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Top 10 Most Read in March: Caesarean section and for-profit status of hospitals, mental health links to diet, and weight discrimination

10 Apr, 17 | by Emma Gray

Caesarean sections and for-profit status of hospitals, the link between diet and mental health, and the effect of weight discrimination on physical activity

File:Fruits and Vegetables at Pike Place Market.jpg

The Top 10 Most Read articles in March showed great variety in topics and study types. In the top spot this month is a systematic review and meta-analysis by Hoxha et al discussing the association of for-profit status of a hospital and the odds of a woman having a caesarean section. Nguyen et al, at number four, undertake a cross-sectional study to investigate the association between fruit and vegetable consumption and the prevalence of psychological distress in middle-ages and older Australians, finding that there is potential for increased fruit and vegetable consumption in helping to reduce psychological distress. Reaching number seven this month is a study looking at the association between perceived weight discrimination and physical activity, by Jackson and Steptoe of UCL. At number eight this month we see a clinical trial comparing flucloxacillin with clindamycin to flucloxacillin alone for the treatment of limb cellulitis, while at number ten we have a pilot study carried out to inform the design of a future trial to determine the effectiveness and cost-effectiveness of a pharmacist-delivered medicines reconciliation service.

Rank Author(s) Title
1 Hoxha et al. Caesarean sections and for-profit status of hospitals: systematic review and meta-analysis
2 Burt et al. Understanding negative feedback from South Asian patients: an experimental vignette study
3 Ravnskov et al.
4 Nguyen et al. Fruit and vegetable consumption and psychological distress: cross-sectional and longitudinal analyses based on a large Australian sample
5 Williams et al. Childhood academic ability in relation to cigarette, alcohol and cannabis use from adolescence into early adulthood: Longitudinal Study of Young People in England (LSYPE)
6 Fenton et al. Systematic review of the association between dietary acid load, alkaline water and cancer
7 Jackson et al. Association between perceived weight discrimination and physical activity: a population-based study among English middle-aged and older adults
8 Brindle et al. Adjunctive clindamycin for cellulitis: a clinical trial comparing flucloxacillin with or without clindamycin for the treatment of limb cellulitis
9 Abraha et al. Systematic review of systematic reviews of non-pharmacological interventions to treat behavioural disturbances in older patients with dementia. The SENATOR-OnTop series
10 Cadman et al. Pharmacist provided medicines reconciliation within 24 hours of admission and on discharge: a randomised controlled pilot study

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

Top 10 Most Read: Negative primary care feedback from minority ethnic patients, higher caesarean sections in for-profit hospitals, adolescents’ sex and drug habits, and biased psychology

13 Mar, 17 | by Yaiza del Pozo Martin



February sees five new entries in the top 10 most read articles. At number one this month is an experimental vignette study investigating why minority ethnic groups report poorer primary care experience in patient surveys. Burt and colleagues designed an experiment in the UK to determine whether South Asian people rate simulated GP consultations the same or differently from White British. The findings suggest that the lower scores reported by Pakistani patients in national surveys represent genuinely worse experiences of communication compared to the White British majority.

Making its way up to the top and catching significant online attention, is a systematic review exploring whether researchers’ conflicts of interest are adequately reported in publications related to psychological therapies. The authors show that non-financial conflicts of interests, especially the inclusion of own primary studies and researcher allegiance, are frequently seen in systematic reviews in the field of psychology.

At number five, another systematic review and meta-analysis exploring the connections between caesarean sections and for-profit status of hospitals. Hoxha and colleagues establish that regardless of women’s risk and contextual factors, private for-profit hospitals are more likely to perform caesarean interventions to women as compared with non for profit hospitals. The authors recommend examining the incentive structures of for-profit hospitals to set strategies that encourage appropriate provision of caesarean sections.

Other new entries on February include two research papers looking at adolescent’s behaviours. The first one is an interesting epidemiological study concluding that brainy adolescents are at a reduced risk of cigarette smoking, but are more likely to drink alcohol regularly and use cannabis. The second on is a qualitative study exploring the views and experiences of young people about their school-based sex and relationship education.

