1013 e-Letters

  • Search strategy for this scoping review too limited and missed some JLA Priority Setting Partnerships

    I read this paper with interest - I think there is a lot to be gained from studying the James Lind Alliance approach and the diversity of methods that have been applied by James Lind partnerships. I do think however that your search strategy (and approach to searching) was unnecessarily narrow and wonder why you didn't start with the James Lind PSP website (http://www.jla.nihr.ac.uk/priority-setting-partnerships/) which lists all the JLA PSPs undertaken and would have been the best place to start. Had you done this (and/or used Google) you would have identified more JLA PSPs, including ours on pressure ulcers (reported here http://www.jla.nihr.ac.uk/priority-setting-partnerships/pressure-ulcers/ and also [1, 2]. I bring this to your attention merely because we considered extensively some of the issues your raise regarding facilitating broad participation and we have also discussed other methodological aspects.

    [1] Cullum N, Buckley H, Dumville J, Hall J, Lamb K, Madden M, Morley R, O'Meara S, Goncalves PS, Soares M, Stubbs N. Wounds research for patient benefit: a 5 year programme of research. NIHR Journals Library; 2016
    [2] Madden M, Morley R. Exploring the challenge of health research priority setting in partnership: reflections on the methodology used by the James Lind Alliance Pressure Ulce...

    Show More
  • Rapid action is needed

    As corresponding author of the only paper out of 68 that "appeared to have undertaken a reassessment, which led to a correction" I have some sympathy for the authors of the other 67 papers. We decided that it was important that the problem due to the inclusion of subsequently retracted papers needed to be brought to the attention of readers, which we assumed would be relatively rapid. After agreement with my co-authors I emailed to the journal some text to highlight the problem and for readers to ignore the principle findings and rely on a secondary analysis which had excluded the suspect trials. The first email was sent on 18th August 2017. After receiving no response or acknowledgement a second email was sent on 13th November 2018, with a third on the 30th January 2018. A response was received on the 18th February 2018 and a correction published June 2018. Therefore it took the best part of a year to flag up an uncontested correction, which was a simple thing to do. It would be of interest to see if any of the authors of the remaining 67 papers had tried or are still trying to have a correction issues.
    David Torgersoni

  • Adverse mortality trends in Scotland

    As readers will be aware, in the early years of the adverse mortality trends it was postulated that this may be due to UK government austerity. Using data at local authority level in England, Wales and Scotland this hypothesis has been questioned [1], and looks to have been a case of (inadvertent) correlation and not causation. This paper [1] also makes reference to the contribution from a series of influenza epidemics which coincidentally occurred in the austerity years.

    It has also been pointed out that the use of calendar year data has been acting to conceal complex spatiotemporal patterns affecting deaths which resemble outbreaks of an infectious agent (influenza excluded as the causative agent) [2,3]. For this very reason the Office for National Statistics has begun publishing quarterly mortality data for England [4].

    Since age standardized mortality is a single measure of mortality (with inherent assumptions), it is suggested that wider measures including single year of age patterns may need to be investigated.

    As pointed out by the Scottish study, further research is indeed required.

    1. Jones R. Austerity in the UK and poor health: Were deaths directly affected. British Journal of Healthcare Management 2019; 25(11): in press

    2. Jones R. The calendar year fallacy: the danger of reliance on calendar year data in end-of-life capacity and financial planning. International Journal Health Planning Management 2019; doi: 10.1002/hpm.2838...

    Show More
  • Please Review and Revise to Include the Acupuncture Results

    To the editors of the BMJ:

    Allina Health is a Minnesota based not-for-profit healthcare system caring for patients across our 90+ clinics, 12 hospitals, 15 pharmacies, specialty care centers and specialty medical services. This includes our Penny George Institute for Health and Healing, which brings together physical therapy, chiropractic care and acupuncture alongside our traditional healthcare system to provide whole-person-care. As one of the largest healthcare systems in the United States, we are deeply committed to making a positive difference in the opioid crisis by including access to all effective modalities of care.

    We found your recently published paper (by Kazis et al [BMJ Open 2019;9e028633] regarding their retrospective study of the association between initial health provider for low back pain with subsequent opioid use) to be a very valuable study with the potential to further shape healthcare’s response to the opioid epidemic. Unfortunately, some of the pertinent concluding evidence has been left out of the abstract - specifically acupuncture effectiveness. We are reaching out to request that you address this in order to maximize the acceptance of all effective treatments in responding to our opioid crisis.

    In the body of the study, data on three types of conservative therapists as well as various types of physicians are included. It showed that there was a decrease in both early and long-term opioid use among patients with either physi...

    Show More
  • Key reference unavailable

    Probably the most important reference cannot be reached, number 23:


    Attempting to follow it gives the message: "Sorry - we can't find the page you are looking for"

    This is the reference which provides the justification for what seems to be the extremely high carbon footprint for each inhaler. Without this, it is difficult to have any faith in the conclusions of this paper.

    In general, it is bad practice to provide a citation to a non-permanent web resource.

