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Welcome to the BMJ Open blog. BMJ Open is an open access journal, dedicated to publishing medical research from all disciplines and therapeutic areas.

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We will be updating the blog with news about the journal, highly accessed papers, press coverage, events and matters of interest in the open access and publishing world, and anything else that catches our eye.

Study reveals lack of supporting evidence for claims about fertility treatments

28 Nov, 16 | by Emma Gray

Many claims made by UK fertility clinics about the benefits of treatments beyond standard IVF procedures are not backed up by evidence, finds a study published in the online journal BMJ Open.

These can range from £50 for a single screening blood test to as much as £8000 for egg freezing packages.

The researchers, led by Professor Carl Heneghan at Oxford University’s Centre for Evidence Based Medicine (CEBM), say “there is a need for more information on interventions to be made available by fertility centres, to support well informed treatment decisions.”

The findings will be part of a Panorama undercover investigation broadcast on Monday 28 November at 8.30pm on BBC One.

Infertility is a significant problem, affecting about 1 in 7 UK couples, many of whom seek medical help to have a child.

UK fertility centres are regulated by the Human Fertilisation and Embryology Authority (HFEA). But despite this regulation it has been suggested that some of the treatments offered on top of routine IVF might not be evidence based, are costly, and some clinics might be using techniques that have not been stringently tested.

So the researchers set out to record claims of benefit for treatments offered on top of standard IVF by UK fertility centre websites – and identify the evidence used to support these claims.

A total of 74 fertility centre websites, incorporating 1401 web pages were examined for claims. The team found 276 claims of benefit relating to 41 different fertility interventions made by 60 of the 74 centres.

79 (29%) of the claims included numbers to explain the chances of improved fertility outcomes, but the team identified only 13 websites where any references were included, which referred to just 16 published references. Of these 16 references, only five were high level systematic review evidence.

The authors point to some study limitations, but say it is unlikely that a repeat of their analysis would change the pattern of findings substantially.

“Our findings demonstrate that whilst many claims were made on the benefits of fertility treatments, there was a lack of supporting evidence cited, with the majority of the websites providing no sources for claims made,” they conclude.

In a linked analysis published by The BMJ, Professor Heneghan and colleagues searched for evidence to support 38 interventions offered by UK fertility centres on top of standard IVF, focusing on the key outcome of live birth rates.

They found that most treatments are not supported by good evidence. The National Institute for Health and Care Excellence (NICE) provides clear advice on only 13 (34%) of the 38 interventions investigated, and systematic reviews (the highest level of available evidence) were available for only 27.

They also found that information on harms is often poorly reported.

People seeking fertility treatment need good quality evidence to make informed choices, they write. The current approach by HFEA leaves patients and clinicians to seek evidence for themselves or from staff in private clinics selling fertility services.

“We do not believe this approach is realistic.”

They say there is “an urgent need for randomised controlled trials for many interventions that are currently being offered” and call for changes in guidance to help couples make informed decisions.

Panorama: Inside Britain’s Fertility Business will be broadcast on Monday 28 November at 8:30pm on BBC One

BBC Panorama will reveal that 26 out of 27 so-called “add-on” treatments being offered by UK fertility clinics have no good scientific evidence from trials that they improve the chance of having a baby.  Some may even be harmful.

“Add-on” treatments include things like additional procedures, additional drugs or devices to house an embryo. They can cost anywhere between £100 and £3000 on top of standard fertility care.

Panorama commissioned Oxford University’s Centre for Evidence-Based Medicine to do the research, which has taken almost a year to complete.  

Researchers identified 27 treatments on offer at UK fertility clinics they considered to be “add-ons”.

Only one treatment – called endometrial scratch – had even moderate quality evidence that shows an increase in the chances of a baby with standard fertility care like IVF.  There are still question marks over the evidence for that treatment.  Due to its limitations the researchers noted there is currently a randomised trial ongoing in the UK to determine its effectiveness.  

One “add-on” treatment called Preimplantation Genetic Screening (PGS) tests embryos for abnormalities. A trial in 2007 discovered that an earlier version of this process may have lowered birth rates.  

Many clinics sell newer, more accurate versions, in some cases for up to £3000.  Initial research looks promising and randomised trials are underway, but as yet there is no high quality evidence from robust trials that these new versions improve your chances of having a baby.

Panorama found evidence that, when marketing this add-on treatment, not all clinics are giving patients the full picture to enable them to make a properly informed decision.  

