As nearness to death is an important contributor to hospital utilization, especially in the last six months of life, is it possible for the data to be reanalysed in relation to nearness to death in this cohort?
We read with interest this paper which asserts that recent increases in infant mortality have affected poorer areas of England disproportionately. In our analyses of largely post-neonatal unexplained infant deaths we too have found a proportional increase of poorer families; markers of deprivation including maternal age, education, parity and smoking status will all impact on infant mortality. (1-3) However, it is perhaps worth pointing out that this recent increase in infant mortality in England & Wales from 2014 to 2017 is limited to neonatal deaths, the rate of post-neonatal deaths (4 weeks to 1 year old) has flat-lined in these 4 years from 1.09 deaths per 1000 live births in 2014 to 1.08 deaths per 1000 live births in 2017. Furthermore, in the data release by the Office for National Statistics (ONS) for 2017, (4) they report a 23.5% reduction in infant mortality in the most deprived areas over the last 10 years, compared with a 10.0% reduction in the most affluent areas. Using the data provided in that release on age at death we can see that the increase in overall infant mortality is driven by very early neonatal deaths of infants under 1 day old, from 1.3 per 1000 live births in 2014 to 1.5 in 2015, and 1.6 in 2016 and 2017. Mortality in all other age groups within infancy from one day to one year show reductions over that time. (4) The major contributory causes to early neonatal mortality are prematurity, congenital anomalies and infections, with a small but...
We read with interest this paper which asserts that recent increases in infant mortality have affected poorer areas of England disproportionately. In our analyses of largely post-neonatal unexplained infant deaths we too have found a proportional increase of poorer families; markers of deprivation including maternal age, education, parity and smoking status will all impact on infant mortality. (1-3) However, it is perhaps worth pointing out that this recent increase in infant mortality in England & Wales from 2014 to 2017 is limited to neonatal deaths, the rate of post-neonatal deaths (4 weeks to 1 year old) has flat-lined in these 4 years from 1.09 deaths per 1000 live births in 2014 to 1.08 deaths per 1000 live births in 2017. Furthermore, in the data release by the Office for National Statistics (ONS) for 2017, (4) they report a 23.5% reduction in infant mortality in the most deprived areas over the last 10 years, compared with a 10.0% reduction in the most affluent areas. Using the data provided in that release on age at death we can see that the increase in overall infant mortality is driven by very early neonatal deaths of infants under 1 day old, from 1.3 per 1000 live births in 2014 to 1.5 in 2015, and 1.6 in 2016 and 2017. Mortality in all other age groups within infancy from one day to one year show reductions over that time. (4) The major contributory causes to early neonatal mortality are prematurity, congenital anomalies and infections, with a small but significant number of deaths relating to intrapartum events, especially in babies of low birth weight or short gestation. (5) We therefore feel that any analysis looking at trends over time should be applied to early neonatal deaths, as this is clearly the age range in which something has changed. Efforts to understand the very real inequalities in infant health outcomes for families experiencing poverty are vital if we are to identify how best to overcome them, but we must do so with accuracy and a determination to engage with the complexity within which they operate. It is likely that strategies to reduce early neonatal mortality – which will need to target services directed to pregnant women – will be different to those aimed at reducing later infant mortality.
References
1. Blair PS, Sidebotham P, Berry PJ, Evans M, Fleming PJ. Major epidemiological changes in sudden infant death syndrome: a 20-year population-based study in the UK. Lancet (London, England). 2006;367(9507):314-9.
2. Blair PS, Sidebotham P, Evason-Coombe C, Edmonds M, Heckstall-Smith EM, Fleming P. Hazardous cosleeping environments and risk factors amenable to change: case-control study of SIDS in south west England. BMJ (Clinical research ed). 2009;339:b3666.
3. Fleming PJ, Blair PS, Ward Platt M, Tripp J, Smith IJ. Sudden infant death syndrome and social deprivation: assessing epidemiological factors after post-matching for deprivation. Paediatric and perinatal epidemiology. 2003;17(3):272-80.
4. Office for National Statistics. Child and infant mortality in England and Wales: 2017. 2019.
5. Lehtonen L, Gimeno A, Parra-Llorca A, Vento M. Early neonatal death: A challenge worldwide. Seminars in fetal & neonatal medicine. 2017;22(3):153-60.
We read with interest the recent paper by Kazis et al [BMJ Open 2019;9e028633], an observational retrospective study of the association between initial health provider for low back pain with subsequent opioid use.
This included data on three types of conservative therapists as well as various types of physicians. Initial treatment from any of the former, namely physical therapists (PTs), chiropractors and acupuncturists, was associated with substantially decreased odds for both early and long-term opioid use. However, these results, though tabulated, described and discussed in the main text of the paper do not transfer in the same form to the abstract. Specifically, the acupuncture results have been removed.
The benefits of both PT and chiropractic are stated in two places in the Results section and once in the Conclusions, but there is no mention of acupuncture. Although we understand that the sample of acupuncturists was relatively small, acupuncture reduced short and long term exposure to opioids by 75% to 90% compared to the same patient starting with a PCP, and the confidence interval was significant and similar to PT.
Given that many people will look initially or only at the abstract, this omission misleads the reader into inferring that acupuncture did not have the same benefits as the other two conservative treatments. The implications for health care policy/access/delivery are of concern. Does a...
We read with interest the recent paper by Kazis et al [BMJ Open 2019;9e028633], an observational retrospective study of the association between initial health provider for low back pain with subsequent opioid use.
This included data on three types of conservative therapists as well as various types of physicians. Initial treatment from any of the former, namely physical therapists (PTs), chiropractors and acupuncturists, was associated with substantially decreased odds for both early and long-term opioid use. However, these results, though tabulated, described and discussed in the main text of the paper do not transfer in the same form to the abstract. Specifically, the acupuncture results have been removed.
