors, it could possibly be concluded from this finding that there is now evidence to support performance of GLS during the screening of SSc patients and the use of this GLS result for early diagnosis of myocardial involvement. However, there are a number of reasons why such a conclusion should be considered premature. (1) There remain significant discrepancies in the literature with respect to the effect of SSc on GLS which require explanation but have not been explained by this meta-analysis. Moreover, errors have been made in study selection, with one particularly concerning error being that one of the included studies is actually a study of multiple sclerosis, not systemic sclerosis 2. A further error is that one of the other included studies reported a standard deviation (SD) of GLS of 8.9% in the control group, a very large number which suggests substantial errors of GLS measurement in this group and should therefore have invalidated its inclusion 3. (2) In healthy subjects the absolute value of GLS decreases with age and is higher in females 4. This is of particular importance for any study of SSc given that patie...
In the meta-analysis and systematic review by Qiao et al regarding the assessment of cardiac involvement in systemic sclerosis (SSc) using speckle tracking echocardiography the authors have reported that left ventricular (LV) global longitudinal strain (GLS) is lower in SSc patients than in healthy control subjects 1. While not specifically stated by the authors, it could possibly be concluded from this finding that there is now evidence to support performance of GLS during the screening of SSc patients and the use of this GLS result for early diagnosis of myocardial involvement. However, there are a number of reasons why such a conclusion should be considered premature. (1) There remain significant discrepancies in the literature with respect to the effect of SSc on GLS which require explanation but have not been explained by this meta-analysis. Moreover, errors have been made in study selection, with one particularly concerning error being that one of the included studies is actually a study of multiple sclerosis, not systemic sclerosis 2. A further error is that one of the other included studies reported a standard deviation (SD) of GLS of 8.9% in the control group, a very large number which suggests substantial errors of GLS measurement in this group and should therefore have invalidated its inclusion 3. (2) In healthy subjects the absolute value of GLS decreases with age and is higher in females 4. This is of particular importance for any study of SSc given that patients with SSc encompass a wide age range and it is a disease which can affect males and females. The presence or absence of differences in GLS between SSc and control subjects could therefore be influenced by the age and sex makeup of each group. For example, confounding of the findings could result if most of the older subjects were females in one group and males in the other group. An effect of age and sex on the results of a study cannot be excluded simply by having non-significant differences in age and sex frequency between the SSc and control groups on univariate analysis; it requires multivariate regression analysis with adjustment for both sex and age. (4) Even in the studies in which there were statistically significant differences in GLS between SSc patients and control subjects there were often only minor differences in the means and there was substantial overlap between the ranges of GLS results in control subjects and SSc patients. Indeed, GLS is well recognized to vary over a wide range in normal subjects 4, and consistent with previous findings, in the control subjects in the studies included in this series, (excluding the study with a SD of 8.9%), the SD of GLS ranged up to 2.7%. This variability has important implications for using measured GLS to determine if an individual with SSc has impaired cardiac function. Thus, not only are there differences in GLS due to sex and age4, but if the mean GLS is -20% and the SD is 2.5% then the 95% confidence limits in normal subjects would vary from as low as -15% to as high as -25%. It is therefore problematic that -18% was used as the cutoff for normality in one GLS study in SSc 5. (5) For GLS to be clinically useful in SSc we will need evidence that its measurement leads to improvement in outcomes. The recent negative 3 year findings from the SUCCOUR study regarding the possible benefit of GLS guided cardioprotective therapy in patients undergoing potentially cardiotoxic chemotherapy have shown that an outcome benefit from the measurement of GLS might be predicted from observational evidence but cannot be assumed 6.
1. Qiao W, Bi W, Wang X, et al. Cardiac involvement assessment in systemic sclerosis using speckle tracking echocardiography: a systematic review and meta-analysis. BMJ Open 2023;13(2):e063364. doi: 10.1136/bmjopen-2022-063364
2. Mincu RI, Magda SL, Mihaila S, et al. Impaired Cardiac Function in Patients with Multiple Sclerosis by Comparison with Normal Subjects. Sci Rep 2018;8(1):3300. doi: 10.1038/s41598-018-21599-0
3. Zairi I, Mzoughi K, Jnifene Z, et al. Speckle tracking echocardiography in systemic sclerosis: A useful method for detection of myocardial involvement. Ann Cardiol Angeiol (Paris) 2019;68(4):226-31. doi: 10.1016/j.ancard.2018.08.027
4. Dalen H, Thorstensen A, Aase SA, et al. Segmental and global longitudinal strain and strain rate based on echocardiography of 1266 healthy individuals: the HUNT study in Norway. Eur J Echocardiogr 2010;11(2):176-83.
5. Jiang X, Zhang F, Li Y, et al. Clinical assessment of cardiac impairment favored by two-dimensional speckle tracking echocardiology in patients with systemic sclerosis. Rheumatology (Oxford) 2022;61(6):2432-40. doi: 10.1093/rheumatology/keab724
6. Negishi T, Thavendiranathan P, Penicka M, et al. Cardioprotection Using Strain-Guided Management of Potentially Cardiotoxic Cancer Therapy: 3-Year Results of the SUCCOUR Trial. JACC Cardiovasc Imaging 2023;16(3):269-78. doi: 10.1016/j.jcmg.2022.10.010
Thank you for your interest in our research and acknowledgment of its importance for the general population and healthcare systems. We appreciate your attention to the methods we chose for conducting the upcoming meta-analysis.