The two most read articles the previous month, systematic reviews by Ravnskov et al. and Fenton et al., stay up in the ranking at the second and third positions respectively. January’s highlight article, a cohort study by Anick Bérard and colleagues indicating that antidepressants increase the risk of a wide range of organ-specific malformations, continues halfway through the ranking. Also, an enlightening survey by Boulton and colleagues reporting the unacceptably high amount of sugars hidden in drinks marketed to children continues to be highly read.

Finally, the cross-sectional study by Murdoch and colleagues investigating the lack of evidence and efficacy, and potential harmful effects, of a clinic website in Canada offering naturopathy, homeopathy, chiropractic and acupuncture to treat serious conditions such as allergy and asthma, continues to grow in popularity online. In light of the results, the authors call for a policy response to safeguard the public interest. We would like to take this opportunity to direct you to: Should doctors recommend homeopathy?


Rank Author(s) Title
1 Burt et al. Understanding negative feedback from South Asian patients: an experimental vignette study
2 Ravnskov et al. Lack of an association or an inverse association between low-density-lipoprotein cholesterol and mortality in the elderly: a systematic review
3  Fenton et al. Systematic review of the association between dietary acid load, alkaline water and cancer
4  Lieb et al. Conflicts of interest and spin in reviews of psychological therapies: a systematic review
5 Hoxha et al. Caesarean sections and for-profit status of hospitals: systematic review and meta-analysis
6 Bérard et al. Antidepressant use during pregnancy and the risk of major congenital malformations in a cohort of depressed pregnant women: an updated analysis of the Quebec Pregnancy Cohort
7 Murdoch et al. Selling falsehoods? A cross-sectional study of Canadian naturopathy, homeopathy, chiropractic and acupuncture clinic website claims relating to allergy and asthma
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 Boulton et al. How much sugar is hidden in drinks marketed to children? A survey of fruit juices, juice drinks and smoothies
10 Williams et al. Childhood academic ability in relation to cigarette, alcohol and cannabis use from adolescence into early adulthood: Longitudinal Study of Young People in England (LSYPE)

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

Identifying individuals at high risk of developing Alzheimer’s disease

7 Mar, 17 | by Yaiza del Pozo Martin

As we age, we can appreciate how our body changes in our hair, skin, and joints, letting us know that we are getting older. Alongside these obvious changes, our brain starts its own aging process too, although the symptoms might not be as noticeable. This perception mismatch is one of the key challenges in the prevention of neurodegenerative disorders.

In recent decades, thanks to the development of advanced imaging techniques, the changes occurring in our brain as we age have been observed permitting early diagnosis of neurodegenerative processes such as Alzheimer’s disease.  However, making a confident diagnosis relying on few symptoms and brain images remains challenging because some of the Alzheimer’s indicators are also an inevitable part of normal ageing.

Now, a new study published this month in BMJ Open, brings the prevention of Alzheimer’s disease a step forward.  Combining the current diagnostic imaging tests used by doctors with powerful statistical analyses, researchers propose a model that could not only help accurate early diagnosis, but also the identification of healthy people at high risk of developing Alzheimer’s disease.

Normal ageing or Alzheimer’s disease?

Alzheimer’s disease is a progressive disorder that affects between 10 and 30% of the population over 65 years of age according to the best estimates to date. The main brain areas damaged during disease progression are the cerebral cortex, responsible for our motor coordination and perception of sensory information, and the hippocampus, responsible for much of our memory. Using Magnetic Resonance Imaging (MRI) images of the brain, which reveal the anatomic structure of the brain, doctors can in most cases diagnose Alzheimer’s disease in contrast to healthy ageing. However, prevention – the identification of healthy individuals at risk of Alzheimer’s disease before brain damage occurs – is yet to be achieved. This is what this timely study by Cespedes and colleagues set out to answer: How can individuals at high risk of developing Alzheimer’s disease be identified?


