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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.

Publication has begun – see the latest articles here and find out more about the journal here.

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.

Healthy foods and diet patterns, patient knowledge and research funding: Most read articles in December

6 Jan, 14 | by flee

The most-read article in December was Rao et al’s article on healthier foods and diet patterns and whether they cost more than less healthy options. Carpenter et al‘s article on bed sharing and the risk of SIDS continues to be popular. Other newly-published papers in the top ten most read include Krusche et al‘s evaluation of the feasibility of a web-based mindfulness course for stress and depression.

Rank Author(s) Title
1 Rao et al Do healthier foods and diet patterns cost more than less healthy options? A systematic review and meta-analysis
2 Krusche et al Mindfulness online: an evaluation of the feasibility of a web-based mindfulness course for stress, anxiety and depression
3 Snow et al What happens when patients know more than their doctors? Experiences of health interactions after diabetes patient education: a qualitative patient-led study
4 Carpenter et al Bed sharing when parents do not smoke: is there a risk of SIDS? An individual level analysis of five major case–control studies
5 Head et al Differences in research funding for women scientists: a systematic comparison of UK investments in global infectious disease research during 1997–2010
6 Werb et al The temporal relationship between drug supply indicators: an audit of international government surveillance systems
7 Nielsen et al Mental health status and risk of new cardiovascular events or death in patients with myocardial infarction: a population-based cohort study
8 Doyle et al A systematic review of evidence on the links between patient experience and clinical safety and effectiveness
9 Ford et al Current treatments in diabetic macular oedema: systematic review and meta-analysis
10 Gehring et al Factors influencing clinical trial site selection in Europe: the Survey of Attitudes towards Trial sites in Europe (the SAT-EU Study)


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

Clinical Commissioning Groups in England serve too many masters

12 Dec, 13 | by bdevaney

Accountability regime much more complex than in previous system; potentially competing agendas

Clinical Commissioning Groups, the new family doctor-led bodies responsible for commissioning the largest chunk of healthcare in England, are accountable to too many masters with potentially competing agendas, concludes research published in BMJ Open.

Clinical Commissioning Groups, or CCGs for short, are membership bodies that came on stream in April this year as part of a major restructuring of health and social care services in England. They replaced primary care trusts (PCTs).

The ostensible aim of the restructuring was to boost the accountability of those responsible for commissioning care for patients while at the same time giving them greater autonomy than their predecessor organisations had enjoyed.

The authors wanted to take a detailed look at the accountability relationships of eight CCGs, to get a snapshot of how these were developing. The degree of autonomy that CCGs have, will to a large extent, depend on these relationships, they say.

Between September 2011 and June 2012, they interviewed 91 people, including family doctors (GPs), managers, and governing body members; sat in on many different types of meetings, totalling 439 hours; and analysed a wide range of documents.

CCGs are externally accountable to NHS England (the government); Monitor (the regulator), Health and Wellbeing Boards (public health and social care); the local Health Watch (patients); the public; local medical committees (GP bodies); and the local authority Overview and Scrutiny Committee (public health).

They are also internally accountable to the CCG governing body, member practices and locality groups.

Based on the evidence they gathered, the authors conclude that CCGs are indeed more accountable than PCTs. But they “are at the centre of complex web of accountability relationships, both internal and external,” they say.

“However, whether this translates into being more responsive, or more easily held to account, remains to be seen,” they caution.

Previous research indicates that complex accountability arrangements tend to generate confusion, “and where organisations are accountable to multiple audiences, the interests of these audiences may differ, generating unintended consequences,” they suggest.

The accountability relationship with NHS England is the only one that is clearly defined, and where sanctions apply, the authors point out. “The accountability to other external bodies, such as Health and Wellbeing Boards, is, by contrast, much weaker,” the say.

Accountability to the regulator may be enforced by competition law, but it is unclear how this will work in practice, they suggest, while accountability to the public is political and based on “the relatively weak notion of ‘transparency’ with no associated sanctions,” they point out.

The responses of the interviewees indicate that CCGs may choose to satisfy their public audiences rather than the government and possibly avoid “hard decisions in the face of public opposition,” they say.