After careful consideration of your suggestions to revise a threshold for the I2 test, we agree that elimination of the 75% cut-off is suitable for addressing the first specific objective, which is to calculate the prevalence of sexual dysfunctions. The second specific objective is to find out the relationship between breast feeding types and sexual dysfunctions. To measure reliably the effect of particular feeding types on the likelihood of sexual dysfunction, we should analyze studies with matching cohorts and time since delivery. For high credibility of study findings, we will adhere to the common rule of assessing between-study heterogeneity and maintain a 75% threshold for the I2 index.
In the “Study design and data source” section we highlighted the inclusion of peer-reviewed papers in the meta-analysis. However, recent studies advocate for necessity to cover grey literature and, in particular, official reports (1). Therefore, we decided to search for reports from local and international organizations. A method proposed by Naing et al. for an official national survey is not suggested by JBI (2)(3). We will consider this technique for critical appraisal of prevalence studies rather than for sensitivity...
Thank you for your interest in our research and acknowledgment of its importance for the general population and healthcare systems. We appreciate your attention to the methods we chose for conducting the upcoming meta-analysis.
After careful consideration of your suggestions to revise a threshold for the I2 test, we agree that elimination of the 75% cut-off is suitable for addressing the first specific objective, which is to calculate the prevalence of sexual dysfunctions. The second specific objective is to find out the relationship between breast feeding types and sexual dysfunctions. To measure reliably the effect of particular feeding types on the likelihood of sexual dysfunction, we should analyze studies with matching cohorts and time since delivery. For high credibility of study findings, we will adhere to the common rule of assessing between-study heterogeneity and maintain a 75% threshold for the I2 index.
In the “Study design and data source” section we highlighted the inclusion of peer-reviewed papers in the meta-analysis. However, recent studies advocate for necessity to cover grey literature and, in particular, official reports (1). Therefore, we decided to search for reports from local and international organizations. A method proposed by Naing et al. for an official national survey is not suggested by JBI (2)(3). We will consider this technique for critical appraisal of prevalence studies rather than for sensitivity analysis.
In conclusion, we would like to thank you for providing suggestions on improvement the study methodology and encouraging greater reflection and debate. The proposed tools are acknowledged and can be considered at the time of statistical analysis of the literature.
References:
1. Paez A. Gray literature: An important resource in systematic reviews. J Evid-Based Med. 2017;10(3):233–40.
2. Naing L, Winn T, Rusli BN. Practical issues in calculating the sample size for prevalence studies. Arch Orofac Sci. 2006;1:9–14.
3. Munn Z, Moola S, Lisy K, Riitano D, Tufanaru C. Methodological guidance for systematic reviews of observational epidemiological studies reporting prevalence and cumulative incidence data. JBI Evid Implement. 2015;13(3):147–53.
We sincerely thank Al-Haddad for their interest and support of our article (Healey SJR, Fakes K, Nair BR. Inequitable treatment as perceived by international medical graduates (IMGs): a scoping review. BMJ Open 2023;13:e071992.)
At the time of writing, we were able to only access GMC data from 2020 (The changing medical workforce. General medical council [PDF]. 2020. P103. Available: https://www.gmc-uk.org/-/media/documents/somep-2020_pdf-84684244.pdf), which estimates the combined EEA (European Economic Area) and IMG (International Medical Graduate) figure at about 36%. Increased numbers of IMGs (including EEA) over more recent years, in the new data Al-Haddad has cited, calls for even greater need to better explore and action the needs and challenges faced by all IMGs in the UK and indeed across the world. We strongly support further study into this much needed area.
Dear Editor
I read with interest the paper by Jasim and co-authors that described a focus group exploration of patients’ and public experiences of the UK NHS elective total joint arthroplasty pathway. (1)
The results were interesting – especially when the patient journey was described as a maze rather than a pathway. Even though the number of participants was small, the message was clear: there was a lack of patient-centredness to the pathway.
However, a greater issue is if anything can be done about the problem. In the future, it is likely that all care pathways will be electronic. Thus, it is tempting to believe that technological advances will enable the pathway to be much more personalised to the needs of individual patients.
In the future, could pathways automatically start where patients are rather than where the system assumes they should? Could pathways automatically and immediately tell patients where they are in their journey so that they are fully informed in real time? Could pathways enable patients to get to their destination by the quickest possible route?
Technology would also allow healthcare providers to continually track patients along different pathways. Doctors would see where patients might have been blocked and where some might have stepped off the pathway. This could potentially happen with all patients so the number of participants analysed would be far higher and results far more reliable.
Yours
Cath...
Dear Editor
I read with interest the paper by Jasim and co-authors that described a focus group exploration of patients’ and public experiences of the UK NHS elective total joint arthroplasty pathway. (1)
The results were interesting – especially when the patient journey was described as a maze rather than a pathway. Even though the number of participants was small, the message was clear: there was a lack of patient-centredness to the pathway.
However, a greater issue is if anything can be done about the problem. In the future, it is likely that all care pathways will be electronic. Thus, it is tempting to believe that technological advances will enable the pathway to be much more personalised to the needs of individual patients.
In the future, could pathways automatically start where patients are rather than where the system assumes they should? Could pathways automatically and immediately tell patients where they are in their journey so that they are fully informed in real time? Could pathways enable patients to get to their destination by the quickest possible route?
Technology would also allow healthcare providers to continually track patients along different pathways. Doctors would see where patients might have been blocked and where some might have stepped off the pathway. This could potentially happen with all patients so the number of participants analysed would be far higher and results far more reliable.
