BMJ Open

Bakhbakhi, Danya; Burden, Christy; Storey, Claire; Heazell, Alexander Edward; Lynch, Mary; Timlin, Laura; Gold, Katherine; Siassakos, Dimitrios

doi: 10.1136/bmjopen-2018-023792pmid: 30798293

ObjectiveEngaging bereaved parents in the review process that examines their care before and after a perinatal death might help parents deal with their grief more effectively and drive improvements in patient safety. The objective of this study is to explore whether healthcare professionals would accept or support parent engagement in the perinatal mortality review process.DesignQualitative focus group interviews. Transcripts were analysed with an inductive thematic approach.SettingTwo geographically distinct tertiary maternity hospitals in the UK.ParticipantsFive focus groups were conducted with clinical staff including midwives, obstetricians, neonatologists, nursing staff and chaplaincy services.ResultsTwenty-seven healthcare professionals unanimously agreed that parents’ involvement in the perinatal mortality review process is useful and necessary. Six key themes emerged including: parental engagement; need for formal follow-up; critical structure of perinatal mortality review meeting; coordination and streamlining of care; advocacy for parents including role of the bereavement care lead; and requirement for training and support for staff to enable parental engagement.ConclusionsHealthcare professionals strongly advocated engaging bereaved parents in the perinatal mortality review: empowering parents to ask questions, providing feedback on care, helping generate lessons and providing them with the opportunity to discuss a summary of the review conclusions with their primary healthcare professional contact. The participants agreed it is time to move on from ‘a group of doctors reviewing notes’ to active learning and improvement together with parents, to enable better care and prevention of perinatal death.

Wu, Haibin; Eggleston, Karen N; Zhong, Jieming; Hu, Ruying; Wang, Chunmei; Xie, Kaixu; Chen, Yiwei; Chen, Xiangyu; Yu, Min

doi: 10.1136/bmjopen-2017-020647pmid: 30389755

ObjectiveTo evaluate type 2 diabetes mellitus (T2DM)-related direct medical costs by complication type and complication number, and to assess the impacts of complications as well as socioeconomic factors on direct medical costs.DesignA cross-sectional study using data from the region’s diabetes management system, social security system and death registry system, 2015.SettingTongxiang, China.ParticipantsIndividuals diagnosed with T2DM in the local diabetes management system, and who had 2015 insurance claims in the social security system. Patients younger than 35 years and patients whose insurance type changed in the year 2015 were excluded.Main outcome measuresThe mean of direct medical costs by complication type and number, and the percentage increase of direct medical costs relative to a reference group, considering complications and socioeconomic factors.ResultsA total of 19 015 eligible individuals were identified. The total cost of patients with one complication was US$1399 at mean, compared with US$248 for patients without complications. The mean total cost for patients with 2 and 3+ complications was US$1705 and US$2994, respectively. After adjustment for socioeconomic confounders, patients with one complication had, respectively, 83.55% and 38.46% greater total costs for inpatient and outpatient services than did patients without complications. The presence of multiple complications was associated with a significant 44.55% adjusted increase in total outpatient costs, when compared with one complication. Acute complications, diabetic foot, stroke, ischaemic heart disease and diabetic nephropathy were the highest cost complications. Gender, age, education level, insurance type, T2DM duration and mortality were significantly associated with increased expenditures of T2DM.ConclusionsComplications significantly aggravated expenditures on T2DM. Specific kinds of complications and the presence of multiple complications are correlated with much higher expenditures. Proper management and the prevention of related complications are urgently needed to reduce the growing economic burden of diabetes.

Rohwer, Anke; Wager, Elizabeth; Young, Taryn; Garner, Paul

doi: 10.1136/bmjopen-2018-024777pmid: 30413518

ObjectivesTo examine whether regional biomedical journals in Africa had policies on plagiarism and procedures to detect it; and to measure the extent of plagiarism in their original research articles and reviews.DesignCross sectional survey.Setting and participantsWe selected journals with an editor-in-chief in Africa, a publisher based in a low or middle income country and with author guidelines in English, and systematically searched the African Journals Online database. From each of the 100 journals identified, we randomly selected five original research articles or reviews published in 2016.OutcomesFor included journals, we examined the presence of plagiarism policies and whether they referred to text matching software. We submitted articles to Turnitin and measured the extent of plagiarism (copying of someone else’s work) or redundancy (copying of one’s own work) against a set of criteria we had developed and piloted.ResultsOf the 100 journals, 26 had a policy on plagiarism and 16 referred to text matching software. Of 495 articles, 313 (63%; 95% CI 58 to 68) had evidence of plagiarism: 17% (83) had at least four linked copied or more than six individual copied sentences; 19% (96) had three to six copied sentences; and the remainder had one or two copied sentences. Plagiarism was more common in the introduction and discussion, and uncommon in the results.ConclusionPlagiarism is common in biomedical research articles and reviews published in Africa. While wholesale plagiarism was uncommon, moderate text plagiarism was extensive. This could rapidly be eliminated if journal editors implemented screening strategies, including text matching software.