Internal accountabilities are equally complex, and it is unclear what sanctions would, or could. be applied to general practices that transgress the rules of the CCG, the authors emphasise.

“This early study raises some important issues and concerns, including the risk that the different bodies to whom CCGs are accountable will have differing (or conflicting) agendas, and the lack of clarity over the operation of sanction regimes,” they conclude.

UK women scientists have fewer studies funded, and are given less money, than men

9 Dec, 13 | by flee

Women scientists specialising in infectious disease research have fewer studies funded than men, and receive less funding across most topic areas in the specialty than their male peers, finds a study published in BMJ Open.

These gender discrepancies have remained broadly unchanged for more than a decade, the findings show.

Attempts should be made to explore the reasons behind these differences, particularly in light of the fact that the UK government is committed to boosting the number of women choosing a career in science, say the study authors.

They base their findings on an analysis of funding awards made to UK academic institutions for all infectious disease research from 1997 to 2010. They included all disease categories; public and philanthropic funders; and all phases of the research and development pipeline.

Some 6052 studies were included in the final analysis, worth a total of £2.274 billion in grants.  Almost three quarters of these (72%, 4357) were awarded to men, with the remainder (28%, 1695) awarded to women.

And men got most of the total investment, clocking up £1.786 million (78.5%), while women got £488 million (21.5%). Women’s total share ranged from just over 14% in 1998 to just under 27% in 2009.

Analysis of the sums awarded to individual research projects showed that women also received substantially less money than men did. The average value of a grant awarded to men was £179,389 compared with £125,556 for women.

Male lead researchers (principal investigators or PIs for short) were awarded more than their female counterparts across all topic categories in the specialty, with the exception of neurological and sexually transmitted infections.

Women got the smallest share of total funding for the earliest phase of research and development (pre-clinical research) – at just over 18% – and got the largest (for them) for the latest phase (operational research) – at just under 31%.

The authors emphasise that they were unable to assess the success and failure rates of grant applications by gender, and so can’t draw any conclusions about potential inherent bias.

Similarly, they didn’t know the seniority of the lead researcher in each of the studies so couldn’t tell whether there were more men than women scientists at senior level leading research projects and seeking funding. This might explain some of the discrepancy.

But previous research indicates that there are significant gender differences in the amount of funding awarded, even after taking account of the seniority of the principal investigator.

The authors comment that the differences in research funding awarded by gender are “substantial,” and that these differences are “clear and consistent.”

They write: “Women received less funding in absolute amounts and in relative terms, by funder and the type of science funded along the R&D pipeline. These differences in funding between men and women persist over time.”

And they conclude: “We strongly urge policy-makers, funders and scientists to urgently investigate the factors leading to the observed differences and develop policies to address them, in order to ensure that women are appropriately supported in scientific endeavour.”

The findings are discussed further in the accompanying video abstract here.

Social stigma, patient knowledge and bed sharing: Most read articles in November

6 Dec, 13 | by bdevaney

The most-read article in November was Snow et al’s article on what happens when patients have more knowledge than their doctors. Werb et al‘s article on international government surveillance systems continues to be popular. Other newly-published papers in the top ten include Rajmil et al‘s look at the impact of the economic crisis on children’s health and Browne et al’s study of the social stigma around type 2 diabetes.

Rank Author(s) Title
1 Snow et al What happens when patients know more than their doctors? Experiences of health interactions after diabetes patient education: a qualitative patient-led study
2 Carpenter et al Bed sharing when parents do not smoke: is there a risk of SIDS? An individual level analysis of five major case–control studies
3 Werb et al The temporal relationship between drug supply indicators: an audit of international government surveillance systems
4 Ford et al Current treatments in diabetic macular oedema: systematic review and meta-analysis
5 Doyle et al A systematic review of evidence on the links between patient experience and clinical safety and effectiveness
6 Wakefield et al Introduction effects of the Australian plain packaging policy on adult smokers: a cross-sectional study
7 Rajmil et al Impact of the economic crisis on children’s health in Catalonia: a before–after approach
8 Browne et al ‘I call it the blame and shame disease’: a qualitative study about perceptions of social stigma surrounding type 2 diabetes
9 Nguyen et al Statin treatment and risk of recurrent venous thromboembolism: a nationwide cohort study
10 Taylor et al Prevalence and incidence rates of autism in the UK: time trend from 2004–2010 in children aged 8 years


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

C-section rate for private patients double that of publicly funded patients

25 Nov, 13 | by bdevaney

Differences in medical or obstetric risks don’t fully explain disparity.