Yours
Catherine Walsh
References
1) Jasim S, Aspinal F, Mehta R, et al
‘Maze’ not pathway: focus group exploration of patients’ and public experiences of the UK NHS elective total joint arthroplasty pathway
BMJ Open 2023;13:e066762.
The study could capture sensible data, which is known to be notoriously difficult to acquire. But the study fails to achieve its primary objective, which is the feasibility of community surveillance for assessing suicides and attempt suicides. It only answers the second objective: added benefits of community surveillance to hospital and police records.
India is often referred to as a ‘nation within nations’ and such community interventions studied in a specific area (2 districts in the state of Gujarat) cannot be generalised for the Nation, but further multicentric studies will help in better understanding.
The study recruited a good number of informants (833), 13% of them dropped out of the study. Even after recruiting such a huge number, 42(36%) attempted suicides and 26 (30%) suicides had only a single informer, which is not ideal for the validity of the results. This also shows if community surveillance has to be implemented, it will require huge manpower at the community level to support the same.
The researchers employed data triangulation by comparing information from hospital records, police records, and data obtained through community surveillance. This approach not only increased the study's validity but also uncovered 55 (63%) suicide cases that had not been documented elsewhere, highlighting the limitations of existing systems. However, it is crucial to acknowledge that a quarter of the hospitals(13 out of 53) in the area did not contribu...
The study could capture sensible data, which is known to be notoriously difficult to acquire. But the study fails to achieve its primary objective, which is the feasibility of community surveillance for assessing suicides and attempt suicides. It only answers the second objective: added benefits of community surveillance to hospital and police records.
India is often referred to as a ‘nation within nations’ and such community interventions studied in a specific area (2 districts in the state of Gujarat) cannot be generalised for the Nation, but further multicentric studies will help in better understanding.
The study recruited a good number of informants (833), 13% of them dropped out of the study. Even after recruiting such a huge number, 42(36%) attempted suicides and 26 (30%) suicides had only a single informer, which is not ideal for the validity of the results. This also shows if community surveillance has to be implemented, it will require huge manpower at the community level to support the same.
The researchers employed data triangulation by comparing information from hospital records, police records, and data obtained through community surveillance. This approach not only increased the study's validity but also uncovered 55 (63%) suicide cases that had not been documented elsewhere, highlighting the limitations of existing systems. However, it is crucial to acknowledge that a quarter of the hospitals(13 out of 53) in the area did not contribute to the study, potentially impacting the assessment of the incremental advantages of community surveillance over the current system. Additionally, the non-response from the private hospitals emphasizes the potential need for legislative measures, such as an act or law, to mandate data sharing by private institutions if community surveillance and data triangulation are to be effectively implemented.
We can also note that Table 3 provides a comprehensive comparison of the ability of community surveillance, hospital records, and police records to obtain additional data on suicide attempts. While the table offers valuable insights into the effectiveness of these data sources, it is important to note the presence of missing values, particularly in the "Police records" row. Missing values can impact the validity and interpretability of statistical tests, such as the McNemar's χ2 test. The McNemar's test is designed for paired categorical data, comparing the frequency of discordant pairs (those changing from case to non-case or vice versa) between two related samples. However, in cases where data is missing or unavailable for one of the paired variables, the test's assumptions are not met, rendering it inappropriate for analysis.
In the "Police records" row of Table 3, there are instances where values are missing (e.g., the number of cases and non-cases for police records). As a result, conducting a McNemar's test between "Community surveillance" and "Police records" would be methodologically unsound due to the absence of complete paired data. This limitation prevents us from making direct statistical comparisons between these two sources using the McNemar's test.To address this limitation, researchers should explore alternative approaches, such as imputing missing values or employing other statistical tests suitable for incomplete or unpaired data. Additionally, the interpretation of results should carefully consider the presence of missing values and potential implications on the overall findings and conclusions.
The study gives valuable information about the existence of a data gap in suicides and attempted suicides. This will help researchers to carefully deal with the existing data available on suicides. The article also offers Community surveillance as a potential solution to enhance suicide surveillance and prevention efforts. However, the article falls short in substantiating its feasibility. To address this gap, a multicentric study encompassing India's Cultural and Contextual diversities, evaluating Resources, Infrastructure, Stakeholder Engagement, Scalability, and Sustainability, and comparing the intervention against the gold standard (household survey) is needed. Such an approach will offer a deeper understanding of the viability of community surveillance.
I read with interest the article titled ‘Inequitable treatment as perceived by international medical graduates (IMGs): a scoping review’ by Healey, Fakes and Nair.[1] The authors present their findings on an important issue that affects IMGs worldwide. In the introduction, the authors point out that 1:3 of doctors in the UK are foreign-trained. This proportion is not accurate and stems from confusion about who an IMG is, and how the General Medical Council (GMC) in the UK presents data on IMGs.
An IMG is a doctor who practices medicine in a country different to their country of primary medical qualification (PMQ)[2]; a definition which Healey and colleagues agree with and use for their scoping review.[1] The understandable confusion arises when they and other authors quote figures on the proportion of IMGs in the UK and refer to publications from the GMC. The GMC’s definition of an ‘IMG’ is a doctor whose country of PMQ is outside Europe and practices medicine in the UK.[3] The GMC uses this definition for practical reasons as the process of registering for a license to practice in the UK for doctors whose country of PMQ is within Europe is different to doctors whose country of PMQ is outside Europe.[4] The GMC register in August 2023 showed that the proportion of ‘IMGs’ by the GMC’s definition was indeed 32.5% (i.e., 1:3). However, the proportion of doctors whose PMQ was from Europe was 10%. Therefore, the true proportion of IMGs in the UK is 42.5%.