Tashiro, Ai; Sakisaka, Kayako; Okamoto, Etsuji; Yoshida, Honami

doi: 10.1136/bmjopen-2018-022737pmid: 30478111

ObjectivesTo examine associations between access to medical care, geological data, and infant and child mortality in the area of North-Eastern Japan that was impacted by the Great East Japan Earthquake and Tsunami (GEJET) in 2011.DesignA population-based ecological study using publicly available data.SettingTwenty secondary medical areas (SMAs) in the disaster-affected zones in the north-eastern prefectures of Japan (Iwate, Fukushima and Miyagi). Participants: Children younger than 10 years who died in the 20 SMAs between 2008 and 2014 (n=1 748). Primary and secondary outcome measures: Multiple regression analysis for infant and child mortality rate. The mean values were applied for infant and child mortality rates and other factors before GEJET (2008–2010) and after GEJET (2012–2014).ResultsBetween 2008 and 2014, the most common cause of death among children younger than 10 years was accidents. The mortality rate per 100 000 persons was 39.1±41.2 before 2011, 226.7±43.4 in 2011 and 31.4±39.1 after 2011. Regression analysis revealed that the mortality rate was positively associated with low age in each period, while the coastal zone was negatively associated with fewer disaster base hospitals in 2011. By contrast, the number of obstetrics and gynaecology centres (β=−189.9, p=0.02) and public health nurses (β=−1.7, p=0.01) was negatively associated with mortality rate per person in 2011.ConclusionsIn 2011, the mortality rate among children younger than 10 years was 6.4 times higher than that before and after 2011. Residence in a coastal zone was significantly associated with higher child mortality rates.

Busingye, Doreen; Kilkenny, Monique F; Purvis, Tara; Kim, Joosup; Middleton, Sandy; Campbell, Bruce C V; Cadilhac, Dominique A

doi: 10.1136/bmjopen-2018-022536pmid: 30420348

ObjectiveSpending at least 90% of hospital admission in a stroke unit (SU) is a recommended indicator of receiving high-quality stroke care. However, whether this makes a difference to patient outcomes is unknown. We aimed to investigate outcomes and factors associated with patients with acute stroke spending at least 90% of their admission in an SU, compared with those having less time in the SU.DesignObservational study using cross-sectional data.SettingData from hospitals which participated in the 2015 Stroke Foundation National Audit: Acute Services (Australia) and had an SU. This audit includes an organisational survey and retrospective medical record audit of approximately 40 admissions from each hospital.ParticipantsPatients admitted to an SU during their acute admission were included.Outcome measuresHospital-based patient outcomes included length of stay, independence on discharge, severe complications and discharge destination. Patient, organisational and process indicators were included in multilevel logistic modelling to determine factors associated with spending at least 90% of their admission in an SU.ResultsEighty-eight hospitals with an SU audited 2655 cases (median age 76 years, 55% male). Patients who spent at least 90% of their admission in an SU experienced: a length of stay that was 2 days shorter (coefficient −2.77, 95% CI −3.45 to –2.10), fewer severe complications (adjusted OR (aOR) 0.60, 95% CI 0.43 to 0.84) and were less often discharged to residential aged care (aOR 0.59, 95% CI 0.38 to 0.94) than those who had less time in the SU. Patients admitted to an SU within 3 hours of hospital arrival were three times more likely to spend at least 90% of their admission in an SU.ConclusionSpending at least 90% of time in an SU is a valid measure of stroke care quality as it results in improved patient outcomes. Direct admission to SUs is warranted.