  • Response to Garcia Rodriguez study, September 2019

    We read with interest the recent article by Garcia Rodriguez et al. (2019) [1] “Appropriateness of initial dose of non-vitamin K antagonist oral anticoagulants in patients with non-valvular atrial fibrillation in the UK”. We have concerns that there are significant methodological flaws with the study. Consequently, we suggest that the inferences raised in the Discussion with respect to dosing of apixaban are speculative and the conclusions are not based on a considered evaluation of evidence.

    Bias resulting from misclassification of renal function
    In the study by Rodriguez, the authors state, “For each NOAC cohort, we calculated the percentage of patients appropriately dosed, both overall and according to whether the daily dose of the index NOAC was a standard or reduced dose. For this calculation, patients with missing data on renal function were assumed to have normal renal function.” To assume a ‘missing’ value as ‘normal’ is scientifically unsound, leading to significant misclassification bias which is likely to over-estimate the proportion of patients inappropriately prescribed the lower dose. It is important to note that the level of renal function recording in the THIN and CPRD databases is sub-optimal [3, 4]. We suggest that it would have been methodologically apposite to define the proportion of patients where renal function was unknown and perform a ‘known parameters’ analysis to validate the assumption and extrapolation to the total population....

    Show More
  • Regarding “Early childhood vaccination and subsequent mortality or morbidity: are observational studies hampered by residual confounding? A Danish register-based cohort study”

    The study by Jensen et al. aimed “to examine the degree of residual confounding” in the association between childhood vaccinations and subsequent morbidity and mortality [1]. Jensen et al. conclude that “our study also suggests that residual confounding may have been present in previous Danish register-based studies investigating the impact of MMR [Measles-mumps-rubella vaccine] on the morbidity outcomes respiratory syncytial virus and hospitalisation for infection until 2 years of age” [1].

    Our previous Danish register-based studies referred to in this conclusion examined the effect of having MMR (recommended at 15 months of age) compared with the 3rd dose of diphtheria– tetanus–pertussis–polio–H. influenzae type b (DTP, recommended at 3,5 and 12 months of age) as the most recent vaccine on subsequent infectious disease hospitalisations (adjusted incidence rate ratios [IRR], 0.86; 95% confidence interval [CI], 0.84-0.88) [2] and respiratory syncytial virus infections (adjusted IRR, 0.78; 95% CI, 0.66-0.93)[3].

    There are fundamental methodological differences between our previous studies and the study by Jensen et al. Therefore, the results from Jensen et al. cannot be generalized to these previous studies.

    First, to enhance exchangeability, we restricted the study population to children, who had received the first two DTP doses before 11 months of age [2, 3], to exclude children who did not receive vaccines in a timely fashion, which could be relate...

    Show More
  • New high cost users

    As nearness to death is an important contributor to hospital utilization, especially in the last six months of life, is it possible for the data to be reanalysed in relation to nearness to death in this cohort?

  • Important Omission of Acupuncture in the Abstract Does Not Reflect Results

    Dear BMJ Open Editor Adrian Aldcroft,

    We read with interest the recent paper by Kazis et al [BMJ Open 2019;9e028633], an observational retrospective study of the association between initial health provider for low back pain with subsequent opioid use.

    This included data on three types of conservative therapists as well as various types of physicians. Initial treatment from any of the former, namely physical therapists (PTs), chiropractors and acupuncturists, was associated with substantially decreased odds for both early and long-term opioid use. However, these results, though tabulated, described and discussed in the main text of the paper do not transfer in the same form to the abstract. Specifically, the acupuncture results have been removed.

    The benefits of both PT and chiropractic are stated in two places in the Results section and once in the Conclusions, but there is no mention of acupuncture. Although we understand that the sample of acupuncturists was relatively small, acupuncture reduced short and long term exposure to opioids by 75% to 90% compared to the same patient starting with a PCP, and the confidence interval was significant and similar to PT.

    Given that many people will look initially or only at the abstract, this omission misleads the reader into inferring that acupuncture did not have the same benefits as the other two conservative treatments. The implications for health care policy/access/delivery are of concern. Does a...

    Show More
  • What is driving the increase in infant mortality?

    We read with interest this paper which asserts that recent increases in infant mortality have affected poorer areas of England disproportionately. In our analyses of largely post-neonatal unexplained infant deaths we too have found a proportional increase of poorer families; markers of deprivation including maternal age, education, parity and smoking status will all impact on infant mortality. (1-3) However, it is perhaps worth pointing out that this recent increase in infant mortality in England & Wales from 2014 to 2017 is limited to neonatal deaths, the rate of post-neonatal deaths (4 weeks to 1 year old) has flat-lined in these 4 years from 1.09 deaths per 1000 live births in 2014 to 1.08 deaths per 1000 live births in 2017. Furthermore, in the data release by the Office for National Statistics (ONS) for 2017, (4) they report a 23.5% reduction in infant mortality in the most deprived areas over the last 10 years, compared with a 10.0% reduction in the most affluent areas. Using the data provided in that release on age at death we can see that the increase in overall infant mortality is driven by very early neonatal deaths of infants under 1 day old, from 1.3 per 1000 live births in 2014 to 1.5 in 2015, and 1.6 in 2016 and 2017. Mortality in all other age groups within infancy from one day to one year show reductions over that time. (4) The major contributory causes to early neonatal mortality are prematurity, congenital anomalies and infections, with a small but...

    Show More