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.
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...
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 Medical Research 5(11): 1361-1380. doi: 10.9734/BJMMR/2015/14285
5. Jones R (2015) Are emergency admissions contagious? Brit J Healthcare Management 21(5): 227-235.
6. Jones R (2015) Recurring Outbreaks of an Infection Apparently Targeting Immune Function, and Consequent Unprecedented Growth in Medical Admission and Costs in the United Kingdom: A Review. British Journal of Medicine and Medical Research 6(8): 735-770. doi: 10.9734/BJMMR/2015/14845
7. Jones R (2015) A new type of infectious outbreak? SMU Medical Journal 2(1): 19-25. http://smu.edu.in/content/dam/manipal/smu/documents/Journal%20Issue%203/...
8. Jones R (2015) Small area spread and step-like changes in emergency medical admissions in response to an apparently new type of infectious event. Fractal Geometry and Nonlinear Analysis in Medicine and Biology 1(2): 42-54. doi: 10.15761/FGNAMB.1000110
9. Jones R (2015) Infectious-like spread of an agent leading to increased medical hospital admission in the North East Essex area of the East of England. Fractal Geometry and Nonlinear Analysis in Medicine and Biology 1(3): 98-111. doi: 10.15761/FGNAMB.1000117
10. Jones R (2015) Simulated rectangular wave infectious-like events replicate the diversity of time-profiles observed in real-world running 12 month totals of admissions or deaths. FGNAMB 1(3): 78-79. doi: 10.15761/FGNAMB.1000114
11. Jones R (2015) A time series of infectious-like events in Australia between 2000 and 2013 leading to extended periods of increased deaths (all-cause mortality) with possible links to increased hospital medical admissions. International Journal of Epidemiologic Research 2(2): 53-67. http://ijer.skums.ac.ir/article_12869_2023.html
12. Jones R (2016) Deaths in English Lower Super Output Areas (LSOA) show patterns of very large shifts indicative of a novel recurring infectious event. SMU Medical Journal 3(2): 23-36. https://pdfs.semanticscholar.org/c3aa/71a1b78e053cba4a871093dd43aa896d9e...
13. Jones R (2016) A presumed infectious event in England and Wales during 2014 and 2015 leading to higher deaths in those with
neurological and other disorders. Journal of Neuroinfectious Diseases 7(1): 1000213 doi: 10.4172/2314-7326.1000213
14. Jones R (2016) Unusual trends in NHS staff sickness absence. BJHCM 22(4): 239-240.
15. Jones R (2016) A regular series of unexpected and large increases in total deaths (all-cause mortality) for male and female residents of mid super output areas (MSOA) in England and Wales: How high level analysis can miss the contribution from complex small-area spatial spread of a presumed infectious agent. Fractal Geometry and Nonlinear Analysis in Medicine and Biology 2(2): 1-13. doi: 10.15761/FGNAMB.1000129
16. Jones R (2017) Outbreaks of a Presumed Infectious Agent Associated with Changes in Fertility, Stillbirth, Congenital Abnormalities and the Gender Ratio at Birth. British Journal of Medicine and Medical Research 20(8): 1-36. doi: 10.9734/BJMMR/2017/32372
17. Jones R (2017) Outbreaks of a presumed infectious pathogen creating on/off switching in deaths. SDRP Journal of Infectious Diseases Treatment and Therapy 1(1): 1-6. http://www.openaccessjournals.siftdesk.org/articles/pdf/Outbreaks-of-a-p...
18. Jones R (2017) Year-to-year variation in deaths in English Output Areas (OA), and the interaction between a presumed infectious agent and influenza in 2015. SMU Medical Journal 4(2): 37-69. http://smu.edu.in/content/dam/manipal/smu/smims/Volume4No2July2017/SMU%2...(July%202017)%20-%204.pdf
19. Jones R (2017) A reduction in acute thrombotic admissions during a period of unexplained increased deaths and medical admissions in the UK. European Journal of Internal Medicine doi: http://dx.doi.org/10.1016/j.ejim.2017.09.007
20. Jones R (2017) Deaths and medical admissions in the UK show an unexplained and sustained peak after 2011. European Journal of Internal Medicine (in press). http://www.ejinme.com/article/S0953-6205(17)30370-9/fulltext
21. Jones R (2017) Periods of unexplained higher deaths and medical admissions have occurred previously – but were apparently ignored, misinterpreted or not investigated. European Journal of Internal Medicine (in press)
22. Jones R (2017) Age-specific and year of birth changes in hospital admissions during a period of unexplained higher deaths in England. European Journal of Internal Medicine (in press) http://www.sciencedirect.com/science/article/pii/S0953620517304053
23. Jones R (2017) Role of social group and gender in outbreaks of a novel agent leading to increased deaths, with insights into higher international deaths in 2015. Fractal Geometry and Nonlinear Analysis in Medicine and Biology 3(1): in press.
