Publication Bias and Nonreporting Found in Majority of Systematic Reviews and Meta-analyses in Anesthesiology Journals

Hedin, R.J. et al. Anesthesia & Analgesia. 17 August 2016

Background: Systematic reviews and meta-analyses are used by clinicians to derive treatment guidelines and make resource allocation decisions in anesthesiology. One cause for concern with such reviews is the possibility that results from unpublished trials are not represented in the review findings or data synthesis. This problem, known as publication bias, results when studies reporting statistically nonsignificant findings are left unpublished and, therefore, not included in meta-analyses when estimating a pooled treatment effect. In turn, publication bias may lead to skewed results with overestimated effect sizes. The primary objective of this study is to determine the extent to which evaluations for publication bias are conducted by systematic reviewers in highly ranked anesthesiology journals and which practices reviewers use to mitigate publication bias. The secondary objective of this study is to conduct publication bias analyses on the meta-analyses that did not perform these assessments and examine the adjusted pooled effect estimates after accounting for publication bias.

Methods: This study considered meta-analyses and systematic reviews from 5 peer-reviewed anesthesia journals from 2007 through 2015. A PubMed search was conducted, and full-text systematic reviews that fit inclusion criteria were downloaded and coded independently by 2 authors. Coding was then validated, and disagreements were settled by consensus. In total, 207 systematic reviews were included for analysis. In addition, publication bias evaluation was performed for 25 systematic reviews that did not do so originally. We used Egger regression, Duval and Tweedie trim and fill, and funnel plots for these analyses.

Results: Fifty-five percent (n = 114) of the reviews discussed publication bias, and 43% (n = 89) of the reviews evaluated publication bias. Funnel plots and Egger regression were the most common methods for evaluating publication bias. Publication bias was reported in 34 reviews (16%). Thirty-six of the 45 (80.0%) publication bias analyses indicated the presence of publication bias by trim and fill analysis, whereas Egger regression indicated publication bias in 23 of 45 (51.1%) analyses. The mean absolute percent difference between adjusted and observed point estimates was 15.5%, the median was 6.2%, and the range was 0% to 85.5%.

Conclusions: Many of these reviews reported following published guidelines such as PRISMA or MOOSE, yet only half appropriately addressed publication bias in their reviews. Compared with previous research, our study found fewer reviews assessing publication bias and greater likelihood of publication bias among reviews not performing these evaluations.

Read the abstract here

Local government public health budgets: a time for turning?

The King’s Fund Blog | Published online: 19 August 2016

By David Buck – Senior Fellow, Public Health and Inequalities

In her first month as Prime Minister, Theresa May has signalled that she will focus on inequalities and life chances. Unlike the first woman to occupy Number 10, she may even be one for turning, as evidenced by the Hinkley Point reappraisal. Given this fresh thinking, I wonder whether the Prime Minister will be interested in the current situation with public health budgets.

After a welcome commitment to better funding of public health services in the early years of the coalition (it’s easy to forget that growth in the local government public health grant initially outpaced clinical commissioning group allocations) the ex-Chancellor first slammed the brakes on, then made a £200 million in-year reduction, and finally announced in the Spending Review a further real-terms cut averaging 3.9 per cent each year until 2020/21.

The King’s Fund and many others warned of the false economy of these cuts; the arguments are well rehearsed so I won’t repeat them here. What is worth underlining, though, is how local authorities are planning to cope with these cuts – the first tranche of data on this has now been released – buried though it is on the Department for Communities and Local Government’s website.

Figure 1 below shows the percentage changes in local authorities’ planned spending on public health services between 2015/16 and 2016/17 – a 9 per cent cut on a like-for-like basis(1).

Image source: The King’s Fund

Read the full blog post here

Healthier food procurement

The Local Government Association has published Healthier food procurement.


Obesity is one of the most important public health issues currently being addressed by this country. It is a cause of chronic disease leading to early death. Two-thirds of English adults, more than one fifth of four to five-year old children and more than a third of 10 to 11-year-olds are obese or overweight.

This document provides details of the health challenge around obesity, the importance of diet, dietary advice and includes case studies covering local authority initiatives on healthier vending, ensuring healthier food and snacks are available in NHS organisations, healthier catering and making school foods healthier.

Download the document here

Childhood obesity plan

Public Health England has published Childhood obesity: a plan for action.

Image source:

This document outlines the government’s plan for action to reduce childhood obesity by supporting healthier choices. These include encouraging industry to cut the amount of sugar in food and drinks and supporting primary school children to eat more healthily and stay active.

In relation to this report, the government has also published Soft Drinks Industry Levy: 12 things you should know.

NHS ‘heading into extremely difficult autumn’ amid rising rota gaps

NHS Framework Documant 2008Healthcare services and its professionals are “heading into an extremely difficult autumn”, the Royal College of Physicians (RCP) has warned as the latest workforce survey from the RCPCH revealed widespread staff shortages and rising rota gaps in the field.

The survey, which has been collecting evidence since 2009, found that more than one in four general paediatric posts at senior trainee level are now vacant, with over half of paediatric units not meeting recommended staffing standards. To keep services running, consultants are increasingly providing unplanned cover in addition to covering their own roles.

Full story at National Healthcare Executive

Better GP receptionist training might boost patient experience/satisfaction

Better GP receptionist training in good communication skills might help boost measures of patient experience and satisfaction with their surgery’s performance. | OnMedica | British Journal  of General Practice

8088-2Research published in the British Journal of General Practice assesses how receptionists interact with patients on the phone, in a bid to pinpoint aspects of communication associated with effectiveness and patient satisfaction.