A Panorama reporter went to a fertility fair in November last year and was not given the full picture about the evidence for PGS by every one of clinics she spoke to.

She approached staff from 18 British and foreign clinics at random, asking if PGS would improve her chances on top of IVF.  She told them she was 38 and had been trying for a baby for a year without success.

Five of the 18 clinics were positive about the treatment. Eight said they would only offer it to women over the age of 40 or those who had experienced repeated IVF failures.  There is currently no good scientific evidence from trials that it can increase the birth rate among women in these categories.

Only five clinics gave the full picture, saying that they would not recommend PGS because it lacked evidence.

Pre-teens whose dads embrace parenthood may be less prone to behavioural issues

22 Nov, 16 | by Emma Gray

How new fathers see themselves in child’s early years seems to be most influential

Kids whose dads adjust well to parenthood and feel confident about their new role may be less likely to have behavioural problems in the run-up to their teens, indicates research published in the online journal BMJ Open.

It’s how fathers see themselves as parents in the child’s early years, rather than the amount of direct childcare they give, that seems to be important, the findings suggest.

The nature of parenting in a child’s early years is thought to influence their short and long term wellbeing and mental health, which are in turn linked to development and educational attainment.

But it’s not entirely clear what impact the father’s role might have, as much of the research to date has tended to characterise paternal involvement in a child’s upbringing as one dimensional.

The researchers therefore drew on data from the Avon Longitudinal Study of Parents and Children (ALSPAC) study, which has been tracking the health of nearly 15,000 children since birth, to assess several aspects of paternal involvement.

The parents of 10,440 children who were living with both their mum and dad at the age of 8 months were asked to complete a comprehensive questionnaire about their and their child’s mental health; their attitudes to parenting; time spent on childcare; their child’s behaviour and development; as well as details of household income/education.

When the children were aged 9 and 11, their behaviour was assessed using the strength and difficulties questionnaire (SDQ). This covers emotional symptoms, behaviour (conduct) problems, hyperactivity, peer relationship issues, and helpfulness (pro-social behaviour).

Fathers’ parental involvement was measured by asking them to rate their level of agreement with 58 statements, reflecting the amount of direct childcare they engaged in, including household chores; their attitudes to parenting; the relationship with their child; and how they felt about the birth 8 weeks and 8 months afterwards.

The final analysis was based on almost 7000 9 year olds and nearly 6500 of the same children at the age of 11.

Three key factors emerged in relation to the children’s SDQ scores: (1)  fathers’ emotional response to the baby and their parenting role; (2) how much time the dads spent on direct childcare; and (3) how well they adjusted to their new role, including how confident they felt in their abilities as a parent and partner.

But emotional response and confidence in their new role were most strongly associated with lower odds of behavioural problems when their children reached 9 and 11 years of age.

A high paternal factor 1 score was associated with 21% and 19% lower odds of a higher SDQ score at the ages of 9 and 11, respectively. Similarly, a high paternal factor 3 score was associated with 28% lower odds of a higher SDQ score at both time points.

After taking account of potentially influential factors, such as age at fatherhood, educational attainment and household income, hours worked, and sex of the child, every unit increase in factor 1 scores was associated with 15% lower odds of behavioural problems at the age of 9 and 12% lower odds at the age of 11, compared with kids of the same age, sex, and family background.

Similarly, every unit increase in factor 3 scores was associated with 12% lower odds at the age of 9, and 10% lower odds at the age of 11.

This is an observational study so no firm conclusions can be drawn about cause and effect, and as the researchers note, the study dates back 25 years, since when parenting styles may have changed, so the findings may therefore not be widely generalisable.

But they write: “The findings of this research study suggest that it is psychological and emotional aspects of paternal involvement in a child’s infancy that are most powerful in influencing later child behaviour, and not the amount of time that fathers are engaged in childcare or domestic tasks in the household.”

London 2012 Olympics inspired many local kids to get more involved in sport

22 Nov, 16 | by Emma Gray

But levels of physical fitness significantly worsened

The London 2012 Olympic Games inspired many local children to get more involved in sport, reveal the results of a before and after study, published in the online journal BMJ Open.

But this inspiration did not translate into improved physical fitness, levels of which declined significantly in the aftermath of the event, the findings indicate.

