BMJ medicine最新文献

Objective: To compare routine high risk human papillomavirus (hrHPV) screening with cytological screening in two screening rounds in a well established, routine screening programme for cervical cancer.

Design: Population based cohort study.

Setting: Finland's Mass Screening Registry, 2012-22, with diagnostic follow-up examinations until October 2024.

Participants: 1 180 491 women participating at least once in cytological test (PAP smear) or hrHPV based cervical cancer screening between 2012 and 2022.

Main outcome measures: Numbers and proportions of attendees, positive routine test results, follow-up screening referrals, colposcopy referrals, and incidence of cervical intraepithelial neoplasia ≥grade 2 (CIN2+) in the first and second hrHPV and cytological screening rounds. Results adjusted for age, year, region, and education.

Results: Data for 1 574 688 full screening rounds were analysed. The overall referral rate for colposcopy was 3.37% (n=12 273) in the hrHPV group and 0.98% (n=11 895) in the cytology group, with an adjusted risk ratio of 2.97 (95% confidence interval (CI) 2.87 to 3.07). The overall rate for detection of CIN2+ was 0.92% in the hrHPV group and 0.35% in the cytology group, with an adjusted risk ratio of 2.17 (2.04 to 2.31). For the second hrHPV screening round compared with the first screening round, the adjusted risk ratio was 0.77 (0.71 to 0.84) for referral for colposcopy and 0.57 (0.46 to 0.72) for detection of CIN2+. Actual rates for referral for colposcopy were 3.54% (n=11 709) in the first hrHPV screening round and 2.42% (n=564) in the second screening round. The rate for detection of CIN2+ for hrHPV screening was 0.98% (n=3 248) in the first hrHPV screening round and 0.38% (n=88) in the second screening round. In cytological screening, no observed reduction was seen in either the referral rate or CIN2+ findings. After a negative hrHPV test in the first screening round, CIN2+ was detected in only 0.2% of women (n=44/314 286) in the second screening round.

Conclusions: Within a well established, population based national screening programme, the results of the study indicated that hrHPV screening with a five year interval was effective and safe. hrHPV screening identified precancerous lesions earlier than cytological screening. The incidence of CIN2+ was low in the second screening round in women with a negative hrHPV test result in the initial round and in those aged ≥50 years, and hence a longer screening interval for specific subgroups should be considered.

Objective: To quantify prescribing of hormone replacement therapy (HRT) in women aged 40-60 years by type of HRT and length of use, and to determine sociodemographic factors associated with receiving a HRT prescription.

Design: Population based cohort study.

Setting: QResearch database of primary care practices in England, 1 January 2013 to 13 July 2023, and patient electronic health records for prescribing information .

Participants: 1 978 348 women aged 40-60 years at any time over a 10 year period.

Main outcome measures: Overall uptake of two or more prescriptions of the same type of HRT in women of menopausal age, length of use, and association between ethnic group, deprivation, and geographical region and receiving a HRT prescription before and during the eight years since implementation of National Institute for Health and Care Excellence (NICE) guidance on the menopause in 2015 in the UK.

Results: The cohort comprised 1 978 348 women with a mean age of 49.4 years, and 76.2% were white women. Overall, 379 911 (19.2%) women received two or more HRT prescriptions. Combination HRT formulations in one prescription were the most frequently prescribed (62.4% of those prescribed HRT), with 43.3% receiving oral and 26.3% transdermal formulations. Mean age at first prescription was 49.8 years. Rates for two or more prescriptions of HRT were higher in white women (22.6%) than in other ethnic groups, ranging from 8.9% in Caribbean women to 3.9% in black African women. Prescription rates decreased with increasing social deprivation, from 24.2% in the most affluent to 10.9% in the most deprived groups. London had lower prescription rates (11.7%) than other regions (all >19%). Multivariable Cox regression showed that non-white ethnic groups had significantly lower HRT prescription rates (hazard ratios 0.85-0.92, P<0.001), and each increase in social deprivation group was associated with lower HRT prescription rates (hazard ratio for the most deprived group 0.92, 95% confidence interval 0.92 to 0.93, P<0.001).

Conclusions: This study identified differences in HRT prescribing in England based on ethnic group, socioeconomic status, and geographical location. White women and those in more affluent neighbourhoods were more likely to receive HRT than non-white women and those in more deprived areas. These findings suggest potential inequities that require further exploration.

Case study is a widely used but poorly understood research method, conducted differently in different disciplines. This paper explores philosophical, theoretical and methodological issues in case study research and outlines how to conduct one. It offers preliminary guidance for policy makers on how to select and use case studies for learning and decision making. In social science research, a case study is a detailed, contextualised account of a clearly delineated, real world phenomenon, prepared prospectively using mostly qualitative methods. Social science case studies can be of various kinds (eg, theoretical or naturalistic, single or multiple, typical or extreme). A public health case study is a historical account of a health threat and how it was managed. An implementation science case study evaluates the implementation of an intervention (usually retrospectively), combining quantitative assessment against predefined objectives with a narrative of how the project unfolded. Educational case studies present real world topics as stories illustrated by data and prompt students to discuss these from different angles. Impact case studies summarise the societal impact of a research programme. Many accounts described as case studies are overly brief and superficial. The paper concludes with a call to improve the quality and consistency (and hence the usefulness) of case studies.

Abstract:

Objective: To investigate the magnitude and evolution of inequalities in neonatal mortality rates by using area based socioeconomic indices in France.

Design: National population based study.

Setting: For 2015-20, data from the French National Health Data System (Système National des Données de Santé, SNDS). For 2001-08, neonatal death certificates and aggregate vital statistics data by municipality of residence.