The benefits of both PT and chiropractic are stated in two places in the Results section and once in the Conclusions, but there is no mention of acupuncture. Although we understand that the sample of acupuncturists was relatively small, acupuncture reduced short and long term exposure to opioids by 75% to 90% compared to the same patient starting with a PCP, and the confidence interval was significant and similar to PT.
Given that many people will look initially or only at the abstract, this omission misleads the reader into inferring that acupuncture did not have the same benefits as the other two conservative treatments. The implications for health care policy/access/delivery are of concern. Does access to “conservative therapies” change one’s likelihood of using opioids? The answer is “yes.” Many patients don't want opioids or other analgesics, but they are not given reasonable access to “conservative therapies” due to issues of availability (we don't offer acupuncture, here) or cost (acupuncture is not covered by insurance so you must pay out of pocket and cannot afford it).
We kindly ask that this omission be corrected.
Richard Harris, PhD, LAc. Society for Acupuncture Research
Mark Bovey, MSc. British Acupuncture Council
David Mills, MD, LAc American Society of Acupuncturists
Freda Dreher, MD American Academy of Medical Acupuncture
In response to the letter of 22 May, we are happy to deal with the key issues of conflict of interest, acknowledgement and data interpretation. However, many of the comments in the letter deal with the funding, function and nature of the NHS England contract for the database. We feel this is a matter that should be taken up with NHS England rather than the letter section of this Journal as it has little, if anything, to do with the paper as published.
Regarding the issue of undeclared conflict of interest. Mr Dunn is a burn surgeon with an honorary position at Manchester University and was co-supervisor of the primary author’s PhD at Manchester University. The paper was reviewed by academic peers before publication and the source of funding for the associated PhD was declared. We have reviewed the Journal’s document on competing interests and are satisfied that we declared all interests relevant to the basis, process or conclusions of the work undertaken.
The burn injury database is funded by NHS England and is managed as part of his NHS contract by Mr Dunn who is medical director of the iBID and co-chair of the Burn Care Informatics Board that oversees the use of the iBID data. It is this Board which sanctioned the release of the anonymized data on which this paper and the PhD work was based. In the paper the source of the data is mentioned and my control of this aspect inferred but I accept is not stated. Should the Editor feel an addendu...
In response to the letter of 22 May, we are happy to deal with the key issues of conflict of interest, acknowledgement and data interpretation. However, many of the comments in the letter deal with the funding, function and nature of the NHS England contract for the database. We feel this is a matter that should be taken up with NHS England rather than the letter section of this Journal as it has little, if anything, to do with the paper as published.
Regarding the issue of undeclared conflict of interest. Mr Dunn is a burn surgeon with an honorary position at Manchester University and was co-supervisor of the primary author’s PhD at Manchester University. The paper was reviewed by academic peers before publication and the source of funding for the associated PhD was declared. We have reviewed the Journal’s document on competing interests and are satisfied that we declared all interests relevant to the basis, process or conclusions of the work undertaken.
The burn injury database is funded by NHS England and is managed as part of his NHS contract by Mr Dunn who is medical director of the iBID and co-chair of the Burn Care Informatics Board that oversees the use of the iBID data. It is this Board which sanctioned the release of the anonymized data on which this paper and the PhD work was based. In the paper the source of the data is mentioned and my control of this aspect inferred but I accept is not stated. Should the Editor feel an addendum to the on-line paper is warranted to detail these facts, this would be straightforward.
Regarding the issue of an acknowledgement of contributing services. For the purposes of brevity, we followed the examples of papers from other national registries in not listing all contributing services as this information is available elsewhere.
Regarding the issues of data interpretation and the suggestion that there was insufficient discussion about the reasons for increased admissions, we should point out that almost half the Discussion section of the paper as well as part of the Limitations sections deal with the progressive uptake of the database in England and Wales, which may be the reason for increased numbers. It was also acknowledged that NHS Hospital Episode Statistics data also showed an increase in the numbers and that might be because of the changes implemented due to the National Burn Care Review recommendations published in 2001.
Regarding data cleaning and completeness. It is specifically stated that data cleaning was undertaken before using any variable so as not to lose important information which might influence other variables.
Regarding advocating a continued mandate for the use of iBID. We fail to see how we can be criticised for what we believe would be of benefit to patients and commissioners and any other stakeholder in the healthcare system.
We hope this clarifies matters for the Editor and readership.
Yours sincerely,
Dr Neophytos Stylianou
Prof Iain Buchan
Mr Ken Dunn
I am a licensed acupuncturist in the state of Minnesota, working with a large hospital system. I was looking forward to reading this important study when I heard about it, but I was disappointed and unclear why acupuncture is left out of the conclusion completely although it is included as a "conservative therapy" type.
This study clearly shows acupuncture showed similar results to both chiropractic and PT, as stated in the body of the text: " For early opioid use, patients initially visiting chiropractors had 90% decreased odds (95% CI 0.09 to 0.10) while those visiting an acupuncturists had 91% decreased odds (95% CI 0.07 to 0.12) and those visiting physical therapists had 85% decreased odds (95% CI 0.13 to 0.17). Chiropractors, acupuncturists and physical therapists all had major decreased odds of long-term opioid use compared with those who initially saw PCPs ."
As you can see, however, in the conclusion only chiropractic and PT are mentioned by name: "Results Short-term use of opioids was 22%. Patients who received initial treatment from chiropractors or physical therapists had decreased odds of short-term and long-term opioid use compared with those who received initial treatment from primary care physicians (PCPs) (adjusted OR (AOR) (95% CI) 0.10 (0.09 to 0.10) and 0.15 (0.13 to 0.17), respectively). Compared with PCP visits, initial chiropractic and physical therapy also were associated with dec...