The rate of scheduled caesarean sections among private patients is around double that of publicly funded patients, indicates a study of more than 30,000 women in Ireland, published in BMJ Open.

Differences in the medical and obstetric risks between the two groups don’t fully explain this disparity, say the researchers, who looked at the impact of social, medical and obstetric factors on mode of delivery among women booked for privately or publicly funded care in the same hospital.

The researchers were particularly keen to see if funding source made any difference to operative deliveries, as it’s not clear whether private care within a publicly funded setting prompts higher rates of costly interventions, they say.

Both private and public healthcare have been offered in Irish hospitals for decades at a ratio of 80 (public): 20 (private). And recent changes to UK health policy mean that hospitals in England will now be able to bump up the proportion of income they generate from private healthcare to 49%.

The researchers analysed the method of delivery for just over 30,000 women with singleton pregnancies, in a large urban maternity hospital in Ireland between January 2008 and July 2011.

The hospital delivers between 8000 and 9000 women every year, with obstetric care provided by around 14 consultants and 16 trainees. Out of the total, 24,574 women were publicly funded and 5479 were private patients.

Private patients were more likely to be older, more affluent and better educated, and to be Irish than publicly funded patients. And they were less likely to be single, childless, have an unplanned pregnancy, or to have booked late for obstetric care.

And while they were less likely to have a medical disorder, they were more likely to have had fertility treatment, recurrent miscarriage, or experienced a previous stillbirth or infant death.

The analysis showed that compared with publicly funded patients, private patients were more likely to have a C-section or surgical vaginal delivery—vacuum or forceps.

But the greatest disparity was in the rate of planned C-sections, which was around twice as high among the private patients, particularly for mums who had given birth before, and by C-section.

The differences remained after taking account of medical (including age), obstetric, and social differences between the two groups.

A common argument advanced for planned C-section is that the procedure does less damage to the pelvic floor than a vaginal birth, say the authors, but while private patients requested more C-sections, very few such requests were made.

“We found the differences observed in relation to operative deliveries were not explained by higher rates of medical or obstetric complications among private patients,” write the authors, although older age and higher income may have played their part, they suggest.

But the findings raise important questions about equity, both in terms of use of resources and choice, and whether that choice really is in the best interests of the woman concerned, say the authors.

“Healthcare systems that include public and private patients need to reflect on the potential for disparate rates of intervention and the implications in terms of equity, resource use, and income generation,” they comment.

NHS 111 increases ambulance and urgent and emergency care use

13 Nov, 13 | by bdevaney

Call handling service did not reduce pressures during first year of operation, as intended.

The call handling service NHS 111 increased the use of ambulance and urgent and emergency care services during its first year of operation, shows a detailed evaluation published in BMJ Open.

This is despite the fact that NHS 111 was set up with the intention of relieving pressure on these services by ensuring that patients are directed to care that is appropriate for their level of need, say the researchers.

They were commissioned by the Department of Health in England to evaluate the use and impact of NHS 111, a new 24/7 telephone service for non-emergency healthcare problems, which was rolled out nationwide in March-April this year.

The service is staffed by trained call handlers, who are not clinicians, but who have back-up from nurse advisors. They triage calls to other services or home care, using an algorithm based assessment system, NHS Pathways.

The researchers analysed 36 months of routine data – to include the first year that NHS 111 was up and running (2010-11), and the two years before it started (2008-10) – in the four designated nationally representative pilot sites, and in three comparable sites, covering a total population of 3.6 million.