The researchers carried out a qualitative conversation analysis of incoming calls, recorded ‘for training purposes’, in three English GP surgeries. Data were analysed qualitatively to identify effective communication, then coded to establish the relative prevalence of communication types in each surgery.

The first 150 calls (according to recording time) from each surgery, were selected for detailed analysis. In total, 447 calls were analysed, all of which were transcribed verbatim.

Analysis of the calls showed that the onus lay with patients to drive calls forward and achieve effective service when receptionists failed to offer alternatives to patients whose initial requests could not be met, at the start of the call or when they failed to summarise relevant next steps at the end of the call, when the appointment or service had been completed but some detail remained unclear to the patient.

The researchers conclude that patients in some practices have to ‘push’ for effective service when calling GP surgeries, but that receptionist training in good communication skills could help improve patient experience and satisfaction.

Full reference: Stokoe, E et al. Calling the GP surgery: patient burden, patient satisfaction, and implications for training British Journal of General Practice. Published 16 August 2016

New Drugs for Dementia

dementia cost
Image source: Public Health England

This briefing outlines the challenges in developing new drugs to treat dementia, and provides an overview of UK and international research activities to accelerate progress in this field.

The key points in this POSTnote are:

  • Current drug treatments marginally alleviate symptoms. Psychosocial interventions provide valuable support but access to them is patchy.
  • The development of drugs that address the underlying diseases is challenging due to their complexity.
  • Investing in research and development on dementia drugs is financially risky for the pharmaceutical industry. Drug development is an expensive and slow process and there has been a high failure rate in developing drugs. as they fail to yield positive results during clinical trials.
  • Understanding dementia requires analysis of large amounts of data and therefore a collaborative approach. A robust regulatory and legal framework is needed for privacy, data access and data standardisation so that study outputs can be shared.
  • There are new UK and international initiatives working to accelerate research and support collaboration. There are over ten potential disease-modifying drugs in development that may be available in the next five years. Stakeholders call for continued funding to ensure that the value of current investment is realised.
  • The first disease-modifying drug will be expensive and will not treat all types of dementia. There is growing consensus that treatment needs to start as early as possible, potentially even before symptoms emerge. Clinical implementation will be practically and ethically complex.
  • A healthy and active lifestyle may reduce an individual risk of developing dementia. While further research is needed, improving public health could reduce the number of new cases in the long term.

Full report via Parliamentary Office of Science and Technology

Falls Prevention Horizon Scanning Bulletin by North West health Libraries

Image source: FPHSB

Articles in this issue include:

  • Preventing falls for a person with dementia
  • Implementing exercise programs to prevent falls: systematic descriptive review
  • Evaluation of the clinical utility of the Home Falls and Accidents Screening Tool (HOME FAST)
  • Reducing older people’s falls in the general practice ProAct65+ trial

View the full table of contents here


Dementia map | Showing how regions prevent, diagnose, support and care for dementia patients

Department of Health | Published online: 16 August 2016

For many of us, the first time we hear about dementia might be when an elderly relative is rushed to A&E for something seemingly unrelated. How alert is your hospital to dementia? What is the prognosis for those who are admitted? How long are they likely to stay?

dementia map
Image source: DoH

View the interactive Dementia Map here

Paracetamol: widely used and largely ineffective

Moore, A. Evidently Cochrane | Published online: 12 August 2016


In this guest blog, Andrew Moore, who has authored over 200 systematic reviews, many on pain, lifts the lid on paracetamol. Effective and safe? We are challenged to think again…

People with pain have some very simple demands. They want the pain gone, and they want it gone now. A successful result is one where the pain is reduced by half or more, or where they have no or only mild pain. That result delivers not just on pain, but also improves sleep, depression, quality of life, work, and the ability to get on with life.

or many years paracetamol has been the ‘go-to’ medicine for all sorts of acute and chronic pain conditions. NICE recommends it for back pain and osteoarthritis, and paracetamol or paracetamol/opioid combinations are among the most common medicines for treating neuropathic pain, including back pain with a neuropathic component. Primary care in England spent £87 million on paracetamol in 2015, much for chronic pain conditions – and that does not include equally large amounts for fixed-dose combinations of paracetamol and opioids.

So how does paracetamol stack up against what people with acute back pain want? A Cochrane reviewis unequivocal – it doesn’t work. Not immediately, not later. At no stage between one and 12 weeks is 4,000 mg daily any better than a placebo. Nor does the review find any evidence that it works in chronic back pain either. The results were heavily dependent on one impeccable, large, randomised trial that described average pain intensity dropping steadily with paracetamol or placebo from over 6/10 points (severe pain) at the start of the trial to 3.7 at week 1 (moderate pain), 2.6 by week 2 (mild pain), and then 1.2 by week 12 (mild pain).

It is really difficult when an almost ubiquitous practice (using paracetamol) meets a distinctly inconvenient truth (it doesn’t work). The high quality of the evidence cannot be challenged, so let’s have a quick look for evidence showing that paracetamol is effective in other chronic pain conditions. That’s where the trouble starts – in osteoarthritis, our most recent best evidence indicates a barely significant and tiny benefit of around 3/100 mm over placebo, and a ranking barely above placebo in a network meta-analysis. For chronic neuropathic pain an ongoing Cochrane review reveals a complete lack of any evidence for paracetamol at all. Paracetamol is without effect in cancer pain, and it is the poor relation in acute postoperative pain and migraine.

Read the full blog post here