I am a licensed acupuncturist in the state of Minnesota, working with a large hospital system. I was looking forward to reading this important study when I heard about it, but I was disappointed and unclear why acupuncture is left out of the conclusion completely although it is included as a "conservative therapy" type.
This study clearly shows acupuncture showed similar results to both chiropractic and PT, as stated in the body of the text: " For early opioid use, patients initially visiting chiropractors had 90% decreased odds (95% CI 0.09 to 0.10) while those visiting an acupuncturists had 91% decreased odds (95% CI 0.07 to 0.12) and those visiting physical therapists had 85% decreased odds (95% CI 0.13 to 0.17). Chiropractors, acupuncturists and physical therapists all had major decreased odds of long-term opioid use compared with those who initially saw PCPs ."
As you can see, however, in the conclusion only chiropractic and PT are mentioned by name: "Results Short-term use of opioids was 22%. Patients who received initial treatment from chiropractors or physical therapists had decreased odds of short-term and long-term opioid use compared with those who received initial treatment from primary care physicians (PCPs) (adjusted OR (AOR) (95% CI) 0.10 (0.09 to 0.10) and 0.15 (0.13 to 0.17), respectively). Compared with PCP visits, initial chiropractic and physical therapy also were associated with decreased odds of long-term opioid use in a propensity score matched sample (AOR (95% CI) 0.21 (0.16 to 0.27) and 0.29 (0.12 to 0.69), respectively).
Conclusions Initial visits to chiropractors or physical therapists is associated with substantially decreased early and long-term use of opioids. Incentivising use of conservative therapists may be a strategy to reduce risks of early and long-term opioid use."
This study provides some important information we can use to build on for future research, and to guide treatment plans for patients coming to the clinic or ED with low back pain. I am very interested to know why specific mention of acupuncture was left out of the conclusion, despite having similar results to both chiropractic and PT.
I would appreciate your consideration to include acupuncture in your results and conclusion.
I read the study by Schneider et al. with great interest [1]. They sought to investigate whether “a landmark trial had changed practiced patterns for treatment of patients with displaced midshaft clavicle fractures” (MCF). For the purposes of their study they investigated the prevalence of open reduction and internal fixation (ORIF) in MCFs in two level 1 hospitals. They concluded that after this single trial there was a trend toward more prevalent ORIF and alike studies are needed in the future. I have several concerns regarding their study and conclusions.
A single study, even if level 1, is still a single study done in a certain location at a certain time. It is prone to different biases, between-patient variability and random variation. Even with very large sample size we can´t underestimate the uncertainty and imprecision we have in our results. Also, the framework or statistical methods we use will affect the results we obtain. All these should be appraised when we evaluate and implement studies published in peer-reviewed literature.
COTS trial on MCF was the first major study on this topic [2]. However, considering the complexity of performing an RCT, a fairly large number of them has been published investigating ORIF and nonoperative treatment in MCFs. For example, studies by Woltz et al. and Robinson et al. are RCTs with a sample size exceeding that of COTS study [3,4]. Interestingly neither of these studies was cited by Schneider et al. Woltz et al....
I read the study by Schneider et al. with great interest [1]. They sought to investigate whether “a landmark trial had changed practiced patterns for treatment of patients with displaced midshaft clavicle fractures” (MCF). For the purposes of their study they investigated the prevalence of open reduction and internal fixation (ORIF) in MCFs in two level 1 hospitals. They concluded that after this single trial there was a trend toward more prevalent ORIF and alike studies are needed in the future. I have several concerns regarding their study and conclusions.
A single study, even if level 1, is still a single study done in a certain location at a certain time. It is prone to different biases, between-patient variability and random variation. Even with very large sample size we can´t underestimate the uncertainty and imprecision we have in our results. Also, the framework or statistical methods we use will affect the results we obtain. All these should be appraised when we evaluate and implement studies published in peer-reviewed literature.
COTS trial on MCF was the first major study on this topic [2]. However, considering the complexity of performing an RCT, a fairly large number of them has been published investigating ORIF and nonoperative treatment in MCFs. For example, studies by Woltz et al. and Robinson et al. are RCTs with a sample size exceeding that of COTS study [3,4]. Interestingly neither of these studies was cited by Schneider et al. Woltz et al. conclude “We therefore do not advocate routine operative treatment for displaced midshaft clavicular fractures.”. Robinson et al. state that “The results of the present study do not support routine primary open reduction and plate fixation for the treatment of displaced midshaft clavicular fractures.” All three studies mentioned here showed that ORIF results to significantly reduced risk of nonunion. The difference in functional outcome in the COTS trial barely exceeded minimal important difference whereas Woltz et al. and Robinson et al. failed to do this, although difference in the latter reached nominal statistical significance favoring ORIF. As said, a single study is still a single study. Being chronologically first study in a certain topic does not automatically mean that this particular study should be seen as a benchmark reference. Most importantly, random variation causes point estimates to change from study to study and only in long term we can estimate the true population values like the difference in functional outcome.
Authors state that “Two recent meta-analysis” namely those by Guerra et al. and McKee et al., favor ORIF over nonoperative treatment [5,6]. Basically, all recent meta-analyses pool results from the very same studies. Consequently, they all report similar results. Guerra et al. reported similar results in functional outcome as Woltz et al. and van Smeeing et al. in their meta-analyses [7,8]. Only difference is that Guerran et al. reports “better” functional outcome whereas Wotz et al. and Smeeing et al. report no relevant difference in functional outcome. It is evident that there is poor inferential reproducibility when functional outcome after ORIF and nonoperative treatment is considered.