When Britain was awarded host status for the Olympic Games in London 2012 in 2005, this was based on a bid which promised to “inspire a generation” and “create a legacy of sport and healthy living,” despite there being no evidence of any such outcome from previous events of this kind, say the researchers.

The Active People Survey showed an initial increase of around half a million adults participating in a weekly 30 minute session of sporting activities between April 2012 and April 2013.

But the data indicate that since then, the number of 16-25 year olds doing this has fallen, a trend that has continued, say the researchers.

To find out if London 2012 was associated with increased levels of physical activity, physical fitness and changes in body mass index (BMI), the researchers carried out a before and after study among pupils at six schools within a 50 km radius of the Olympic park in East London.

Some 733 children between the ages of 10 and 16 were assessed in 2008-9, up to 3+years before London 2012, and 931 from the same schools in 2013-14, up to 18 months afterwards.

At both time points they were quizzed about how much inspiration they took from the Games, and how much physical activity they did. Their cardiorespiratory fitness was assessed in a 20 metre shuttle run by peak V02—a measure of oxygen uptake that is linked to the capacity to perform sustained exercise.

Over half (53%) of the children said London 2012 had inspired them to try new sports/ activities.

Children who continued to take part in sports/activities in the 18 months after London 2012 were more active and fitter than those who didn’t. And average BMI was also lower among the girls.

Compared with those who said they weren’t inspired by the Olympics, peak V02 was higher among those who continued to participate in sports/activities 18 months after London 2012.

This 45% of the sample was also more physically active than those who said they were not inspired, or had been only briefly inspired, by London 2012.

But peak V02 was significantly lower after London 2012 than it had been before among all the children. This is a cause for concern as low levels of cardiorespiratory fitness in childhood are associated with a heightened risk of metabolic disorders in adulthood, say the researchers.

This is an observational study so no firm conclusions can be drawn about cause and effect. Furthermore, the researchers caution that they cannot discount the possibility that the children who had been inspired by the Olympics might already have been fitter and more active, or that other factors might have offset any fitness benefits arising from London 2012.

And the true scale of the legacy may never be known due to the lack of any appropriate measures to monitor changes associated with events like London 2012, they point out.

“High levels of inspiration to participate in new activities reported following London 2012 and positive associations with fitness are encouraging…[But] these associations must be interpreted in the context of the significant declines in fitness shown by our repeated cross-sectional comparison,” they write.

“The cost of hosting future mega-events cannot be justified based on the assumption that they will automatically produce health related benefits,” they add.

Eyes on Diabetes – World Diabetes Day 2016

14 Nov, 16 | by Hemali Bedi

 

World Diabetes Day (WDD) is celebrated by millionwdd-logo-date-ens of people around the world on November 14th each year. [1] Led by the IDF, WDD is a global campaign that aims to raise awareness of diabetes and promote efforts to tackle the condition as a global health priority. [2]

The International Diabetes Federation (IDF) estimate that 415 million adults were living with diabetes in 2015, with this number set to rise to around 642 million by 2040. [3] This is equivalent to one in 10 adults. [3]

Diabetes is the leading cause of cardiovascular disease, blindness and kidney failure in many countries around the world, but some of these complications, such as blindness, can be prevented with early detection and treatment. [3]

This year, the theme of WDD is “eyes on diabetes.” [2] Key messages of the campaign are:

  • Screening for type 2 diabetes is essential for managing the condition and reducing the risk of complications.
  • Screening for diabetes complications is a vital for the management of both types of diabetes. [2]

Highlighted articles from BMJ Open for World Diabetes Day 2016 include:

 

Sources

  1. World diabetes day 2016. Diabetes UK. https://www.diabetes.org.uk/Get_involved/World-Diabetes-Day/, accessed 8 November 2016
  2. World diabetes day. IDF. http://www.idf.org/wdd-index/about.html, accessed 31 October 2016
  3. World diabetes day 2016. IDF. http://www.idf.org/wdd-index/wdd2016.html accessed, 31 October 2016

Top 10 Most Read: The Male-Female Gap in Alcohol Use, requests for genital cosmetic surgery and opposition to standardised tobacco packaging in the UK.