Yeowell, Gillian; Smith, Philip; Nazir, Jameel; Hakimi, Zalmai; Siddiqui, Emad; Fatoye, Francis

doi: 10.1136/bmjopen-2018-021889pmid: 30467131

PurposeTo evaluate persistence and adherence of oral pharmacotherapy used in the treatment of overactive bladder (OAB) in a real-world setting.Materials and methodsSystematic literature searches of six electronic publication databases were performed to identify observational studies of patients with OAB treated with antimuscarinics and/or mirabegron. Studies obtaining persistence and adherence data from sources other than electronic prescription claims were excluded. Reference lists of identified studies and relevant systematic reviews were assessed to identify additional relevant studies.ResultsThe search identified 3897 studies, of which 30 were included. Overall, persistence ranged from 5% to 47%. In studies reporting data for antimuscarinics and mirabegron (n=3), 1-year persistence was 12%–25% and 32%–38%, respectively. Median time to discontinuation was <5 months for antimuscarinics (except one study (6.5 months)) and 5.6–7.4 months for mirabegron. The proportion of patients adherent at 1 year varied between 15% and 44%. In studies reporting adherence for antimuscarinics and mirabegron, adherence was higher with mirabegron (mean medication possession ratio (MPR): 0.59 vs 0.41–0.53; mean proportion of days covered: 0.66 vs 0.55; and median MPR: 0.65 vs 0.19–0.49). Reported determinants of persistence and adherence included female (sex), older age group, use of extended-release formulation and treatment experience.ConclusionMost patients with OAB discontinued oral OAB pharmacotherapy and were non-adherent 1 year after treatment initiation. In general, mirabegron was associated with greater persistence and adherence compared with antimuscarinics. Combined with existing clinical trial evidence, this real-world review merits consideration of mirabegron for first-line pharmacological treatment among patients with OAB.PROSPERO registration numberCRD42017059894.

van Lieshout, Christianne T; Tijdink, Joeri K; Smulders, Yvo M

doi: 10.1136/bmjopen-2018-023534pmid: 30413513

ObjectivesTo assess the duration of display of conflict of interest (COI) disclosure slides of presentations at the European Society of Cardiology (ESC) Congress 2016, and to identify factors associated with the duration of display of the disclosure slide.DesignCross-sectional observational study.Outcome measuresDisplay duration of the COI disclosure slide and display duration per disclosure.ResultsAnalysis of official video recordings of all oral presentations, viewed on the ESC website. 1673 oral presentations were analysed. In 706 presentations (42.2%), COIs were present on the disclosure slide. The median display duration of the disclosure slide was 2.49 s (minimum value: 0.16 s; IQR 1.47–4.08). In multivariable analysis, time spent on COI disclosures was positively related to the number of COIs (+0.11 s per extra COI), older estimated age of the speaker (+3.92 s for 75–85 years compared with <25 years), verbally commenting on disclosures (up to +8.25 s) and disclosures being of a non-commercial nature (+2.83 s). In addition, speakers from Eastern, Southern and Western Europe, Africa+East Asia and Asia showed their disclosures significantly shorter than the reference group (Northern Europe).ConclusionCOI disclosure slides are often displayed too briefly to reasonably assess their content. Several factors appear to influence the duration of display of the COI disclosure slides, but none do so to the degree that the display duration becomes sufficiently long.

Pyakurel, Prajjwal; Tripathy, Jaya Prasad; Oo, Myo Minn; Acharya, Bijay; Pyakurel, Ujjwal; Singh, Suman Bahadur; Subedi, Laxmi; Yadav, Kamlesh Prasad; Poudel, Mukesh; Pandey, Dipesh Raj; Budhathoki, Shyam Sundar; Lohani, Guna Raj; Jha, Nilambar

doi: 10.1136/bmjopen-2018-022002pmid: 30446573

ObjectivesThe study aimed at estimating out-of-pocket (OOP) expenditure, catastrophic health expenditure (CHE) and distress financing due to hospitalisation and outpatient care among industrial workers in Eastern Nepal.MethodsWe conducted a cross-sectional study involving industrial workers employed in a large-scale industry in Eastern Nepal. Those who were hospitalised in the last 1 year or availed outpatient care within the last 30 days were administered a structured questionnaire to estimate the cost of illness. CHE was defined as expenditure more than 20% of annual household income. Distress financing was defined as borrowing money/loan or selling assets to cope with OOP expenditure on health.ResultsOf 1824 workers eligible for the study, 1405 (77%) were screened, of which 85 (6%) were hospitalised last year; 223 (16%) attended outpatient department last month. The median (IQR) OOP expenditure from hospitalisation and outpatient care was US$124 (71–282) and US$36 (19–61), respectively. Among those hospitalised, the prevalence of CHE and distress financing was found to be 13% and 42%, respectively, and due to outpatient care was 0.4% and 42%, respectively. Drugs and diagnostics account for a large share of direct costs in both public and private sectors. More than 80% sought hospitalisation and outpatient care in a private sector.ConclusionIndustrial workers face significant financial risks due to ill health compared with the general population. Poor utilisation and higher cost of care in public health facilities warrant strengthening of public sector through increased government spending. The labour act 2014 of Nepal should be strictly adhered.