To conclude, in some cases landmark trial may exist but when very similar studies or even larger ones have been published, this labeling should be done with caution. No single study provides a clear answer to any clinical question, be the study of any quality. Evidence should be considered as a whole. To this matter I disagree that COTS trial should be viewed as a turning point in the treatment of MCF, most importantly because subsequent, larger studies have concluded the opposite than is concluded in the COTS trial. It is evident that ORIF results clearly better result in terms of nonunion rate but with the cost of higher complication rate while difference in functional outcome is below clinical significance. All this relates to issues in inferential reproducibility highlighting the importance of shared decision making in the process of deciding between ORIF and nonoperative treatment. There is no objective superiority between ORIF and nonoperative treatment in MCFs and all possible outcomes we measure are basically equal and value-laden.
References:
[1] Schneider P, Bransford R, Harvey E, Agel J. Operative treatment of displaced midshaft clavicle fractures: has randomised control trial evidence changed practice patterns? BMJ Open 2019;9:e031118. doi:10.1136/bmjopen-2019-031118.
[2] Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am 2007;89:1–10. doi:89/1/1 [pii].
[3] Woltz S, Stegeman SA, Krijnen P, van Dijkman BA, van Thiel TP, Schep NW, et al. Plate Fixation Compared with Nonoperative Treatment for Displaced Midshaft Clavicular Fractures: A Multicenter Randomized Controlled Trial. J Bone Joint Surg Am 2017;99:106–12. doi:10.2106/JBJS.15.01394 [doi].
[4] Robinson CM, Goudie EB, Murray IR, Jenkins PJ, Ahktar MA, Read EO, et al. Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: a multicenter, randomized, controlled trial. J Bone Joint Surg Am 2013;95:1576–84. doi:10.2106/JBJS.L.00307 [doi].
[5] Guerra E, Previtali D, Tamborini S, Filardo G, Zaffagnini S, Candrian C. Midshaft Clavicle Fractures: Surgery Provides Better Results as Compared With Nonoperative Treatment: A Meta-analysis. Am J Sports Med 2019:363546519826961. doi:10.1177/0363546519826961.
[6] McKee RC, Whelan DB, Schemitsch EH, McKee MD. Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials. J Bone Joint Surg Am 2012;94:675–84. doi:10.2106/JBJS.J.01364.
[7] Smeeing DPJ, van der Ven DJC, Hietbrink F, Timmers TK, van Heijl M, Kruyt MC, et al. Surgical Versus Nonsurgical Treatment for Midshaft Clavicle Fractures in Patients Aged 16 Years and Older: A Systematic Review, Meta-analysis, and Comparison of Randomized Controlled Trials and Observational Studies. Am J Sports Med 2017;45:1937–45. doi:10.1177/0363546516673615.
[8] Woltz S, Krijnen P, Schipper IB. Plate Fixation Versus Nonoperative Treatment for Displaced Midshaft Clavicular Fractures. J Bone Jt Surg 2017;99:1051–7. doi:10.2106/JBJS.16.01068.
The article of Hofstede et al on unnecessary vitamin testing in general practice deals with exploring the barriers and facilitators to reduce the number of (unnecessary) vitamin D and B12 laboratory testing.
We consider that there are significant differences between both laboratory tests. It is true that neither vitamin D nor B12 tests are recommended for screening purposes, and their request from primary care has exponentially increased over time. Nonetheless, the latter is not equivalent to inappropriate demand.
It is known that vitamin D over testing is common in certain scenarios; and it can result in over treatment and potential intoxication. The vitamin B12 case is, however, a completely different topic. Subjects with vitamin B12 deficiency do not often show anemia, macrocytosis nor specific symptoms of vitamin deficiency and the adverse effects of such a condition, especially neurological symptoms that could be irreversible if not treated in six months. That is the reason why the laboratory professional should be screening for new deficit cases; especially, when an easy and affordable treatment is available - a monthly intramuscular supplementation - without any possibility of intoxication.
Less than half of patients with vitamin B12 deficiency have macrocytosis. However, macrocytosis can be used to improve the diagnosis of severe vitamin B12 deficiency through computer-assisted interventions in the clinical laboratory process. Additionally, morpho...
The article of Hofstede et al on unnecessary vitamin testing in general practice deals with exploring the barriers and facilitators to reduce the number of (unnecessary) vitamin D and B12 laboratory testing.
We consider that there are significant differences between both laboratory tests. It is true that neither vitamin D nor B12 tests are recommended for screening purposes, and their request from primary care has exponentially increased over time. Nonetheless, the latter is not equivalent to inappropriate demand.
It is known that vitamin D over testing is common in certain scenarios; and it can result in over treatment and potential intoxication. The vitamin B12 case is, however, a completely different topic. Subjects with vitamin B12 deficiency do not often show anemia, macrocytosis nor specific symptoms of vitamin deficiency and the adverse effects of such a condition, especially neurological symptoms that could be irreversible if not treated in six months. That is the reason why the laboratory professional should be screening for new deficit cases; especially, when an easy and affordable treatment is available - a monthly intramuscular supplementation - without any possibility of intoxication.
Less than half of patients with vitamin B12 deficiency have macrocytosis. However, macrocytosis can be used to improve the diagnosis of severe vitamin B12 deficiency through computer-assisted interventions in the clinical laboratory process. Additionally, morphological and quantitative neutrophil abnormalities that are common in megaloblastic anemias and can be detected nowadays through modern CBC hematology analyzers, could also be associated with vitamin B12 deficiency and used for its detection. Finally, certain common therapies in primary care such as proton pump inhibitors suppress the production of gastric acid and might thus lead to malabsorption and deficiency of vitamin B12.
Through simple computerized interventions based on LIS and agreed with general Practitioners, is possible to correct the vitamin B121 over request; but also to identify potentially dangerous under request through the detection of new cases of vitamin B12 deficit.
We read with immense interest the article by Bernado and co-authors that investigated the epidemiology of influenza-like illness (ILI) and the prescription of antivirals or antibiotics between 2015 and 2017. Antibiotic prescribing for ILI showed a significant decline from 30.3% in 2015, to 28.0% in 2016, and 26.7% in 2017 [1].