I read with interest the article titled ‘Inequitable treatment as perceived by international medical graduates (IMGs): a scoping review’ by Healey, Fakes and Nair.[1] The authors present their findings on an important issue that affects IMGs worldwide. In the introduction, the authors point out that 1:3 of doctors in the UK are foreign-trained. This proportion is not accurate and stems from confusion about who an IMG is, and how the General Medical Council (GMC) in the UK presents data on IMGs.
An IMG is a doctor who practices medicine in a country different to their country of primary medical qualification (PMQ)[2]; a definition which Healey and colleagues agree with and use for their scoping review.[1] The understandable confusion arises when they and other authors quote figures on the proportion of IMGs in the UK and refer to publications from the GMC. The GMC’s definition of an ‘IMG’ is a doctor whose country of PMQ is outside Europe and practices medicine in the UK.[3] The GMC uses this definition for practical reasons as the process of registering for a license to practice in the UK for doctors whose country of PMQ is within Europe is different to doctors whose country of PMQ is outside Europe.[4] The GMC register in August 2023 showed that the proportion of ‘IMGs’ by the GMC’s definition was indeed 32.5% (i.e., 1:3). However, the proportion of doctors whose PMQ was from Europe was 10%. Therefore, the true proportion of IMGs in the UK is 42.5%.
Rectifying this misrepresentation of the proportion of IMGs in the UK is not merely a pedantic exercise but is important for other reasons. First, the proportion of 42.5% is significantly higher than 32.5% and illustrates the larger scale of the issues faced by IMGs in the UK. Second, the experiences of IMGs are similar whether their country of PMQ is from Europe or outside Europe[2 5], as is the gap in their educational attainment compared to UK graduates which is demonstrated in educational outcome data from the GMC.[6] Finally, if the GMC’s definition of ‘IMGs’ is used in the UK, there is a risk of excluding European graduate IMGs in the UK from interventions that are designed to address the educational gap between them and UK graduates.[7]
Dear BMJ Open,
Having perused the article titled "A Protocol for a Systematic Review and Meta-analysis Investigating the Risk of Sexual Dysfunctions in Breastfeeding Females," I found it captivating and of great significance to the general population. The notion behind this study is innovative, as it tackles the concerns of numerous patients who worry about potential sexual disturbances during breastfeeding. I firmly believe that this article will provide invaluable insights into a topic that greatly interests a wide audience.
Given my keen interest in this study, and with the aim of enhancing its quality and the reliability of the final findings, I would like to offer a few suggestions.
Firstly, the authors mention their intent to perform a meta-analysis only if the heterogeneity index falls below 75% (I2 ≤ 75%). As you are well aware, prevalence studies often exhibit substantial residual heterogeneity. Such heterogeneity is inherent in the nature of these studies and has been deemed acceptable within the existing literature (1, 2). In fact, many high-quality prevalence meta-analyses have reported I2 values exceeding 90% and even 99%, despite attempts to mitigate heterogeneity through techniques like subgroup analyses (3-6). Therefore, I contend that imposing strict eligibility criteria for inclusion in the meta-analyses would be ill-suited for this study, as it is expected to encompass numerous situations with high I2 values. Excluding a signi...
Dear BMJ Open,
Having perused the article titled "A Protocol for a Systematic Review and Meta-analysis Investigating the Risk of Sexual Dysfunctions in Breastfeeding Females," I found it captivating and of great significance to the general population. The notion behind this study is innovative, as it tackles the concerns of numerous patients who worry about potential sexual disturbances during breastfeeding. I firmly believe that this article will provide invaluable insights into a topic that greatly interests a wide audience.
Given my keen interest in this study, and with the aim of enhancing its quality and the reliability of the final findings, I would like to offer a few suggestions.
Firstly, the authors mention their intent to perform a meta-analysis only if the heterogeneity index falls below 75% (I2 ≤ 75%). As you are well aware, prevalence studies often exhibit substantial residual heterogeneity. Such heterogeneity is inherent in the nature of these studies and has been deemed acceptable within the existing literature (1, 2). In fact, many high-quality prevalence meta-analyses have reported I2 values exceeding 90% and even 99%, despite attempts to mitigate heterogeneity through techniques like subgroup analyses (3-6). Therefore, I contend that imposing strict eligibility criteria for inclusion in the meta-analyses would be ill-suited for this study, as it is expected to encompass numerous situations with high I2 values. Excluding a significant number of studies from quantitative evidence synthesis would result in missing data, thereby reducing the statistical power of the analyses and potentially introducing bias.
Secondly, the article mentions that sensitivity analyses will be performed solely using the leave-one-out method. Considering that this study incorporates prevalence studies and gray literature, where sample sizes often vary and peer-review may be lacking, I propose that the authors expand their investigation into sensitivity by considering the sufficiency of sample sizes and the inclusion of peer-reviewed reports. To conduct a comprehensive sensitivity analysis, I suggest utilizing the tool proposed by Naing et al. (which is also employed in JBI tools) (7).
1. Higgins JP. Commentary: Heterogeneity in meta-analysis should be expected and appropriately quantified. Int J Epidemiol. 2008;37(5):1158-60.
2. Migliavaca CB, Stein C, Colpani V, Barker TH, Ziegelmann PK, Munn Z, et al. Meta-analysis of prevalence: I(2) statistic and how to deal with heterogeneity. Res Synth Methods. 2022;13(3):363-7.