8 Nov, 16 | by Ed Sucksmith

alcohol-492871_960_720

October sees six new entries make it into our top ten most read articles. In at number 2 is a systematic review investigating birth cohort changes in male-to-female ratios in indicators of alcohol use and related harms. The authors concluded that the male–female gap in alcohol use was closing over time, with women now drinking almost as much as men. At number 3 is a survey of GPs’ knowledge, attitudes and practice regarding female genital cosmetic surgery in Australia. The study found high rates of women contacting their GP about genital normality concerns, with those requesting female genital cosmetic surgery frequently having a suspected or diagnosed psychological problem.

Other new entries include a documentary analysis of opponents to standardised packaging in the UK by Dr Jenny Hatchard and colleagues from the University of Bath and Aston University. The authors found that opposition to standardised packaging was primarily undertaken by third parties with financial relationships to major tobacco manufacturers, whilst a lack of transparency regarding these links created a misleading impression of diverse and widespread opposition.

Ravnskov et al.’s systematic review on the associations between low-density-lipoprotein cholesterol and mortality remains in first place for a fifth month in a row.

 

Rank Author(s) Title
1 Ravnskov et al. Lack of an association or an inverse association between low-density-lipoprotein cholesterol and mortality in the elderly: a systematic review
2 Slade et al. Birth cohort trends in the global epidemiology of alcohol use and alcohol-related harms in men and women: systematic review and metaregression
3 Simonis et al. Female genital cosmetic surgery: a cross-sectional survey exploring knowledge, attitude and practice of general practitioners
4 Fenton et al. Systematic review of the association between dietary acid load, alkaline water and cancer
5 Power et al. Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach
6 Nazar et al. New transfer of care initiative of electronic referral from hospital to community pharmacy in England: a formative service evaluation
7 Hatchard et al. Standardised tobacco packaging: a health policy case study of corporate conflict expansion and adaptation
8 Pound et al. What do young people think about their school-based sex and relationship education? A qualitative synthesis of young people’s views and experiences
9 Dean et al. Community-based Rehabilitation Training after stroke: protocol of a pilot randomised controlled trial (ReTrain)
10 Johnson et al. Early real-world evidence of persistence on oral anticoagulants for stroke prevention in non-valvular atrial fibrillation: a cohort study in UK primary care

‘Worried well’ may be boosting their risk of heart disease

3 Nov, 16 | by Emma Gray

Potential consequences of health anxiety underlines need to treat it, say researchers

People who needlessly worry that they have, or will develop, serious illness—popularly referred to as ‘the worried well’—may be boosting their risk of developing heart disease, suggests research published in the online journal BMJ Open.

Anxiety is a known risk factor for heart disease. And health anxiety, which describes persistent preoccupation with having or acquiring a serious illness, and seeking prompt medical advice, on the basis of misattributed bodily symptoms in the absence of any physical disease, seems to be no exception, say the researchers.

And as such, it needs to be taken seriously and treated properly, they suggest.

They base their findings on 7052 participants of the Norwegian Hordaland Health Study (HUSK), a long term collaborative research project between the National Health Screening Service, the University of Bergen, and local health services.

The participants, all of whom were born between 1953 and 1957, filled in two questionnaires about their health, lifestyle, and educational attainment. And they had a physical check-up, consisting of blood tests, weight, height, and blood pressure measurements, taken between 1997 and 1999.

Levels of health anxiety were assessed using a validated scale (Whiteley Index), comprising 14 items scored from 1-5. Those (710) whose total score amounted to 31 or more were in the top 10% of the sample and considered to have health anxiety.

The heart health of all the participants was subsequently tracked using national data on hospital treatment episodes and death certification up to the end of 2009.

Anyone who received treatment for, or whose death was linked to, coronary artery disease occurring within a year of entering the study, was excluded, on the grounds that they might already have been ill.

In all, 234 (3.3%) of the entire sample had an ischaemic event—a heart attack or bout of acute angina—during the monitoring period, with the average time to the first incident just over 7 years.

But the proportion of those succumbing to heart disease was twice as high (just over 6%) among those who displayed health anxiety as it was among those who didn’t (3%).

While established risk factors for heart disease explained part of the association found, health anxiety was still linked to a heightened risk, after taking account of other potentially influential factors.

Those with health anxiety at the start of the study were 73% more likely to develop heart disease than those who weren’t in this state of mind, the analysis showed. And the higher the Whiteley Index score, the greater was the risk of developing heart disease.

This is an observational study, so no firm conclusions can be drawn about cause and effect, added to which the researchers admit that health anxiety often exists alongside other mental health issues, such as general anxiety and depression, making it hard to differentiate.