Inappropriate prescribing of antimicrobials, particularly in primary care, is one of the main factors causing the emergence of antibiotic-resistant organisms. A failure to address antibiotic resistance could result in an estimated 10 million additional deaths worldwide every year by 2050, exceeding the 8.2 million lives a year currently lost to cancer and the cumulative economic loss to world economies might be as high as US$100 trillion [2]. With a long-term goal to accomplish meaningful and sustained change in antibiotic prescribing practices, the Agency for Healthcare Research and Quality (AHRQ) Safety Programme for Improving Antibiotic Use has introduced an organised approach to incorporate four moments of antibiotic decision making into thought process when antibiotic therapy is considered. The four moments framework includes synthesising all relevant patient information to determine the likelihood of an infection that requires antibiotic therapy, thinking carefully about specific patient risk factors and severity of illness in association with the likely source of infection, performing a daily antibiotic time-out for...
We read with immense interest the article by Bernado and co-authors that investigated the epidemiology of influenza-like illness (ILI) and the prescription of antivirals or antibiotics between 2015 and 2017. Antibiotic prescribing for ILI showed a significant decline from 30.3% in 2015, to 28.0% in 2016, and 26.7% in 2017 [1].
Inappropriate prescribing of antimicrobials, particularly in primary care, is one of the main factors causing the emergence of antibiotic-resistant organisms. A failure to address antibiotic resistance could result in an estimated 10 million additional deaths worldwide every year by 2050, exceeding the 8.2 million lives a year currently lost to cancer and the cumulative economic loss to world economies might be as high as US$100 trillion [2]. With a long-term goal to accomplish meaningful and sustained change in antibiotic prescribing practices, the Agency for Healthcare Research and Quality (AHRQ) Safety Programme for Improving Antibiotic Use has introduced an organised approach to incorporate four moments of antibiotic decision making into thought process when antibiotic therapy is considered. The four moments framework includes synthesising all relevant patient information to determine the likelihood of an infection that requires antibiotic therapy, thinking carefully about specific patient risk factors and severity of illness in association with the likely source of infection, performing a daily antibiotic time-out for every patient receiving antibiotics, and assessing whether patients have had appropriate clinical responses [3].
In mid-2018, we conducted a retrospective cross-sectional surveillance analysis in a primary care health clinic in Malaysia to glean preliminary data to warrant further research regarding adherence to antibiotic guidelines and stewardship interventions for reducing inappropriate antibiotic use. We found that nearly one in six prescriptions in our setting (n=396/2,391; 16.6%) had antibiotic. The antibiotics were commonly prescribed in patients with upper respiratory tract infection (URTI) (n=239; 60.4%), skin and soft tissue infection (n=107; 27.0%), and urinary tract infection (UTI) (n=31; 7.8%). In URTI patients, the main antibiotics prescribed were penicillins (85.8%) and macrolides (14.2%). For skin and soft tissue infection, the main antibiotics prescribed were penicillins – cloxacillin (87.9%) and amoxicillin (9.3%). For UTI treatment, the main antibiotics chosen were cephalosporins – cephalexin (74.2%) and cefuroxime (12.9%). All prescriptions had a duration of five or seven days. None of the analysed prescriptions were indicated for chronic and recurrent cases, repeat prescriptions, and antibiotic prophylaxis.
The antibiotic prescribing rate for URTI (acute cough and bronchitis, acute tonsillitis, acute pharyngitis, acute otitis media, and acute sinusitis) was high (60.4%). Whilst phenoxymethylpenicillin was the preferred treatment suggested in the National Antibiotic Guideline of Malaysia, our study revealed that it was not prescribed in all prescriptions analysed [4]. The patients were far more likely to receive broad-spectrum antibiotics, namely amoxicillin and erythromycin. 116 of the 239 prescriptions (48.5%) were given to children aged less than 10 years.
For skin and soft tissue infections (cellulitis and impetigo), cloxacillin was the preferred treatment suggested in the National Antibiotic Guideline of Malaysia and 87.9% of the prescriptions were concordant with the recommendation [4].
For UTI (acute cystitis), trimethoprim and nitrofurantoin which were the preferred treatment suggested in National Antibiotic Guideline were not prescribed [4]. However, almost three-fourths of these prescriptions were for cephalexin. As compared to the previous study prior to the introduction of 2nd Edition of National Antibiotic Guideline in Malaysia, co-trimoxazole was the most commonly prescribed antibiotic given to patients with UTI-like symptoms or diagnosis [5]. Trimethoprim and nitrofurantoin were not available in our setting, hence, cephalexin was used as the alternative.
In many countries, successful programmes to prevent inappropriate antibiotic use usually consist of two important components: one directed at the clinicians and the other at the caregivers, aiming to improve their knowledge in addition to change the attitudes and beliefs that lead to inappropriate demand for antibiotic prescriptions for children [6]. In addition to passive dissemination of guideline, prudent use of antibiotics in primary care setting can be achieved with the implementation of academic detailing by senior family physicians and antibiotic interactive seminars which provide feedback of prescribing data to prescribers [7]. Other approaches to optimise antibiotic use are strengthening antimicrobial stewardship efforts, obtaining infectious diseases expertise through telemedicine consultation, regular review of prescriptions, or guideline education for prescribers, and use of an online antimicrobial prescribing survey to document the utilisation of antimicrobials and assess the prescribing practise across all health care facilities. Hence, we concluded that broad-spectrum antibiotic prescribing was very common in our primary care setting. The implementation of stewardship programmes targeting different geographic regions, diagnostic conditions, and patient populations are necessary to improve antibiotic prescribing, thereby boosting the long-term quality of patient care.