24. Jones R (2017) Different patterns of male and female deaths in 2015 in English and Welsh local authorities question the role of austerity as the primary force behind higher deaths. Fractal Geometry and Nonlinear Analysis in Medicine and Biology 3(2): in press.
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.
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...
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 budgets prevents the updating of evidence based practices.
• Morale: Although difficult to quantify, the over burdening of staff caused by an erosion of pay, facilities, pharmacological and investigative armamentarium has led to a decrease in staff morale. Trainees are no longer applying for run through training whilst they analyse their options, resulting in the loss of enthusiastic middle grade staff that were once essential for the delivery of first class health care.
We therefore have the perfect storm and with it the adverse effect upon mortality is clear. Funding must be increased if we are to avoid the unnecessary and preventable loss of life..
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.
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...
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 bold front page headline conveys certainty around its safety, which is irresponsible.
Such misreporting may boost newspaper sales, but does not benefit public health. Providing a health message in plain contradiction to existing Department of Health guidelines, when this is explicitly not supported by the research supposedly being reported, is irresponsible. Today’s unborn babies won’t be buying copies of your paper anytime soon, but one day this misreporting could cost them, and the nation looking after them, very dearly."
Yours,
Dr Luisa Zuccolo, on behalf of the authors of “Low alcohol consumption and pregnancy and childhood outcomes: time to change guidelines indicating apparently ‘safe’ levels of alcohol during pregnancy? A systematic review and meta-analysis. BMJ Open doi 10.1136/bmjopen-2016-015410”
Despite our hard work communicating the message without ambiguity to the media and answering personally all media calls, some coverage ‘got it wrong', which was completely beyond our control. We appreciate efforts by public health and clinical colleagues like yourselves to point out which messages are misleading or plain wrong, striving for trustworthy information in this dangerous era of 'Fake news'. "
The open access journal 'Roars Transactions, a Journal on Research Policy and Evaluation' has published on 2 November 2017 a paper with reflections on the unavailability of the ICMJE disclosure form of Dr. Moylan.
The title of this paper is: 'Is partial behaviour a plausible explanation for the unavailability of the ICMJE disclosure form of an author in a BMJ journal?'.
The paper can be accessed at https://riviste.unimi.it/index.php/roars/article/view/9073 The paper is published in the section ‘Discussion notes’. The editors of 'Roars Transactions, a Journal on Research Policy and Evaluation' are encouraging readers to submit comments / responses. These comments / responses will be published alongside the paper. I am hereby inviting the readers of this eletter to submit comments / responses about this topic to both journals (BMJ Open and Roars Transactions, a Journal on Research Policy and Evaluation). Copy/pasted from the Abstract of my new paper:
'This case study about the ethical behaviour in the field of scholarly publishing documents an exception on the rule for research articles in the medical journal BMJ Open that ICMJE disclosure forms of authors must be made available on request. The ICMJE, the International Committee of Medical Journal Editors, has developed these forms for the disclosure of conflicts of interest for authors of medic...
The open access journal 'Roars Transactions, a Journal on Research Policy and Evaluation' has published on 2 November 2017 a paper with reflections on the unavailability of the ICMJE disclosure form of Dr. Moylan.
The title of this paper is: 'Is partial behaviour a plausible explanation for the unavailability of the ICMJE disclosure form of an author in a BMJ journal?'.
The paper can be accessed at https://riviste.unimi.it/index.php/roars/article/view/9073 The paper is published in the section ‘Discussion notes’. The editors of 'Roars Transactions, a Journal on Research Policy and Evaluation' are encouraging readers to submit comments / responses. These comments / responses will be published alongside the paper. I am hereby inviting the readers of this eletter to submit comments / responses about this topic to both journals (BMJ Open and Roars Transactions, a Journal on Research Policy and Evaluation). Copy/pasted from the Abstract of my new paper:
'This case study about the ethical behaviour in the field of scholarly publishing documents an exception on the rule for research articles in the medical journal BMJ Open that ICMJE disclosure forms of authors must be made available on request. The ICMJE, the International Committee of Medical Journal Editors, has developed these forms for the disclosure of conflicts of interest for authors of medical publications. The case refers to the form of the corresponding author of an article in BMJ Open on retraction notices (Moylan and Kowalczuk, 2016). The corresponding author is a member of the council of COPE, the Committee on Publication Ethics. I will argue that the unavailability of the form relates to personal conflicts of interest with the corresponding author about my efforts to retract a fatally flawed study on the breeding biology of the Basra Reed Warbler Acrocephalus griseldis. I describe my attempts to get the form and I will argue that its unavailability can be attributed to partial behaviour by BMJ, the publisher of BMJ Open. This study complements other sources reporting ethical issues at COPE.'