But the findings back current thinking on the potentially harmful effects of anxiety on health, they say.

“[Our research] further indicates that characteristic behaviour among persons with health anxiety, such as monitoring and frequent check-ups of symptoms, does not reduce the risk of [coronary heart disease] events,” they write.

If anything, putting the body on a permanent state of high alert may have the opposite effect, they suggest.

“These findings illustrate the dilemma for clinicians between reassuring the patient that current physical symptoms of anxiety do not represent heart disease, contrasted against the emerging knowledge on how anxiety, over time, may be causally associated with increased risk of [coronary artery disease],” they conclude.

The findings “underline the importance of proper diagnosis and treatment of health anxiety,” they add.

Current system unlikely to pick up surgeons with above average patient death rates

31 Oct, 16 | by Emma Gray

Performance within ‘expected’ range not good enough to detect outliers, say researchers

Publishing the patient death rates of individual surgeons in England is unlikely to pick up those whose mortality rates are above average, because the caseload varies so much, concludes the first analysis of its kind published in the online journal BMJ Open.  

Performance within the ‘expected’ range is too crude a measure to detect doctors whose practice might be a cause for concern, and is therefore creating a false sense of security, say the researchers.

When the patient death rates for individual surgeons were first published in June 2013, the move was hailed as a major breakthrough in transparency that would drive up standards of care in England.

But the chances of detecting a surgeon whose death rates are worse than the national average is a question of statistical power, say the researchers: in other words, the greater the caseload, the greater the ability to detect worrying trends.

To assess how reliable the available data for individual surgeons are, the researchers reviewed the outcomes for three common high risk procedures—bowel surgery, gullet surgery, and planned aortic aneurysm repair—and three common low risk procedures—hip replacement, bariatric surgery, and thyroid removal.

And they analysed every surgeon’s caseload for each of the procedures, all of which were carried out between 2010 and 2014 across England.

They focused in particular on how well these data would be able to detect a surgeon whose patient death rate in hospital or within 30 or 90 days of the patient’s discharge was between two and five times higher than the national average.

Unsurprisingly, the higher risk procedures were associated with a higher death rate of between 2.2-4.5% while the lower risk ones were associated with a death rate of 0.07-0.4%.

But caseload was an issue. For example, the average number of bowel surgery operations carried out by individual surgeons was 55 over three years, but ranged from just 3 to 237.

With an average national 90 day death rate of 3%, the national average of 55 cases provides 20% statistical power to detect a mortality rate three times the national average. That means that around 20 out of 100 individual surgeons with an actual death rate of 9% would fall outside the expected range.

But the caseload would have to be more than 200 to provide 90% statistical power of detecting a surgeon whose 90 day mortality rate is three times the national average.

Similar findings emerged for gullet surgery, where the average number of procedures was 23 over a two year period, but ranged from 10 to 81.

Based on national 30 day death rates of 2.4%, the average number of cases would provide less than 20% statistical power to detect a surgeon with a patient death rate four times the national average.

And a caseload of 300 procedures would be needed to provide 80% statistical power to detect a 90 day mortality rate twice as high as the national average over two years.

For low risk procedures, the national average caseload ranged from 48 to 75 per surgeon, meaning that fewer than 20 out of 100 surgeons with an actual mortality rate five times the national average would be picked up.

For hip replacements, for example, an annual caseload of more than 500 cases would be needed to provide 80% statistical power to pick up just one individual with a mortality rate five times the national average.

At these kinds of rates it is unlikely that a surgeon would ever perform enough procedures in his/her entire career for a mortality rate five times the national average to be detected, say the researchers.

“On the basis of these rates and published case volumes, surgeons with mortality rates in excess of that expected are highly unlikely to be detected,” they write. “Performance within an expected mortality rate range cannot therefore be considered reliable evidence of acceptable performance.”

More meaningful outcome measures are required, they say. These could include patient satisfaction, the ease with which routine daily tasks can be performed (functional health status), and other health related quality of life indicators.

And an individual’s performance could be addressed by regular internal appraisal and feedback from multiple sources, they suggest.

Interpreting performance data for individual surgeons has major implications for patient care, the individual practitioner, and their employer, they emphasise

But they conclude: “This analysis demonstrates that, for these common procedures, mortality rates are not a robust method for detecting divergent practice. It is not surprising that the performance of all but one surgeon across all six procedures was found to be acceptable.”