Participants: Live births with a gestational age ≥22 completed weeks to a mother residing in metropolitan France, 2015-20 (4 293 403 live births and 10 869 neonatal deaths), compared with a 2001-08 study (6 202 918 live births and 14 851 neonatal deaths).

Main outcome measures: Differences in neonatal mortality rate (death before day 28 of life) according to the socioeconomic characteristics of the mother's municipality of residence. Comparison with data from a 2001-08 study to assess changes in socioeconomic inequalities and their contribution to the increase in neonatal mortality rate.

Results: The neonatal mortality rate was 2.53 per 1000 live births in 2015-20. Five indicators, previously associated with perinatal mortality, were combined into a perinatal French deprivation index (P-FDep) for the main analysis. P-FDep was categorised into five equal groups (deprivation groups 1-5) for comparison with other research and into 10 equal groups (deprivation groups 1-10) for more granular analyses, with group 1 being the least and group 5 (or group 10) the most deprived group. The rate in the most deprived compared with the least deprived group for P-FDep was 1.71 (95% confidence interval 1.60 to 1.83) times higher, based on the analysis of deprivation groups 1-5. A mortality gradient existed across the groups, translating into 2496 excess deaths (23.3%) when the rate in the least deprived group was applied to all areas. The gradient was more marked when deprivation groups 1-10 were used (relative risk 1.88, 95% CI 1.71 to 2.07 for the highest to the lowest deprived group). Compared with 2001-08 (neonatal mortality rate 2.39 per 1000), the rate remained constant in the least deprived areas, but worsened in the most deprived areas (+10.1% and +11.7% for groups 4 and 5, respectively), increasing the relative risks between the highest and lowest groups, which were 1.54 (95% CI 1.46 to 1.62) for deprivation groups 1-5 and 1.67 (1.55 to 1.79) for deprivation groups 1-10, in 2001-08.

Conclusions: In this study, the socioeconomic level of the mother's place of residence was strongly associated with the neonatal mortality rate. The data showed that inequalities have widened, contributing to the increase in the neonatal mortality rate.

Objective: To evaluate the effectiveness of various de-implementation interventions in primary care, targeting care (treatments or tests) that provides no or limited value for patients (low value care).

Design: Systematic review and meta-analysis.

Data sources: Medline and Scopus databases, from inception to 10 July 2024.

Eligibility criteria for selecting studies: Randomised trials comparing de-implementation interventions with placebo or sham intervention, no intervention, or other de-implementation intervention strategies in primary care. Eligible trials provided information on the use of low value care, total volume of care, appropriate care, and health outcomes.

Data extraction and synthesis: Titles, abstracts, and full texts were screened, data were extracted, and risk of bias was assessed independently and in duplicate. Random effects meta-analyses were conducted, and the certainty of evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

Results: 13 008 abstracts were screened and 140 were eligible for inclusion in the study. Median follow-up was 287 days (interquartile range 180-365). In 75 (54%) trials the aim was to reduce the use of antibiotics, in 42 (30%) to reduce other drug treatments, in 17 (12%) to reduce imaging, and in 15 (11%) to reduce laboratory testing. The certainty of the evidence was moderate that provider education combined with audit and feedback reduced the use of targeted low value care (odds ratio 0.73, 95% confidence interval (95% CI) 0.63 to 0.84). Provider education (0.86, 95% CI 0.72 to 1.03), audit and feedback (0.82, 0.67 to 1.00), and patient education (0.70, 0.30 to 1.66), and a combination of these strategies (point estimates for odds ratios ranging from 0.57 to 0.64) may reduce the use of targeted low value care (low certainty of evidence for all).

Conclusions: The results suggested with moderate certainty of evidence that provider education combined with audit and feedback reduced the use of targeted low value care. Individual strategies may slightly reduce the use of targeted low value care, but achieving a meaningful impact on low value care may require the use of multiple strategies. The results may be useful for patients, clinicians, policy makers, and guideline developers when deciding on future de-implementation strategies and research priorities.

Systematic review registration: PROSPERO CRD42023411768.

Objectives: To identify and quantify prescriptions after a covid-19 infection compared with other acute respiratory infections in previously healthy patients and those with chronic disease.

Design: Comparative observational study based on German routine data.

Setting: Ambulatory care of all residents in Germany with statutory health insurance (88% of the German population).

Participants: Adults receiving a diagnosis of covid-19 or an acute respiratory infection between the fourth quarter of 2020 and the second quarter of 2021 who had rarely (70 797 and 173 822 with covid-19 and acute respiratory infection, respectively) or frequently (900 593 and 1 755 691, respectively) accessed outpatient medical care in the past.

Main outcome measures: Difference in differences in the proportion of prescriptions of relevant drugs before and one year after infection.

Results: In patients who used the healthcare system less frequently before their covid-19 infection than afterwards, increases in prescription rates for antidiabetics (difference in differences 0.23%, P=0.007), antithrombotics (0.71%, P=0.02), and cardiovascular drugs like beta blockers (0.25%, P=0.03) were observed compared with patients with other acute respiratory infections. One year after infection, the difference in antidiabetic prescription rates was highest. Although a peak in antihypertensive prescription rates was observed six months after infection, antithrombotics were predominantly prescribed during the acute phase. Conversely, patients who had already used the healthcare system on a regular basis before their infection showed no significant long term increases in prescription rates across the drug groups analysed.

Conclusions: This study supports findings that diseases such as diabetes and cardiovascular disease are more prevalent after covid-19 than after other acute respiratory infections. Because the effect is apparent in real world data, future societal implications should be considered, including increased disease burden and growing demand for medical care owing to the increasing need for drugs.