The routine data analysed covered the use of emergency ambulance calls and incidents; attendances at emergency care departments; contacts with out of hours urgent care services; and calls to the telephone triage service NHS Direct.

During its first year of operation at the four pilot sites, over 400,000 calls were made to NHS 111, just over 277,000 of which were triaged using NHS Pathways. Of the triaged calls, 28% were referred to a nurse for clinical advice, and over half were judged to need primary or urgent care services.

The number of calls to NHS Direct fell by almost 20% during the study period, which is not unexpected, says lead author Janette Turner, in an accompanying podcast, as NHS 111 is intended to replace this service.

But compared with the three other sites, NHS 111 did not reduce the overall number of emergency ambulance calls, attendances at emergency care, or use of urgent care services at the four pilot sites during the study period.

And contrary to expectations, NHS 111 did not reduce emergency ambulance incidents, which rose by just under 3% – equivalent to an extra 24 incidents per 1000 triaged calls, each month.

The authors estimate that this could translate into an additional 14,500 call-outs for an ambulance service attending 500,000 incidents a year. Nor did it curb overall emergency and urgent care activity, which rose by between 5-12% per month at each site.

The researchers point out that a triage system designed to be used by handlers without clinical expertise will inevitably err on the side of caution and might offer less flexibility than one designed for clinicians. In the accompanying podcast, Ms Turner suggests that this issue may resolve as the service matures and the handlers gain more confidence.

And the provision of a single point of telephone service that quickly guides people needing urgent care advice to the most appropriate service “is sensible,” given the public’s confusion about which service to access, they say.

NHS 111 also offers an easily remembered number, with an emphasis on fast triage and smooth transfer to ‘the right service first time,’ all of which patients say they want, they add.

But the researchers say their findings raise other key questions, including the potential increase in volume of callers prompted by the planned closure of NHS Direct, and therefore the service’s sustainability, and whether NHS 111 is actually creating rather than curbing demand.

And they suggest: “It is probably unrealistic to expect any one service, such as NHS 111, to do everything, and real improvements may only be gained when a series of coordinated measures designed to increase efficiency across all services are implemented.”

The findings are discussed further in the accompanying podcast here.

Government surveillance systems, cleaning agents and autism: Most read articles in October

6 Nov, 13 | by bdevaney

The most-read article in October was  Werb et al‘s article on international government surveillance systems. Carpenter et al’s article on SIDS and bed sharing remained popular for the third month in a row.  Other newly-published papers in the top ten include Vandenplas et al‘s clinical insight on the relationship between asthma and cleaning agents, and Kalil et al’s review of hospital-acquired pneumonia.

Rank Author(s) Title
1 Werb et al The temporal relationship between drug supply indicators: an audit of international government surveillance systems
2 Johansson et al Common psychosocial stressors in middle-aged women related to longstanding distress and increased risk of Alzheimer’s disease: a 38-year longitudinal population study
3 Carpenter et al Bed sharing when parents do not smoke: is there a risk of SIDS? An individual level analysis of five major case–control studies
4 Taylor et al Prevalence and incidence rates of autism in the UK: time trend from 2004–2010 in children aged 8 years
5 Doyle et al A systematic review of evidence on the links between patient experience and clinical safety and effectiveness
6 Vandenplas et al Asthma related to cleaning agents: a clinical insight
7 Nybergh et al Psychometric properties of the WHO Violence Against Women instrument in a male population-based sample in Sweden
8 Ford et al Current treatments in diabetic macular oedema: systematic review and meta-analysis
9 Kalil et al Treatment of hospital-acquired pneumonia with linezolid or vancomycin: a systematic review and meta-analysis
10 MacCallum et al Patient safety and estimation of renal function in patients prescribed new oral anticoagulants for stroke prevention in atrial fibrillation: a cross-sectional study


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

Large medical research funders committed to open access publishing

24 Oct, 13 | by bdevaney

But smaller medical charities, although keen, fear impact on budgets and funded researchers.

Large medical research funding bodies are fully committed to open access publishing. But although smaller charitable funders back the principle, they worry about the impact open access will have on their budgets and their funded researchers, reveals a qualitative study published in BMJ Open.