3. Ardekani A, Sepidarkish M, Mollalo A, Afradiasbagharani P, Rouholamin S, Rezaeinejad M, et al. Worldwide prevalence of human papillomavirus among pregnant women: A systematic review and meta-analysis. Rev Med Virol. 2023;33(1):e2374.
4. Hooi JKY, Lai WY, Ng WK, Suen MMY, Underwood FE, Tanyingoh D, et al. Global Prevalence of Helicobacter pylori Infection: Systematic Review and Meta-Analysis. Gastroenterology. 2017;153(2):420-9.
5. Cohen A, Mathiasen VD, Schön T, Wejse C. The global prevalence of latent tuberculosis: a systematic review and meta-analysis. Eur Respir J. 2019;54(3).
6. Stockdale AJ, Kreuels B, Henrion MYR, Giorgi E, Kyomuhangi I, de Martel C, et al. The global prevalence of hepatitis D virus infection: Systematic review and meta-analysis. J Hepatol. 2020;73(3):523-32.
7. Naing L, Winn T, Nordin R. Pratical Issues in Calculating the Sample Size for Prevalence Studies. Archives of Orofacial Sciences. 2006;1.
Dear sirs,
Practically all therapeutic modalities for the treatment of C. difficile enteritis have one thing in common. They are hugely expensive limiting their use even in affluent societies. Alanyl-glutamine is an exciting approach, as it is a relatively simple molecule, and may therefore be cheaper.
A very old treatment tool exists however, that has been very rarely studied or used in recent years: bismuth. There is data that it is effective in C. difficile enteritis, has very few negative effects and is dirt cheap. The latter is probably one of the reasons for the lack of motivation for research about it. The use of bismuth salts in treating C. difficile enteritis is something definitely worthy of further study. Besides the 100 plus years of experience with bismuth, no approval or licencing is necessary.
Yours sincerely
Z. Lengyel MD, PhD.
The authors of the study protocol of the OECD International Survey of People Living with Chronic Conditions (PaRIS survey) wish to inform readers about some changes in the study protocol and implementation of the Main Survey.
Study protocol
As mentioned in the published article (see Protocol amendments), the study protocol would be modified based on the experiences with and results of the Field Trial. These modifications include:
1. Calculation of the sample sizes
Sample sizes for the Main Survey were based on statistical simulations carried out on the data collected in the Field Trial. The simulations were conducted with the data of four main outcome measures: the Physical Health and Mental Health scales of the PROMIS® Scale v1.2 – Global Health, the WHO-5 Wellbeing Index, and the Person-centred Coordinated Care Experience Questionnaire (P3CEQ). The main criterion for determining the sample size was the reliability of country-level estimates for each of the four scales. Given the characteristics of the scales and the clustering within practices and countries, the value of this reliability depends largely on the number of practices per country and the number of patients per practice. The reliability of each scale was simulated for different combinations of numbers of primary care practices and patients per practice. The combination of 100 practices and 75 patients per practice resulted in sufficiently reliable scales (>.70) at country level. Th...
The authors of the study protocol of the OECD International Survey of People Living with Chronic Conditions (PaRIS survey) wish to inform readers about some changes in the study protocol and implementation of the Main Survey.
Study protocol
As mentioned in the published article (see Protocol amendments), the study protocol would be modified based on the experiences with and results of the Field Trial. These modifications include:
1. Calculation of the sample sizes
Sample sizes for the Main Survey were based on statistical simulations carried out on the data collected in the Field Trial. The simulations were conducted with the data of four main outcome measures: the Physical Health and Mental Health scales of the PROMIS® Scale v1.2 – Global Health, the WHO-5 Wellbeing Index, and the Person-centred Coordinated Care Experience Questionnaire (P3CEQ). The main criterion for determining the sample size was the reliability of country-level estimates for each of the four scales. Given the characteristics of the scales and the clustering within practices and countries, the value of this reliability depends largely on the number of practices per country and the number of patients per practice. The reliability of each scale was simulated for different combinations of numbers of primary care practices and patients per practice. The combination of 100 practices and 75 patients per practice resulted in sufficiently reliable scales (>.70) at country level. Therefore, we estimate that an average of 100 primary care practices per country and 75 eligible patients per primary care practice (7500 eligible patients per country) are required to be able to demonstrate meaningful differences in patient-reported care experiences and outcomes among the participating countries.
2. Final changes to the survey instruments
Minor modifications were made to the questionnaire for primary care service users. In some cases, more explanation was provided and for some questions and response options the wording was revised to improve consistency or clarity. The resulting final questionnaire consists of 119 items, including the aforementioned core instruments.
In the questionnaire for primary care practices the questions on the impact of the COVID-19 outbreak on primary care delivery were removed as they were no longer relevant and also to shorten the questionnaire. Furthermore, some changes were made to questions that did no not perform well in the Field Trial. This was particularly the case for a set of questions on patient care plans. The final questionnaire for primary care practices consists of 34 items.
Implementation of the survey
England (UK) has withdrawn from the survey after the Field Trial because of changed policy priorities.
The PaRIS survey is an OECD initiative. Interested OECD member and non-member states can participate in future cycles of the PaRIS survey by signing a participation agreement between the Ministry of Health and the OECD Secretariat.