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...
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 stroke from the index date to the end point, taking into account the immortal time between discharged date (index time) and the date of first acupuncture treatmentafter stroke admission (follow-up start) in the acupuncture group.
However, we believe that misclassified immoral time bias is still present in this study from the definition of acupuncture treatment group. Immortal time typically arises when, by design, the outcome of interest cannot occur during a certain period of follow-up time. 4Indeed, the 5,610 patients defined as exposed to acupuncture during 2000 to 2009 had to have at least five (5) courses of acupuncture treatment. The bias is introduced because the time between the first and five (5) courses of acupuncture treatment during follow-up is “immortal”, that is, the patients must be dementia-free to have received the five (5) courses of acupuncture treatment. Misclassification of this immoral time can lead to overestimated beneficial effects.
Based on the data presented in the study, the 5,610 patients who received five (5) courses of acupuncture treatment generated 27,208 person-years of exposer (720 events, 26.5 per 1000 person-years) and other 5,610 patients for non-acupuncture group generated 29,594 person-years of exposer (1,025 events, 34.6 per 1000 person-years). However, Suissa S3. said that immoral time bias is introduced by misclassifying unexposed person-time as exposed person-time. Therefore, it would be informative if the authors repeated their analysis using a time-dependent approach or introducing lagging time to reduce detection bias. We believe that this reanalysis would provide a more realistic effect of acupuncture treatment of dementia in this population.
References
1. Shih, Chun-Chuan, et al. "Risk of dementia in patients with non-haemorrhagic stroke receiving acupuncture treatment: a nationwide matched cohort study from Taiwan’s National Health Insurance Research Database." BMJ open 7.6 (2017):e013638. doi: 10.1136/bmjopen-2016-013638.
2. Suissa S. Immortal time bias in pharmaco-epidemiology. American journal of epidemiology. 2008 Feb 15;167(4):492-9.
3. Suissa S, Azoulay L. Metformin and the risk of cancer: time-related biases in observational studies. Diabetes care. 2012 Dec;35(12):2665-73.
4. Lévesque LE, et al. Problem of immortal time bias in cohort studies: example using statins for preventing progression of diabetes. BMJ 2010;340:b5087.
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.
We have read the respective authors. We agreed with their all listeratire and proposed protocols but we would like to add in the effect of Vitamin D on oxidative stress followed by its impact on inflammation in obesity or diabetes or diet restriction/non restriction states to be highlighted. With them the impact of article will be more wider and more focused though insulin resistance is not being addressed with these vitals.
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.
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
Show More2. 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...
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.
There can be no doubt that constraints on healthcare spending has an adverse effect upon mortality.
Show MoreIf 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...
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.
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...
Show MoreThe open access journal 'Roars Transactions, a Journal on Research Policy and Evaluation' has published on 2 November 2017 a paper with reflections on the unavailability of the ICMJE disclosure form of Dr. Moylan.
The title of this paper is: 'Is partial behaviour a plausible explanation for the unavailability of the ICMJE disclosure form of an author in a BMJ journal?'.
The paper can be accessed at https://riviste.unimi.it/index.php/roars/article/view/9073 The paper is published in the section ‘Discussion notes’. The editors of 'Roars Transactions, a Journal on Research Policy and Evaluation' are encouraging readers to submit comments / responses. These comments / responses will be published alongside the paper. I am hereby inviting the readers of this eletter to submit comments / responses about this topic to both journals (BMJ Open and Roars Transactions, a Journal on Research Policy and Evaluation). Copy/pasted from the Abstract of my new paper:
'This case study about the ethical behaviour in the field of scholarly publishing documents an exception on the rule for research articles in the medical journal BMJ Open that ICMJE disclosure forms of authors must be made available on request. The ICMJE, the International Committee of Medical Journal Editors, has developed these forms for the disclosure of conflicts of interest for authors of medic...
Show MoreCorresponding 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...
Show MoreDear 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/
We have read the respective authors. We agreed with their all listeratire and proposed protocols but we would like to add in the effect of Vitamin D on oxidative stress followed by its impact on inflammation in obesity or diabetes or diet restriction/non restriction states to be highlighted. With them the impact of article will be more wider and more focused though insulin resistance is not being addressed with these vitals.
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