References
1. Bernardo CO, Gonzalez-Chica D, Stocks N. Influenza-like illness and antimicrobial prescribing in Australian general practice from 2015 to 2017: a national longitudinal study using the MedicineInsight dataset. BMJ Open 2019;9:e026396. doi: 10.1136/bmjopen-2018-026396
2. Rahimi S. Urgent action on antimicrobial resistance. Lancet Respir Med 2019;7:208-9. doi: 10.1016/S2213-2600(19)30031-1
3. Tamma PD, Miller MA, Cosgrove SE. Rethinking how antibiotics are prescribed: incorporating the 4 moments of antibiotic decision making into clinical practice. JAMA 2019;321:139−40. doi: 10.1001/jama.2018.19509
4. Pharmaceutical Services Division. National Antibiotic Guideline (Second Edition). Ministry of Health Malaysia. Available at: https://www.pharmacy.gov.my/v2/sites/default/files/document-upload/natio... Accessed 15 March 2019.
5. Teng CL, Tong SF, Khoo EM, et al. Antibiotics for URTI and UTI-prescribing in Malaysian primary care settings. Aust Fam Physician 2011;40:325−29.
6. Wong GWK. Reducing antibiotic prescriptions for childhood upper respiratory tract infections. Lancet Glob Health 2017;5:e1170−1. doi: 10.1016/S2214-109X(17)30423-0
7. Mohd Fozi K, Kamaliah MN. The effect of profiling report on antibiotic prescription for upper respiratory tract infection. Malays Fam Physician 2013;8:26−31.
Acknowledgement
All authors would like to thank the Director-General of Health Malaysia for his permission to publish this correspondence.
Funding
This correspondence receives no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of competing interests
All authors declare they have no actual or potential conflict of interest relevant to this correspondence.
The study reported by Ang and co-workers is of great interest to health care providers, especially in view of its publication in a journal read by a general medical audience. It elegantly delineates two programmes that were launched in Singapore to facilitate the safe transition from acute hospital to the home of patients and aimed to decrease inpatient admissions and emergency department attendances, reduce the total inpatient length of stay, and diminish the expenses of care of patients [1].
In Malaysia, we have an integrated care transitions programme that enables stable patients discharged from hospital admissions to undergo subsequent care and continuous treatment follow-ups at designated primary health centres. For more than a decade, Ministry of Health Malaysia has commenced a discharge referral service to ensure the continuity of care and supply of medications with minimal discrepancies when patients are transferred from hospitals to health clinics.
Whilst the Guidelines for Inpatient Pharmacy Practice has been published to consolidate pharmaceutical care activities in both the outpatient and inpatient settings, little is known about the patterns of medications supplied to patients with stable chronic illnesses who receive follow-up care in primary care centres in Malaysia. To address the information gap on the costs and prescribing patterns of chronic medications in primary care settings, we analysed data from an urbanised government-funded health cl...
The study reported by Ang and co-workers is of great interest to health care providers, especially in view of its publication in a journal read by a general medical audience. It elegantly delineates two programmes that were launched in Singapore to facilitate the safe transition from acute hospital to the home of patients and aimed to decrease inpatient admissions and emergency department attendances, reduce the total inpatient length of stay, and diminish the expenses of care of patients [1].
In Malaysia, we have an integrated care transitions programme that enables stable patients discharged from hospital admissions to undergo subsequent care and continuous treatment follow-ups at designated primary health centres. For more than a decade, Ministry of Health Malaysia has commenced a discharge referral service to ensure the continuity of care and supply of medications with minimal discrepancies when patients are transferred from hospitals to health clinics.
Whilst the Guidelines for Inpatient Pharmacy Practice has been published to consolidate pharmaceutical care activities in both the outpatient and inpatient settings, little is known about the patterns of medications supplied to patients with stable chronic illnesses who receive follow-up care in primary care centres in Malaysia. To address the information gap on the costs and prescribing patterns of chronic medications in primary care settings, we analysed data from an urbanised government-funded health clinic in Selangor, Malaysia through the quantification of prescriptions filled and dispensed to patients discharged by tertiary-based specialists.
A cross-sectional, retrospective study was conducted to analyse all prescriptions (n=547) of patients with chronic conditions who were discharged from a tertiary care hospital to Kelana Jaya Health Clinic between January 2017 and December 2017. The costs of medications were calculated based on the procurement price of medicines available at our facility during data collection. The overall costs spent on medications supplied to patients discharged from hospitals were (Malaysian Ringgit) RM39,304.00. The medications accounted for the highest expenditures were metformin (RM5,990.40), gliclazide (RM5,939.60), metoprolol (RM2,265.50), perindopril (RM1,846.95), and human insulin (RM1,817.30). The medications with the lowest spending were allopurinol (RM75.80), haematinic (RM72.00), potassium chloride (RM54.20), sertraline (RM50.20), and digoxin (RM16.80). The most commonly dispensed medications were simvastatin (785,218 tablets), metformin (74,880 tablets), budesonide metered dose inhaler (49,444 canisters), gliclazide (28,440 tablets), and perindopril (21,780 tablets), whereas the medicines that had the lowest rates of dispense were fluvoxamine (360 tablets), sertraline (360 tablets), digoxin (120 tablets), allopurinol (75 tablets), and potassium chloride (54 tablets).
In line with the specific aim of the post-discharge care programmes described by Ang and co-authors to reduce the total expenditures per patient for health services, we envisage utilsation of high-value medications will also help reduce the economic burden of treatment. The use of high-value medicines, defined as guideline-recommended and reasonably priced, should be a priority for all countries, particularly those with limited resources [2, 3]. High-value medicines are not preferentially prescribed in many health care settings and there is currently sparse evidence to demonstrate that higher-priced medications are more effective [3]. Previous research has suggested that the utilisation of high-value medications has the potential to alleviate the financial burden attributed to increasing rates of treatment [2, 3]. In this respect, meticulously designed large cost-effectiveness studies are warranted to ascertain disease specific medications which will yield beneficial outcomes to patients. The study sites must be representative of a full range of health care settings across all states in the country. Identifying the higher-priced medications with known benefits over lower-cost alternatives can serve as a basis for high quality and cost-efficient care [3].