The findings come as Open Access Week (October 21-27), a global annual event to promote open access as the norm in scholarly publishing and research, celebrates its seventh year in business.

The premise of open access is that it provides free, immediate, online access to the results of scholarly research, and ideally, the right to use and reuse those results as desired, rather than restricting access behind a subscription pay wall. The UK leads the world on open access.

Semi-structured interviews about open access policies and preferences were carried out with 12 employees at 10 UK biomedical research funding bodies in the Spring of this year in the public, charitable, and commercial sectors.

The results showed that all three sectors back open access, but that while public and charitable funders have clear policies on it, commercial sector funders don’t tend to.

Most funders are happy to support the “gold” route, whereby a study’s publication is paid for out of a research grant to cover the journal’s costs. This is the model used by BMJ Open and the other open access titles published by BMJ.

But funders said that not all publishers have embraced open access; many are resisting it and are either reluctant to move away from traditional publishing or are using it purely as a means to boost income.

Open access also seemed to be part of a funder’s overall mission – that is, improving health, healthcare, patient outcomes, and patients’ lives – although for many of the charitable funders, this had to be balanced against other types of public communication and support for people living with medical conditions.

But the way in which a funder gets its income influences its attitude to open access. Charities, which rely on public donations, had to be able to justify their costs and make the best use of available cash for all their competing objectives.

But research funders across the board were worried about the escalating costs of open access as the gold route becomes more mainstream and the cost of publishing shifts from institutions to funders.

This is of particular concern to the smaller charitable funders, who have historically not covered off these costs in their overheads, and fear they will need to stump up the additional costs required.

Other key findings:
• Funders find it hard to monitor compliance with open access, as a condition of funding; compliance rates vary enormously.
• Sanctions for breaching funding conditions are not harsh in the belief that it is more important to encourage researchers to comply rather than to punish them when they don’t.
• Research funders are turning their attention to other priorities for publication, including data sharing, research protocols, and negative results, which are not always favoured by more traditional outlets.

Sharmila Nebhrajani, Chief Executive of the Association of Medical Research Charities commented: “The public choose to donate to medical research charities to fund research into new treatments and cures, and they want their money to make a difference. To [do this], charities want everyone to be able to learn from their research findings, which is why they support the principle of open access.”

But this involved upfront costs, which were not always easy for charities to justify because of competing funding needs, she said.

“To make the biggest difference for their patients and supporters, funding open access may not be the best decision for all charities right now. We need to create an environment where it can be,” she said.

“This means prices that are clear and competitive so that charities can get the best deal and show how they are investing their donations to make a difference,” she explained.

The findings are discussed further in the accompanying podcast here.

Open access: the research funders’ perspective

24 Oct, 13 | by Richard Sands, Managing Editor


Anyone following progress on open access since the Finch Review report last year might think that the UK’s direction of travel is pretty much set. Since the Government and then Research Councils UK (RCUK) backed Gold open access, the same policy endorsed by the Wellcome Trust, it seemed likely that this would become much more prevalent for UK academics wishing to publish their work. Once a funder throws both its weight and its money behind a particular course of action, researchers have little reason not to comply.

But for medical research, the Medical Research Council (MRC) and the Wellcome Trust are not the whole story. Certainly, they are major funders and are widely recognised for leading the development of open access policy. But they are part of a wider community of charities, government bodies and commercial organisations who fund medical research. Many UK researchers receive funding from these organisations and, when those researchers come to publish their findings, they must comply with their funders’ rules.

That’s why BMJ commissioned a small qualitative study of ten medical research funders, designed to explore their approach to open access and communicating research findings. The study included the MRC and the Wellcome Trust, but also sought the views of the National Institute for Health Research (NIHR), charities of all sizes, and some pharmaceutical companies who invest in research. The aim was to understand the different policies and priorities of all these funders, in order to ensure that when a researcher submits to one of BMJ’s 50+ journals, they are offered a publication route that allows them to be compliant with their funder’s requirements.

