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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.

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.

BMJ Open’s 2013 year in review

17 Feb, 14 | by Richard Sands, Managing Editor


2013 was another successful year for BMJ Open. Credit and thanks as always goes to our editorial board and especially our peer reviewers for helping make this happen.

BMJ Open’s status as a global journal was confirmed as we received over 2000 submissions from 89 countries and published papers from 60. We published 962 papers, up 47% from 2012.

The number of BMJ Open papers with datasets made available through the open access data repository Dryad passed 50. We signed an agreement to meet the costs of this on authors’ behalf, meaning that authors can preserve and share their data in a way that makes it open, citable, preserved and discoverable at no cost to them.

In mid-year Thomson Reuters calculated a first impact factor for BMJ Open: 1.583. We blogged at the time about why this matters – and why it doesn’t. BMJ is a signatory to the San Francisco Declaration on Research Assessment (DORA) and the impact factor, nice as it is to have, is only one metric among many that can be found on our site. Journal-level and article-level statistics are provided and Altmetric scores can now be found on articles which have them. These give an idea of the shorter-term impact and reach of an article. See below the abstract of this paper for an example.

We are constantly looking for ways to streamline processes for authors. We are working with institutions and funders to help simplify life for authors through our institutional memberships, which apply across journals from BMJ. This initiative eases the administrative burden around organising payment of article publishing charges (APCs) as well as providing authors with discounts. Our APCs remain the same in 2014 as does our generous waivers and discounts policy, which last year saw us waive over £120k in charges.

2013 was another big year for open access to UK medical research as the Wellcome Trust and the UK research councils announced updated, tougher OA mandates. Needless to say, authors can meet the requirements of these and all other funders when publishing in BMJ Open simply by clicking a button at submission.

BMJ commissioned research into the publishing priorities of biomedical funders and the results of that research were made available through BMJ Open during Open Access Week. It showed that OA remains a high priority for funders but is only one of a number of strategies they use for wider engagement.

Press coverage of BMJ Open articles was substantial again, in particular around papers on plain packaging of cigarettes, with particular attention paid to this first evidence to emerge from Australia’s policy (e.g. BBC coverage).  Several papers on other hot topics in public health such as physical activity (The Guardian) received widespread coverage, as did papers on subjects as diverse as the ‘war on drugs’ (CNN), sudden infant death syndrome (BBC), new drug discovery (BBC)and male pattern baldness (Times of India).  We also introduced podcasts and video abstracts to help promote these papers.

Coverage and volume are encouraging but it remains important that we concentrate on keeping publication standards high. These make a difference to the quality and trustworthiness of the research we publish. We follow the International Committee of Medical Journal Editors’ recommendations on trial registration and we reject without review any trial report that fails this test. Our view is that publishing trials that don’t meet these standards means publishing articles that are methodologically and ethically unsound. Unfortunately we reject papers because of a lack of registration on a depressingly regular basis. As AllTrials founders, however, we welcome trials that produced so-called ‘negative’ results and we will be blogging more about our commitment to publishing all (properly conducted) trials soon.

In 2013 BMJ Open also introduced a policy, alongside other journals from BMJ, not to consider research funded by the tobacco industry. There’s more on that here.

It was a busy year and all the signs are that it will be an even busier 2014. Thanks again to our reviewers and authors and we look forward to working with you again in the future.



Tobacco industry claims “plain” packs won’t work based on weak evidence

12 Feb, 14 | by fpearson

Most studies lack policy relevance; and relevant research lacks key indicators of quality, including peer review

A critical evaluation of the volume, relevance and quality of evidence submitted by the tobacco industry to oppose standardised packaging of tobacco products doi:10.1136/bmjopen-2013-003757

Tobacco companies lack strong, relevant evidence to support their claims that standardised (plain) packaging of tobacco products in the UK won’t work, finds research published in BMJ Open.

The aim of plain packaging, with no logos, brand imagery, symbols, or promotional text, is to restrict the already limited opportunities that transnational tobacco companies have to market their products, and deter people from starting smoking.

Australia adopted plain packaging for tobacco products in 2012, the same year that the Department of Health in England held a public consultation on similar plans. The Department then said it wanted to wait for more evidence of the likely impact on tobacco consumption before adopting the policy.