Future efforts and policies aimed at mitigating the burden of non-communicable diseases by paying particular attention to the role of primary health care centres will need to improve patient access to high-value medications, especially in low and middle-income countries.
References
1. Ang IYH, Tan CS, Nurjono M, et al. Retrospective evaluation of healthcare utilisation and mortality of two post-discharge care programmes in Singapore. BMJ Open 2019;9:e027220. doi: 10.1136/bmjopen-2018-027220
2. Porter ME. A strategy for health care reform — toward a value-based system. N Engl J Med 2009;361:109−12. doi: 10.1056/NEJMp0904131
3. Su M, Zhang Q, Bai X, et al. Availability, cost, and prescription patterns of antihypertensive medications in primary health care in China: a nationwide cross-sectional survey. Lancet 2017;390:2559−68. doi: 10.1016/S0140-6736(17)32476-5
Acknowledgement
All authors would like to thank the Director-General of Health Malaysia for his permission to publish this correspondence.
Funding
This correspondence receives no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of competing interests
All authors declare they have no actual or potential conflict of interest relevant to this correspondence.
While this study is focussed on atrial fibrillation patients please be aware that nearness to death is a risk factor in readmission which operates irrespective of age.
Accurate risk modelling will therefore need to include both age and nearness to death.
As nearness to death is an important contributor to hospital utilization, especially in the last six months of life, is it possible for the data to be reanalysed in relation to nearness to death in this cohort?
We read with interest this paper which asserts that recent increases in infant mortality have affected poorer areas of England disproportionately. In our analyses of largely post-neonatal unexplained infant deaths we too have found a proportional increase of poorer families; markers of deprivation including maternal age, education, parity and smoking status will all impact on infant mortality. (1-3) However, it is perhaps worth pointing out that this recent increase in infant mortality in England & Wales from 2014 to 2017 is limited to neonatal deaths, the rate of post-neonatal deaths (4 weeks to 1 year old) has flat-lined in these 4 years from 1.09 deaths per 1000 live births in 2014 to 1.08 deaths per 1000 live births in 2017. Furthermore, in the data release by the Office for National Statistics (ONS) for 2017, (4) they report a 23.5% reduction in infant mortality in the most deprived areas over the last 10 years, compared with a 10.0% reduction in the most affluent areas. Using the data provided in that release on age at death we can see that the increase in overall infant mortality is driven by very early neonatal deaths of infants under 1 day old, from 1.3 per 1000 live births in 2014 to 1.5 in 2015, and 1.6 in 2016 and 2017. Mortality in all other age groups within infancy from one day to one year show reductions over that time. (4) The major contributory causes to early neonatal mortality are prematurity, congenital anomalies and infections, with a small but...
Show MoreDear BMJ Open Editor Adrian Aldcroft,
We read with interest the recent paper by Kazis et al [BMJ Open 2019;9e028633], an observational retrospective study of the association between initial health provider for low back pain with subsequent opioid use.
This included data on three types of conservative therapists as well as various types of physicians. Initial treatment from any of the former, namely physical therapists (PTs), chiropractors and acupuncturists, was associated with substantially decreased odds for both early and long-term opioid use. However, these results, though tabulated, described and discussed in the main text of the paper do not transfer in the same form to the abstract. Specifically, the acupuncture results have been removed.
The benefits of both PT and chiropractic are stated in two places in the Results section and once in the Conclusions, but there is no mention of acupuncture. Although we understand that the sample of acupuncturists was relatively small, acupuncture reduced short and long term exposure to opioids by 75% to 90% compared to the same patient starting with a PCP, and the confidence interval was significant and similar to PT.
Given that many people will look initially or only at the abstract, this omission misleads the reader into inferring that acupuncture did not have the same benefits as the other two conservative treatments. The implications for health care policy/access/delivery are of concern. Does a...
Show MoreDear Editor
In response to the letter of 22 May, we are happy to deal with the key issues of conflict of interest, acknowledgement and data interpretation. However, many of the comments in the letter deal with the funding, function and nature of the NHS England contract for the database. We feel this is a matter that should be taken up with NHS England rather than the letter section of this Journal as it has little, if anything, to do with the paper as published.
Regarding the issue of undeclared conflict of interest. Mr Dunn is a burn surgeon with an honorary position at Manchester University and was co-supervisor of the primary author’s PhD at Manchester University. The paper was reviewed by academic peers before publication and the source of funding for the associated PhD was declared. We have reviewed the Journal’s document on competing interests and are satisfied that we declared all interests relevant to the basis, process or conclusions of the work undertaken.
The burn injury database is funded by NHS England and is managed as part of his NHS contract by Mr Dunn who is medical director of the iBID and co-chair of the Burn Care Informatics Board that oversees the use of the iBID data. It is this Board which sanctioned the release of the anonymized data on which this paper and the PhD work was based. In the paper the source of the data is mentioned and my control of this aspect inferred but I accept is not stated. Should the Editor feel an addendu...
Show MoreTo Whom it May Concern:
I am a licensed acupuncturist in the state of Minnesota, working with a large hospital system. I was looking forward to reading this important study when I heard about it, but I was disappointed and unclear why acupuncture is left out of the conclusion completely although it is included as a "conservative therapy" type.