The full findings of the study are available in an article that’s just been published in BMJ Open, or you can see a brief digest on the BMJ blog. If you read either, you’ll see that open access is welcomed by all of the funders in the study, but the route to implementation is causing them some concerns. There’s also a podcast with the report’s author, available here.

Meeting the costs, monitoring the move, supporting researchers as they transition from one model to another, and ensuring compliance, were issues for most of the funders we spoke to.

This is interesting because it really echoes some work BMJ undertook earlier this year with university staff. Back in January 2013, we ran a series of workshops for librarians, looking at some of the issues that they were facing when trying to implement RCUK’s open access mandate. We heard many of the same messages about money, monitoring, compliance and researcher support. These conversations informed the development of our open access membership model, which is designed to support institutions in meeting some of the challenges they described.

The key message that we heard from both funders and institutions is that researchers must remain in control of how and where they publish their work. Although they might want to see price become more of a factor in that decision, they are very uncomfortable with any suggestion that they should exert direct control over a researcher’s choice of journal. So, the onus is on publishers to help by ensuring that, whichever journal the researcher chooses, they can comply with any conditions imposed on their grant or employment contract. And that’s what we’re trying to do at BMJ.

New cases of autism in UK have levelled off after five-fold surge during 1990s

16 Oct, 13 | by flee

The number of newly diagnosed cases of autism has levelled off in the UK after a five-fold surge during the 1990s, finds research published in BMJ Open.

The findings differ from widely publicised results issued by the US Centers for Disease Control and Prevention (CDC) last year, which reported a 78% increase in the prevalence of the condition in eight year old children between 2004 and 2008 in the US.

Prompted by these data, which found that one in every 88 eight year old children in the US had been diagnosed with an autistic spectrum disorder in or before 2008, the authors wanted to find out if there were comparable rates in the UK.

They used entries into the General Practice Research Database (GPRD), which contains around three million anonymised active patient records from over 300 representative general practices in the UK – equivalent to 5% of the UK population.

Data from practices enrolled from 1990, when the GPRD was set up, were used to calculate the annual prevalence (number of people living with the condition) and the annual incidence (number of newly diagnosed cases) of autistic spectrum disorders among eight year olds, all of whom were born after 1996.

Annual prevalence rates for 2004-2010 were calculated by dividing the number of eight year olds diagnosed as autistic in that or any previous year, by the number of eight year olds enrolled in the database for each year.

Annual incidence rates were calculated by dividing the number of eight year olds who had been newly diagnosed with autism between 2004 and 2010 by the number of eight year olds enrolled into the database for each of those years.

The results showed that the annual prevalence and incidence of autism did not materially change over the entire study period, for either boys or girls.

The annual prevalence of autistic spectrum disorders was estimated at 3.8 per 1000 boys and 0.8 per 1000 girls, while the annual incidence was estimated at 1.2 per 1000 boys  (1190 in total) and 0.2 per 1000 girls (217 in total).

Girls were about 75% less likely to be diagnosed with an autism spectrum disorder as boys.

The UK prevalence of about 4/1000 children is substantially lower than the equivalent US figure of about 11/1000 children in 2008, which was reported in 2012.

“The large difference between countries is closely similar to differences in rates reported for children diagnosed and treated for attention deficit hyperactivity disorder in the two countries,” the authors point out.

Their previously published research, based on the same database, showed that the cumulative incidence of autism among children born in UK between 1988 and 1995 increased continuously by a factor of five during that period.

And they say that both studies provide “compelling evidence that a major rise in incidence rates of autism, recorded in general practice, occurred in the decade of the 1990s but reached a plateau shortly after 2000 and has remained steady through 2010.”

Similar widespread sharp rises in the number of children diagnosed as autistic were also seen in the 1990s in other parts of Europe and North America, they add, making it unlikely that better understanding of the condition or a broadening of the diagnostic criteria alone could have been responsible for these simultaneous large increases.

Given the apparent sudden halt in the rise in rates from early 2000 onwards – at least in the UK – the “actual cause of the dramatic rise in the 1990s remains a mystery,” they write, emphasising that the suggestion that it might be linked to the MMR vaccine has  been conclusively ruled out.