It has since commissioned an independent review of evidence relating to unbranded and standardised packaging, which is due to report this spring.

The researchers analysed evidence cited in submissions made to the Department of Health’s consultation on plain packaging by the UK’s four largest transnational tobacco companies: Imperial Tobacco; Japan Tobacco International; Philip Morris Ltd; and British American Tobacco.

The four companies submitted lengthy consultation responses – 1521 pages in total, of which 328 comprised their main responses and 1193 provided supplementary material.

In these submissions, the companies rejected the conclusions of a systematic review, commissioned by the Department of Health, that there was “strong evidence” that plain packaging would reduce the appeal of tobacco products and increase the prominence of health warnings.

Instead, they argued that there is no evidence that plain packaging would reduce smoking prevalence or deter people from starting to smoke.

The researchers looked at the volume, relevance (subject matter) and quality (as measured by independence from industry, and peer review) of the evidence cited by the companies and compared it with the evidence from the systematic review.

Seventy seven out of 143 pieces of evidence were used to promote the companies’ claim that plain packs “won’t work”. Of these, only 17 (22%) addressed standardised packaging, 14 of which were linked to industry. None was published in peer reviewed journals – a key hallmark of quality.

Compared with the evidence in the systematic review, relevant evidence cited by the tobacco industry was of significantly lower quality.

Across all 77 documents, evidence linked to industry was significantly less likely to have been published in a peer reviewed journal than the independent evidence cited by them.

“With few exceptions, evidence cited by [transnational companies] to promote their claim that standardised packaging ‘won’t work’ lacks either policy relevance or key indicators of quality,” conclude the authors.

Global salt intake, smoking cessation through Facebook and the cost of childbirth: Most read articles in January

6 Feb, 14 | by flee

The most-read article in January was Snow et al.’s patient led study ‘What happens when patients know more than their doctors?’ on the impact of patient education on the lives of people with diabetes. Hsia et al.’s newly-published cross-sectional study on the variation in charges and prices paid for vaginal and caesarean births has also been popular. Other newly-published papers in the top ten most read include Li et al.‘s analysis on the effect of maternal age and place of birth on intrapartum outcomes, and Cobb et al.’s protocol for an RCT on smoking cessation intervention through Facebook.

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 Rao et al. Do healthier foods and diet patterns cost more than less healthy options? A systematic review and meta-analysis
3 Gómez-Perretta et al. Subjective symptoms related to GSM radiation from mobile phone base stations: a cross-sectional study
4 Powles et al. Global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide
5 Hsia et al. Analysis of variation in charges and prices paid for vaginal and caesarean section births: a cross-sectional study
6 Li et al. The effect of maternal age and planned place of birth on intrapartum outcomes in healthy women with straightforward pregnancies: secondary analysis of the Birthplace national prospective cohort study
7 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
8 Ford et al. Current treatments in diabetic macular oedema: systematic review and meta-analysis
9 Krusch et al. Mindfulness online: an evaluation of the feasibility of a web-based mindfulness course for stress, anxiety and depression
10 Cobb et al. Diffusion of an evidence-based smoking cessation intervention through Facebook: a randomised controlled trial study protocol


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

Thank you to our reviewers – 2013

16 Jan, 14 | by sjohar

Peer review is a fundamental part of publishing. Perhaps nowhere more so than in the open access field, which is often more scrutinised than other traditional publishing routes. Recognising this, the BMJ Open team would like to thank all 2725 peer reviewers who refereed for the journal in 2013 – your advice and considered remarks were essential in ensuring the quality and scientific validity of our articles.

At BMJ Open, we are pleased to have several policies in place that highlight the importance of peer review. For example, our open peer review policy allows complete transparency over the history of an article, and gives credit to specific referees through the disclosure of their names and the publication of their comments. We also provide reviewers with a 25% discount on the article-publishing charge of any manuscript they subsequently submit as an author and give CME accreditation for the submission of timely and thorough comments.

BMJ Open appreciates the support and hard work of all the peer reviewers who gave their valuable time in contributing to the journal throughout 2013. We hope to work with you again and look forward to forging new relationships in 2014. Given our continued success since our launch, we cannot wait to see what this forthcoming year will bring.

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.