Contributors:
Mieke Rijken, Project Director & Senior Researcher / Professor, Nivel (Netherlands Institute for Health Services Research), Utrecht / University of Eastern Finland, Kuopio
Marta Ballaster, Project Coordinator, Avedis Donabedian Research Institute (FAD), Barcelona / Universitat Autònoma de Barcelona (UAB), Barcelona
Janika Bloemeke, Senior Research and Innovation Manager, Optimedis AG, Hamburg (Germany)
Dolf de Boer, Senior Advisor / former Project Director, Nivel (Netherlands Institute for Health Services Research), Utrecht
Wienke Boerma, Senior Researcher, Nivel (Netherlands Institute for Health Services Research), Utrecht
Katherine de Bienassis, Health Policy Analyst, Organisation for Economic Co-operation and Development (OECD), Paris
Peter Groenewegen, Senior Researcher / Professor, Nivel (Netherlands Institute for Health Services Research), Utrecht / Utrecht University, Sociology / Human Geography, Utrecht
Oliver Groene, Head Research and Innovation Department & Vice-Chairman of the Board / Professor, Optimedis AG, Hamburg / Witten/Herdecke University, Witten
Frederico Guanais, Deputy Head of Health Division, Organisation for Economic Co-operation and Development (OECD), Paris
Judith de Jong, Co-Project Director & Head of Research Department / Professor, Nivel (Netherlands Institute for Health Services Research), Utrecht / Maastricht University, CAPHRI, Maastricht
Candan Kendir, Health Policy Analyst, Organisation for Economic Co-operation and Development (OECD), Paris
Niek Klazinga, Coordinator Healthcare Quality Indicator Programme / Professor, Organisation for Economic Co-operation and Development (OECD), Paris / University of Amsterdam, Amsterdam
Ian Porter, Associate Research Fellow, University of Exeter Medical School, APEx, Exeter
Rosa Sunol, President of Board of Trustees / Professor, Avedis Donabedian Research Institute (FAD), Barcelona / Universitat Autònoma de Barcelona (UAB), Barcelona
Laura Thomas, Research Director, Ipsos, London
José Maria Valderas, Professor, University of Exeter Medical School, APEx, Exeter / National University of Singapore, Singapore
Rachel Williams, Research Director, Ipsos, London
Michael van den Berg, Health Policy Analyst, Organisation for Economic Co-operation and Development (OECD), Paris
This important study will help helpers help people living with chronic pain.[1] The expert team – including researchers, clinicians, and patients – reminds us that the experience of chronic pain affects many parts of patients’ lives. The validity, meaning, and authenticity of their insights are strengthened by their use of the PaCER approach - Patient and Community Engagement Research.[2]
Suffering can be more than pain. An even fuller vision of suffering is captured by the Comprehensive Clinical Model of Suffering (CCMS).[3] Both models emphasize the experience of grief, the story of the journey, and the value of acceptance.
Patients with chronic pain and suffering deserve help on their journeys with careful assessment, daily coping strategies, and multiple support sources of support.
The role of helpers and healers starts with recognition and diagnosis. The patient’s healing journey can be supported by witnessing, empathy, and continuity of care.[3,4] Healing can come through finding meaning and editing the narrative of the experience. [5,6]
To provide this recognition, assessment, management, and support, we must improve the training of our healing and helping professionals [7], advance research, and improve the models that guide understanding and care.[8]
REFERENCES
1. Bruce M, Lopatina E, Hodge J, et al. Understanding the chronic pain journey and coping strategies that patients use to manage their chronic pain: a qualitative,...
This important study will help helpers help people living with chronic pain.[1] The expert team – including researchers, clinicians, and patients – reminds us that the experience of chronic pain affects many parts of patients’ lives. The validity, meaning, and authenticity of their insights are strengthened by their use of the PaCER approach - Patient and Community Engagement Research.[2]
Suffering can be more than pain. An even fuller vision of suffering is captured by the Comprehensive Clinical Model of Suffering (CCMS).[3] Both models emphasize the experience of grief, the story of the journey, and the value of acceptance.
Patients with chronic pain and suffering deserve help on their journeys with careful assessment, daily coping strategies, and multiple support sources of support.
The role of helpers and healers starts with recognition and diagnosis. The patient’s healing journey can be supported by witnessing, empathy, and continuity of care.[3,4] Healing can come through finding meaning and editing the narrative of the experience. [5,6]
To provide this recognition, assessment, management, and support, we must improve the training of our healing and helping professionals [7], advance research, and improve the models that guide understanding and care.[8]
REFERENCES
1. Bruce M, Lopatina E, Hodge J, et al. Understanding the chronic pain journey and coping strategies that patients use to manage their chronic pain: a qualitative, patient-led, Canadian study. BMJ Open 2023;13:e072048. DOI:10.1136/bmjopen-2023-072048
3. Phillips WR, Uygur JM, Egnew TR. A comprehensive clinical model of suffering. J Am Board Fam Med. 2023; 36:344-355; DOI: 10.3122/jabfm.2022.220308R1.
4. Scott JG, Cohen D, Dicicco-Bloom B, Miller WL, Stange KC, Crabtree BF. Understanding healing relationships in primary care. Ann Fam Med. 2008; 6(4): 315–322. DOI: 10.1370/afm.860
5. Egnew TR. Suffering, meaning, and healing: challenges of contemporary medicine. Ann Fam Med. 2009; 7(2): 170–175. DOI: 10.1370/afm.943
6. Egnew TR. A narrative approach to healing chronic illness. Ann Fam Med. 2018; 16(2): 160-165. DOI: 10.1370/afm.2182
7. Egnew TR, Lewis PR, Myers KR, Phillips WR. Medical student perceptions of their education about suffering. Fam Med. 2017; 49(6): 423–429.