This study clearly shows acupuncture showed similar results to both chiropractic and PT, as stated in the body of the text: " For early opioid use, patients initially visiting chiropractors had 90% decreased odds (95% CI 0.09 to 0.10) while those visiting an acupuncturists had 91% decreased odds (95% CI 0.07 to 0.12) and those visiting physical therapists had 85% decreased odds (95% CI 0.13 to 0.17). Chiropractors, acupuncturists and physical therapists all had major decreased odds of long-term opioid use compared with those who initially saw PCPs ."
As you can see, however, in the conclusion only chiropractic and PT are mentioned by name: "Results Short-term use of opioids was 22%. Patients who received initial treatment from chiropractors or physical therapists had decreased odds of short-term and long-term opioid use compared with those who received initial treatment from primary care physicians (PCPs) (adjusted OR (AOR) (95% CI) 0.10 (0.09 to 0.10) and 0.15 (0.13 to 0.17), respectively). Compared with PCP visits, initial chiropractic and physical therapy also were associated with dec...
Show MoreI read the study by Schneider et al. with great interest [1]. They sought to investigate whether “a landmark trial had changed practiced patterns for treatment of patients with displaced midshaft clavicle fractures” (MCF). For the purposes of their study they investigated the prevalence of open reduction and internal fixation (ORIF) in MCFs in two level 1 hospitals. They concluded that after this single trial there was a trend toward more prevalent ORIF and alike studies are needed in the future. I have several concerns regarding their study and conclusions.
A single study, even if level 1, is still a single study done in a certain location at a certain time. It is prone to different biases, between-patient variability and random variation. Even with very large sample size we can´t underestimate the uncertainty and imprecision we have in our results. Also, the framework or statistical methods we use will affect the results we obtain. All these should be appraised when we evaluate and implement studies published in peer-reviewed literature.
COTS trial on MCF was the first major study on this topic [2]. However, considering the complexity of performing an RCT, a fairly large number of them has been published investigating ORIF and nonoperative treatment in MCFs. For example, studies by Woltz et al. and Robinson et al. are RCTs with a sample size exceeding that of COTS study [3,4]. Interestingly neither of these studies was cited by Schneider et al. Woltz et al....
Show MoreThe article of Hofstede et al on unnecessary vitamin testing in general practice deals with exploring the barriers and facilitators to reduce the number of (unnecessary) vitamin D and B12 laboratory testing.
Show MoreWe consider that there are significant differences between both laboratory tests. It is true that neither vitamin D nor B12 tests are recommended for screening purposes, and their request from primary care has exponentially increased over time. Nonetheless, the latter is not equivalent to inappropriate demand.
It is known that vitamin D over testing is common in certain scenarios; and it can result in over treatment and potential intoxication. The vitamin B12 case is, however, a completely different topic. Subjects with vitamin B12 deficiency do not often show anemia, macrocytosis nor specific symptoms of vitamin deficiency and the adverse effects of such a condition, especially neurological symptoms that could be irreversible if not treated in six months. That is the reason why the laboratory professional should be screening for new deficit cases; especially, when an easy and affordable treatment is available - a monthly intramuscular supplementation - without any possibility of intoxication.
Less than half of patients with vitamin B12 deficiency have macrocytosis. However, macrocytosis can be used to improve the diagnosis of severe vitamin B12 deficiency through computer-assisted interventions in the clinical laboratory process. Additionally, morpho...
Dear Editor,
We read with immense interest the article by Bernado and co-authors that investigated the epidemiology of influenza-like illness (ILI) and the prescription of antivirals or antibiotics between 2015 and 2017. Antibiotic prescribing for ILI showed a significant decline from 30.3% in 2015, to 28.0% in 2016, and 26.7% in 2017 [1].
Inappropriate prescribing of antimicrobials, particularly in primary care, is one of the main factors causing the emergence of antibiotic-resistant organisms. A failure to address antibiotic resistance could result in an estimated 10 million additional deaths worldwide every year by 2050, exceeding the 8.2 million lives a year currently lost to cancer and the cumulative economic loss to world economies might be as high as US$100 trillion [2]. With a long-term goal to accomplish meaningful and sustained change in antibiotic prescribing practices, the Agency for Healthcare Research and Quality (AHRQ) Safety Programme for Improving Antibiotic Use has introduced an organised approach to incorporate four moments of antibiotic decision making into thought process when antibiotic therapy is considered. The four moments framework includes synthesising all relevant patient information to determine the likelihood of an infection that requires antibiotic therapy, thinking carefully about specific patient risk factors and severity of illness in association with the likely source of infection, performing a daily antibiotic time-out for...
Show MoreThe study reported by Ang and co-workers is of great interest to health care providers, especially in view of its publication in a journal read by a general medical audience. It elegantly delineates two programmes that were launched in Singapore to facilitate the safe transition from acute hospital to the home of patients and aimed to decrease inpatient admissions and emergency department attendances, reduce the total inpatient length of stay, and diminish the expenses of care of patients [1].
In Malaysia, we have an integrated care transitions programme that enables stable patients discharged from hospital admissions to undergo subsequent care and continuous treatment follow-ups at designated primary health centres. For more than a decade, Ministry of Health Malaysia has commenced a discharge referral service to ensure the continuity of care and supply of medications with minimal discrepancies when patients are transferred from hospitals to health clinics.
Whilst the Guidelines for Inpatient Pharmacy Practice has been published to consolidate pharmaceutical care activities in both the outpatient and inpatient settings, little is known about the patterns of medications supplied to patients with stable chronic illnesses who receive follow-up care in primary care centres in Malaysia. To address the information gap on the costs and prescribing patterns of chronic medications in primary care settings, we analysed data from an urbanised government-funded health cl...
Show MoreWhile this study is focussed on atrial fibrillation patients please be aware that nearness to death is a risk factor in readmission which operates irrespective of age.
Accurate risk modelling will therefore need to include both age and nearness to death.
I hope that these comments are helpful.
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