Women catching up with men in alcohol consumption and its associated harms

24 Oct, 16 | by Emma Gray

Trend most evident among young adults, international analysis shows

Women are catching up with men in terms of their alcohol consumption and its impact on their health, finds an analysis of the available international evidence, spanning over a century and published in the online journal BMJ Open.

The trend, known as ‘sex convergence’, is most evident among young adults, the findings show.

Historically, men have been far more likely than women to drink alcohol and to drink it in quantities that damage their health, with some figures suggesting up to a 12-fold difference between the sexes. But now evidence is beginning to emerge that suggests this gap is narrowing.

In a bid to quantify this trend over time, the researchers pooled the data from 68 relevant international studies out of a total of 314, all of which had been published between 1980 and 2014. All the studies included explicit regional or national comparisons of men’s and women’s drinking patterns across at least two time periods.

The studies included data collected between 1948 and 2014, representing people born as far back as 1891, all the way up to 2000, and including a total sample size of more than 4 million. Sixteen of the studies spanned 20 or more years; five spanned 30 or more.

The researchers used the following criteria to inform their data search: lifetime and/or current alcohol misuse or dependence; alcohol related problems; treatment for alcohol issues; and the timeframe of use and the development of related problems.

And they used 11 key indicators of alcohol use and associated harms for their analysis. These were grouped into three broad categories of: any use, which included quantities and frequency; problematic use, which included binge/heavy drinking; and the prevalence of associated harms.

Births were grouped into cohorts—specific timeframes from 1891 to 2000—all of which spanned 5 years, with the exception of the first (1891-1910) and the last (1991-2000).

The pooled data showed that the gap between the sexes consistently narrowed across all three categories of any use, problematic use, and associated harms over time.

Men born between 1891 and 1910 were twice (2.2) as likely as their female peers to drink alcohol; but this had almost reached parity among those born between 1991 and 2000 (1.1).

The same patterns were evident for problematic use, where the gender gap fell from 3 to 1.2, and for associated harms, where the gender gap fell from 3.6 to 1.3.

After taking account of potential mathematical bias in the calculations, the gender gap fell by 3.2% with each successive five year period of births, but was steepest among those born from 1966 onwards.

The calculation used was not designed to address whether alcohol use is falling among men or rising among women, the researchers caution.

But among the 42 studies that reported some evidence for sex convergence, most indicated that this was driven by greater use of alcohol among women, and 5% of the sex ratios were less than 1, suggesting that women born after 1981 may actually be drinking more than their male peers, say the researchers.

While they did not set out to explain the reasons behind their observed findings, they emphasise that their results “have implications for the framing and targeting of alcohol use prevention and intervention programmes.”

And they conclude: “Alcohol use and alcohol use disorders have historically been viewed as a male phenomenon. The present study calls this assumption into question and suggests that young women in particular should be the target of concerted efforts to reduce the impact of substance use and related harms.”

Most read articles in September: young people’s views on school sex education, gender equity in academic medicine and improving patient safety

7 Oct, 16 | by Hemali Bedi

cellular-1352613_1920September’s most read list sees several new entries as well as some popular non-movers. This month’s top spot still belongs to Ravnskov et al and their systematic review on the associations between low-density-lipoprotein cholesterol and mortality in the elderly. Pound et al come in at number three with a qualitative synthesis of young people’s views and experiences of school sex and relationship education (SRE). They concluded that SRE should be delivered by experts who maintain clear boundaries with students and taught using a ‘sex-positive’ approach – one that aims for young people to enjoy their sexuality in a way that is safe, consensual and healthy.

Other new entries this month include Caffrey et al, who performed a multimethod, qualitative study investigating how a gender equity programme, Athena SWAN, could be enabled and whether  interactions between the programme and the context it is implemented into might produce unintended consequences.

At number ten is a multimethod study by Power et al, looking at whether a large-scale two-phase quality improvement programme achieved its aim to improve patient safety using a harm-free care approach.

See below for a full round up of September’s top 10 most read articles.