8. Hsu C, Phillips WR, Sherman KJ, Hawkes R, Cherkin DC. Healing in primary care: a vision shared by patients, physicians, nurses, and clinical staff. Ann Fam Med. 2008; 6(4): 307–314. DOI: 10.1370/afm.838
In the meta-analysis and systematic review by Qiao et al regarding the assessment of cardiac involvement in systemic sclerosis (SSc) using speckle tracking echocardiography the authors have reported that left ventricular (LV) global longitudinal strain (GLS) is lower in SSc patients than in healthy control subjects 1. While not specifically stated by the authors, it could possibly be concluded from this finding that there is now evidence to support performance of GLS during the screening of SSc patients and the use of this GLS result for early diagnosis of myocardial involvement. However, there are a number of reasons why such a conclusion should be considered premature. (1) There remain significant discrepancies in the literature with respect to the effect of SSc on GLS which require explanation but have not been explained by this meta-analysis. Moreover, errors have been made in study selection, with one particularly concerning error being that one of the included studies is actually a study of multiple sclerosis, not systemic sclerosis 2. A further error is that one of the other included studies reported a standard deviation (SD) of GLS of 8.9% in the control group, a very large number which suggests substantial errors of GLS measurement in this group and should therefore have invalidated its inclusion 3. (2) In healthy subjects the absolute value of GLS decreases with age and is higher in females 4. This is of particular importance for any study of SSc given that patie...
Show MoreDear Dr. Majidi,
Thank you for your interest in our research and acknowledgment of its importance for the general population and healthcare systems. We appreciate your attention to the methods we chose for conducting the upcoming meta-analysis.
After careful consideration of your suggestions to revise a threshold for the I2 test, we agree that elimination of the 75% cut-off is suitable for addressing the first specific objective, which is to calculate the prevalence of sexual dysfunctions. The second specific objective is to find out the relationship between breast feeding types and sexual dysfunctions. To measure reliably the effect of particular feeding types on the likelihood of sexual dysfunction, we should analyze studies with matching cohorts and time since delivery. For high credibility of study findings, we will adhere to the common rule of assessing between-study heterogeneity and maintain a 75% threshold for the I2 index.
In the “Study design and data source” section we highlighted the inclusion of peer-reviewed papers in the meta-analysis. However, recent studies advocate for necessity to cover grey literature and, in particular, official reports (1). Therefore, we decided to search for reports from local and international organizations. A method proposed by Naing et al. for an official national survey is not suggested by JBI (2)(3). We will consider this technique for critical appraisal of prevalence studies rather than for sensitivity...
Show MoreWe sincerely thank Al-Haddad for their interest and support of our article (Healey SJR, Fakes K, Nair BR. Inequitable treatment as perceived by international medical graduates (IMGs): a scoping review. BMJ Open 2023;13:e071992.)
At the time of writing, we were able to only access GMC data from 2020 (The changing medical workforce. General medical council [PDF]. 2020. P103. Available: https://www.gmc-uk.org/-/media/documents/somep-2020_pdf-84684244.pdf), which estimates the combined EEA (European Economic Area) and IMG (International Medical Graduate) figure at about 36%. Increased numbers of IMGs (including EEA) over more recent years, in the new data Al-Haddad has cited, calls for even greater need to better explore and action the needs and challenges faced by all IMGs in the UK and indeed across the world. We strongly support further study into this much needed area.
Dear Editor
I read with interest the paper by Jasim and co-authors that described a focus group exploration of patients’ and public experiences of the UK NHS elective total joint arthroplasty pathway. (1)
The results were interesting – especially when the patient journey was described as a maze rather than a pathway. Even though the number of participants was small, the message was clear: there was a lack of patient-centredness to the pathway.
However, a greater issue is if anything can be done about the problem. In the future, it is likely that all care pathways will be electronic. Thus, it is tempting to believe that technological advances will enable the pathway to be much more personalised to the needs of individual patients.
In the future, could pathways automatically start where patients are rather than where the system assumes they should? Could pathways automatically and immediately tell patients where they are in their journey so that they are fully informed in real time? Could pathways enable patients to get to their destination by the quickest possible route?
Technology would also allow healthcare providers to continually track patients along different pathways. Doctors would see where patients might have been blocked and where some might have stepped off the pathway. This could potentially happen with all patients so the number of participants analysed would be far higher and results far more reliable.
Show MoreYours
Cath...
The study could capture sensible data, which is known to be notoriously difficult to acquire. But the study fails to achieve its primary objective, which is the feasibility of community surveillance for assessing suicides and attempt suicides. It only answers the second objective: added benefits of community surveillance to hospital and police records.
Show MoreIndia is often referred to as a ‘nation within nations’ and such community interventions studied in a specific area (2 districts in the state of Gujarat) cannot be generalised for the Nation, but further multicentric studies will help in better understanding.
The study recruited a good number of informants (833), 13% of them dropped out of the study. Even after recruiting such a huge number, 42(36%) attempted suicides and 26 (30%) suicides had only a single informer, which is not ideal for the validity of the results. This also shows if community surveillance has to be implemented, it will require huge manpower at the community level to support the same.
The researchers employed data triangulation by comparing information from hospital records, police records, and data obtained through community surveillance. This approach not only increased the study's validity but also uncovered 55 (63%) suicide cases that had not been documented elsewhere, highlighting the limitations of existing systems. However, it is crucial to acknowledge that a quarter of the hospitals(13 out of 53) in the area did not contribu...