Chan, Stanley Kam Chung; Zhang, Dexing; Bögels, Susan M; Chan, Christian Shaunlyn; Lai, Kelly Yee Ching; Lo, Herman Hay Ming; Yip, Benjamin Hon Kei; Lau, Elsa Ngar Sze; Gao, Tiffany Ting; Wong, Samuel Yeung Shan

doi: 10.1136/bmjopen-2018-022514pmid: 30420347

IntroductionMindfulness is one of the potential alternative interventions for children with attention-deficit hyperactivity disorder (ADHD). Some evidence suggests that mindfulness is related to changes in brain regions associated with ADHD. The potential benefits of mindfulness on children with ADHD, as well as the feasibility of this intervention approach, are warranted through prior local and foreign studies. This study aims to evaluate the effect of mindfulness-based group intervention for children with ADHD and their respective parents through a robust research design.Methods and analysisThis study will adopt a randomised controlled trial design including 140 children aged 8–12 years with ADHD together with one of their parents (n=140). These families will be randomised into intervention group (n=70) who will be offered the MYmind programme delivered by trained healthcare professionals, and an active control group (n=70) who will be offered the CBT programme. The intervention includes 8 weekly 90 min group sessions for children with ADHD (aged 8–12 years) and their respective parents. The primary and secondary outcomes will include children’s attention, ADHD-related symptoms, behaviours, executive function and mindfulness levels measured by validated objective measures and parent’s reported instruments. Parents’ parental stress, parenting styles, ADHD related symptoms, well-being, rumination level and mindfulness levels will also be measured. Analysis is by intention to treat. The effects of intervention will be evaluated by comparing outcomes between the two arms, as well as comparing outcomes within subject through comparing measurements at baseline (T0), immediately after the 8 week intervention (T1) and at 3 (T2) and 6 (T3) months postintervention.Ethics and disseminationEthics approval has been granted by the Joint Chinese University of Hong Kong – New Territories East Cluster Clinical Research Ethics Committee (The Joint CUHK-NTEC CREC). Participants will be required to sign informed consent form from both parents and children. Findings will be reported in conferences and peer-reviewed publications in accordance with recommendations of Consolidated Standards of Reporting Trials.Trial registration numberChiCTR1800014741; Pre-results.

Kim, Seoyoun; Lee, Sook-Hyun; Kim, Me-Riong; Kim, Eun-Jung; Hwang, Deok-Sang; Lee, Jinho; Shin, Joon-Shik; Ha, In-Hyuk; Lee, Yoon Jae

doi: 10.1136/bmjopen-2017-021070pmid: 30397006

ObjectivesNeck pain is a significant condition that is second only to depression as a cause of years lived with disability worldwide. Thus, identifying and understanding effective treatment modalities for neck pain is of heightened importance. This systematic review aimed to investigate the effects of cupping on neck pain from the current literature.DesignSystematic review and meta-analysis of randomised controlled trials (RCTs).SettingNine databases, including Chinese, Korean and Japanese databases, were searched for data up to January 2018 with no restrictions on publication language.ParticipantsPatients with neck pain.InterventionsCupping therapy as the sole or add-on intervention compared with no treatment or active controls.Primary and secondary outcome measuresPain severity, functional disability and quality of life.ResultsEighteen RCTs were selected. Compared with the no intervention group, the cupping group exhibited significant reduction in pain (mean difference (MD) −2.42(95% CI −3.98 to −0.86)) and improvement in function (MD −4.34(95% CI −6.77 to −1.19)). Compared with the active control, the cupping group reported significant reduction in pain (p=0.0009) and significantly improved quality of life (p=0.001). The group that received control treatment with cupping therapy (add-on group) displayed significant pain reduction compared with the active control group (p=0.001). Of the 18 studies, only 8 reported occurrence of adverse events, which were mostly mild and temporary.ConclusionsCupping was found to reduce neck pain in patients compared with no intervention or active control groups, or as an add-on treatment. Depending on the type of control group, cupping was also associated with significant improvement in terms of function and quality of life; however, due to the low quality of evidence of the included studies, definitive conclusions could not be drawn from this review. Future well-designed studies are needed to substantiate the effectiveness of cupping on neck pain.PROSPERO registration numberCRD42016047218.