Rank Author(s) Title
1 Ravnskov et al. Lack of an association or an inverse association between low-density-lipoprotein cholesterol and mortality in the elderly: a systematic review
2 Ferrer et al. Comparative study analysing women’s childbirth satisfaction and obstetric outcomes across two different models of maternity care
3 Pound et al. What do young people think about their school-based sex and relationship education? A qualitative synthesis of young people’s views and experiences
4 Caffrey et al. Gender equity programmes in academic medicine: a realist evaluation approach to Athena SWAN processes
5 Teschke et al. Bicycling injury hospitalisation rates in Canadian jurisdictions: analyses examining associations with helmet legislation and mode share
6 Quigley et al. Association between home birth and breast feeding outcomes: a cross-sectional study in 28,125 mother–infant pairs from Ireland and the UK
7 Pradhan et al. Nutrition interventions for children aged less than 5 years following natural disasters: a systematic review
8 Ma’som et al Attitudes and factors affecting acceptability of self-administered cervicovaginal sampling for human papillomavirus (HPV) genotyping as an alternative to Pap testing among multiethnic Malaysian women
9 Assiri et al Investigating the epidemiology of medication errors and error-related adverse drug events (ADEs) in primary care, ambulatory care and home settings: a systematic review protocol
10 Power et al. Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach

Most read figures are based on pdf downloads and full text views. Abstract views are excluded.

Guest blog: Improving peer review using peer-reviewed studies #PeerRevWk16

19 Sep, 16 | by aaldcroft

This week is the second ever “peer review week”. The theme for this year is “Recognition for Review”. Peer review week aims to highlight the importance of peer review, which is a crucial part of the research process. We asked Dr Adrian Barnett, from the Queensland University of Technology, and a member of our editorial board, to survey articles published in BMJ Open that present research on medical publishing and peer review

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It’s challenging to do peer review well and current models of peer review in health and medical research are regularly criticised by researchers who all have personal stories of when peer reviewers got things badly wrong. My own favourite recent example is a reviewer asking us to consider snow in our study of how rainfall impacts on salmonellosis in sub-tropical Queensland.

If we believe in peer review then we should believe in using peer review to improve peer review, and there are interesting studies that have highlighted problems with peer review. This introspective research is part of the growing field of meta-research or research on research, which uses research to examine and improve the entire research process. Such research is sorely needed considering that 85% of current health and medical research is wasted.

BMJ Open welcomes research on peer review and there are 54 papers in the category of “Medical publishing and peer review” including research on peer review as well other important meta-research issues, such as unpublished studies and how research is reported. The first paper in the category from 2011 examined reporting guidelines, and the most recent in 2016 looks at the reporting of conflicts of interest.

Can meta-research help when it comes to the difficult problem of recognition for review? To recognise good peer review we need to judge the quality of peer review, which means reviewing the reviewers.

An observational study compared the quality of reviews for reviewers suggested by authors with reviewers found by editors. The concern is that author-suggested reviewers may be too friendly, and in extreme cases be fake reviewers. The benefit of author-suggested reviewers is that it saves editors time in finding suitable experts. The study found no difference between the quality of reviews, but author-suggested reviewers were far more likely to recommend publication, with 64% of author-recommend reviewers recommending acceptance compared with just 35% of reviewers found by editors. It is possible that many authors suggest reviewers whose views agree with their own and whose work they have cited. Does this count as rigorous peer review, or would it be better if papers were critically analysed by researchers with a variety of views?

Another observational study examined peer reviewers comments for drug trials sponsored by industry compared with non-industry studies. The industry-sponsored studies had fewer comments on poor experimental design and inappropriate statistical analyses, and my guess is (based on personal experience) the industry trials employed more specialist staff because they have bigger budgets.

Both these studies had to spend time and effort reviewing the peer reviewers’ comments, and this extra effort is a key barrier to improving peer review.

Instead of reviewing every review a solution is to randomly check a sample of reviews. This would allow a reasonable number of reviews to be examined and graded in detail. If peer reviewers realise there’s a chance their work will be checked, then they should provide better reviews. The same idea is used by the tax office, who can’t afford to audit everyone but can increase compliance by random auditing.

Another benefit of regular random audits is that it would provide great data for tracking the quality of peer review over time, and allow a journal to ask whether things are getting better, or whether a policy change improved average review quality.

Of course the random tax audit works because there are severe penalties for those who are caught. A peer review audit would likely have to provide positive incentives, which could include a letter of commendation for the best reviews, promotion to the editorial board, or even the well-used incentive of money.

Dr Adrian Barnett is a statistician at the Queensland University of Technology, Brisbane. He works in meta-research which uses research to analyse how research works with the aim of making evidence-based recommendations to increase the value of research. @aidybarnett