I read with interest the article titled ‘Inequitable treatment as perceived by international medical graduates (IMGs): a scoping review’ by Healey, Fakes and Nair.[1] The authors present their findings on an important issue that affects IMGs worldwide. In the introduction, the authors point out that 1:3 of doctors in the UK are foreign-trained. This proportion is not accurate and stems from confusion about who an IMG is, and how the General Medical Council (GMC) in the UK presents data on IMGs.
An IMG is a doctor who practices medicine in a country different to their country of primary medical qualification (PMQ)[2]; a definition which Healey and colleagues agree with and use for their scoping review.[1] The understandable confusion arises when they and other authors quote figures on the proportion of IMGs in the UK and refer to publications from the GMC. The GMC’s definition of an ‘IMG’ is a doctor whose country of PMQ is outside Europe and practices medicine in the UK.[3] The GMC uses this definition for practical reasons as the process of registering for a license to practice in the UK for doctors whose country of PMQ is within Europe is different to doctors whose country of PMQ is outside Europe.[4] The GMC register in August 2023 showed that the proportion of ‘IMGs’ by the GMC’s definition was indeed 32.5% (i.e., 1:3). However, the proportion of doctors whose PMQ was from Europe was 10%. Therefore, the true proportion of IMGs in the UK is 42.5%.
Rectif...
Show MoreDear BMJ Open,
Show MoreHaving perused the article titled "A Protocol for a Systematic Review and Meta-analysis Investigating the Risk of Sexual Dysfunctions in Breastfeeding Females," I found it captivating and of great significance to the general population. The notion behind this study is innovative, as it tackles the concerns of numerous patients who worry about potential sexual disturbances during breastfeeding. I firmly believe that this article will provide invaluable insights into a topic that greatly interests a wide audience.
Given my keen interest in this study, and with the aim of enhancing its quality and the reliability of the final findings, I would like to offer a few suggestions.
Firstly, the authors mention their intent to perform a meta-analysis only if the heterogeneity index falls below 75% (I2 ≤ 75%). As you are well aware, prevalence studies often exhibit substantial residual heterogeneity. Such heterogeneity is inherent in the nature of these studies and has been deemed acceptable within the existing literature (1, 2). In fact, many high-quality prevalence meta-analyses have reported I2 values exceeding 90% and even 99%, despite attempts to mitigate heterogeneity through techniques like subgroup analyses (3-6). Therefore, I contend that imposing strict eligibility criteria for inclusion in the meta-analyses would be ill-suited for this study, as it is expected to encompass numerous situations with high I2 values. Excluding a signi...
Dear sirs,
Practically all therapeutic modalities for the treatment of C. difficile enteritis have one thing in common. They are hugely expensive limiting their use even in affluent societies. Alanyl-glutamine is an exciting approach, as it is a relatively simple molecule, and may therefore be cheaper.
A very old treatment tool exists however, that has been very rarely studied or used in recent years: bismuth. There is data that it is effective in C. difficile enteritis, has very few negative effects and is dirt cheap. The latter is probably one of the reasons for the lack of motivation for research about it. The use of bismuth salts in treating C. difficile enteritis is something definitely worthy of further study. Besides the 100 plus years of experience with bismuth, no approval or licencing is necessary.
Yours sincerely
Z. Lengyel MD, PhD.
The authors of the study protocol of the OECD International Survey of People Living with Chronic Conditions (PaRIS survey) wish to inform readers about some changes in the study protocol and implementation of the Main Survey.
Study protocol
As mentioned in the published article (see Protocol amendments), the study protocol would be modified based on the experiences with and results of the Field Trial. These modifications include:
1. Calculation of the sample sizes
Show MoreSample sizes for the Main Survey were based on statistical simulations carried out on the data collected in the Field Trial. The simulations were conducted with the data of four main outcome measures: the Physical Health and Mental Health scales of the PROMIS® Scale v1.2 – Global Health, the WHO-5 Wellbeing Index, and the Person-centred Coordinated Care Experience Questionnaire (P3CEQ). The main criterion for determining the sample size was the reliability of country-level estimates for each of the four scales. Given the characteristics of the scales and the clustering within practices and countries, the value of this reliability depends largely on the number of practices per country and the number of patients per practice. The reliability of each scale was simulated for different combinations of numbers of primary care practices and patients per practice. The combination of 100 practices and 75 patients per practice resulted in sufficiently reliable scales (>.70) at country level. Th...
This important study will help helpers help people living with chronic pain.[1] The expert team – including researchers, clinicians, and patients – reminds us that the experience of chronic pain affects many parts of patients’ lives. The validity, meaning, and authenticity of their insights are strengthened by their use of the PaCER approach - Patient and Community Engagement Research.[2]
Suffering can be more than pain. An even fuller vision of suffering is captured by the Comprehensive Clinical Model of Suffering (CCMS).[3] Both models emphasize the experience of grief, the story of the journey, and the value of acceptance.
Patients with chronic pain and suffering deserve help on their journeys with careful assessment, daily coping strategies, and multiple support sources of support.
The role of helpers and healers starts with recognition and diagnosis. The patient’s healing journey can be supported by witnessing, empathy, and continuity of care.[3,4] Healing can come through finding meaning and editing the narrative of the experience. [5,6]
To provide this recognition, assessment, management, and support, we must improve the training of our healing and helping professionals [7], advance research, and improve the models that guide understanding and care.[8]
REFERENCES
1. Bruce M, Lopatina E, Hodge J, et al. Understanding the chronic pain journey and coping strategies that patients use to manage their chronic pain: a qualitative,...
Show MorePages