The researchers obtained the brain images from patients from the Australian Imaging Biomarker and Lifestyle Study of Ageing (AIBL), an ongoing study which aims to discover factors potentially influencing the development of Alzheimer’s disease. A group of healthy adults, subjects having mild cognitive impairments, and Alzheimer’s disease patients had a MRI scan done every 18 months from the age of 65. The authors analysed the images obtained using an authoritative statistical technique and observed marked differences between the three groups. Comparing the volume of the hippocampus, one of the main areas affected by neuron loss during Alzheimer’s disease, allowed the identification of high-risk individuals who progressed from being healthy to having cognitive impairment over time (graphical representation below). Additionally, the researchers could detect specific time points when major degenerative events were likely to occur.

Image: graphical results representing the average volume of hippocampus in the brain against the age of the participants in healthy ageing adults (BLUE), subjects with minor cognitive impairments (GREEN) and diagnosed Alzheimer’s disease patients (RED). Note the marked differences in the hippocampus volume between the 3 groups in patients over 80 years of age. 

Clinical implications

To date, treatments that fight brain damage are used to ameliorate Alzheimer’s disease progression, but the future and ultimate goal of the research community is prevention; if individuals at high risk of Alzheimer’s disease could be confidently identified, active treatments beginning at around 50 years of age could prevent disease onset in the future. That is why using analyses such as the one described in this study could become crucial in preventing disease onset in still healthy individuals before clinically evident symptoms emerge, eradicating Alzheimer’s disease.

To learn more about the study, share it, or comment on it, please click here.

Paternal involvement in child-rearing, health anxiety, and the global epidemiology of alcohol use: Most read articles in November

9 Dec, 16 | by Emma Gray

Paternal involvement in early child-rearing, health anxiety and risk of ischaemic heart disease, and the global epidemiology of alcohol use

The Top 10 Most Read list for November contains a number of new entries including papers on the reasons for retraction of articles, and the relationship between earlobe creases and coronary artery disease. At number one this month is a longitudinal study by Reece et al, which looks into the possibility that cannabis-exposed patients may be ageing more quickly. Entering the list at four and five respectively, are Farren et al and Berge et al with studies on the emotional distress in women after early pregnancy loss and the prospective association of health anxiety with ischaemic heart disease. A study on the involvement of fathers in early child-rearing on behaviour and development in their pre-adolescent children by Opondo et al reaches number six, finding that psychological and emotional aspects of paternal involvement in children’s early upbringing, particularly how new fathers see themselves as parents and adjust to the role, is associated with positive outcomes in children. It also received a press release and some attention on social media. Finally, returning at number eight this month, we have a popular article on birth cohort trends in the global epidemiology of alcohol use and alcohol-related harms in men and women by Slade et al, which concludes that the male-female gap in indicators of alcohol use and related harms is closing.

Rank Author(s) Title
1 Reece et al. Cannabis exposure as an interactive cardiovascular risk factor and accelerant of organismal ageing: a longitudinal study
2 Ravnskov et al. Lack of an association or an inverse association between low-density-lipoprotein cholesterol and mortality in the elderly: a systematic review
3 Spoelman et al. Effect of an evidence-based website on healthcare usage: an interrupted time-series study
4 Farren et al. Post-traumatic stress, anxiety and depression following miscarriage or ectopic pregnancy: a prospective cohort study
5 Berge et al. Health anxiety and risk of ischaemic heart disease: a prospective cohort study linking the Hordaland Health Study (HUSK) with the Cardiovascular Diseases in Norway (CVDNOR) project
6 Opondo et al. Father involvement in early child-rearing and behavioural outcomes in their pre-adolescent children: evidence from the ALSPAC UK birth cohort
7 Wang et al. Relationship between diagonal earlobe creases and coronary artery disease as determined via angiography
8 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
9 Hashem et al. Cross-sectional survey of the amount of free sugars and calories in carbonated sugar-sweetened beverages on sale in the UK
10 Moylan et al. Why articles are retracted: a retrospective cross-sectional study of retraction notices at BioMed Central

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

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:



  1. World diabetes day 2016. Diabetes UK., accessed 8 November 2016
  2. World diabetes day. IDF., accessed 31 October 2016
  3. World diabetes day 2016. IDF. accessed, 31 October 2016

‘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.”