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Press releases Saturday 24 November 2007
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(1) Active parents raise active children
(2) Should all medical students be graduates first?
(3) GP targets are not meeting patients' needs
(4) Doctors challenge NICE guidelines on heart drug
(1) Active parents raise active children
(Early life determinants of physical activity in 11 and 12 year olds: a cohort study)
BMJ Online First
Parents who are active during pregnancy and early in their child's life tend to raise more active children, finds a study published on bmj.com today.
Some risk factors for adult diseases are associated with lower levels of physical activity in children. Associations have also been reported between early life factors (from birth to around five years) and childhood obesity.
But little is known about the early life influences on children's physical activity.
So researchers identified children aged 11 to 12 who were taking part in the Avon Longitudinal Study of Parents and Children (ALSPAC). Each child was asked to wear an accelerometer for seven days, which recorded minute by minute the intensity and frequency of physical activity.
Valid data, defined as at least three days of at least 10 hours per day, were collected from 5,451 children and were analysed against various factors hypothesised to affect physical activity.
Several factors showed a modest association with later physical activity. These included mother's activity during pregnancy (specifically brisk walking and swimming), season of birth, one or both parents' physical activity when the child was aged 21 months, and having an older sibling.
The authors explain that the link with mother's activity during pregnancy is unlikely to be due to biological factors inside the womb. Instead, mothers who are physically active during pregnancy are likely to keep active after pregnancy, and that this in turn influences children's physical activity.
The association with season of birth is difficult to explain, they add, but it may be linked to school starting age.
Smoking in the mother and her partner were both positively associated with physical activity. This is surprising, say the authors, because maternal smoking during pregnancy is associated with childhood obesity, but they suggest it may be a result of the social patterning of smoking behaviour.
Few of the pre-school exposures (2-5 years) were associated with later physical activity. There was a small association with TV viewing at 38 and 54 months, but this was modest.
We have shown that early life factors have limited influence on later physical activity in 11 to 12 year olds, but that children are slightly more active if their parents are active early in the child's life, say the authors.
Helping parents to increase their physical activity therefore may promote children's activity.
They recommend that future research should re-examine these associations in later adolescence when physical activity declines, particularly in girls.
Contact:
Calum Mattocks, Research Associate, Department of Social Medicine, University of Bristol, UK
Email: cmattocks{at}bristol.ac.uk
(2) Should all medical students be graduates first?
(Head to Head: Should all medical students be graduates first?)
http://www.bmj.com/cgi/content/short/335/7629/1072
Most people in the UK enter medical college straight from school. But would changing to a single system of graduate entry medical schools provide the diverse workforce needed for the future?
Two experts debate the issue in this week's BMJ.
We must stop the headlong rush of pupils going straight from school into five year long medical courses, argues Ed Peile, Professor of Medical Education at the University of Warwick. If we do what we have always done, we will always get a niche medical workforce.
Graduate entry medicine can widen diversity, he says. Around 10% of UK medical school places are on graduate entry courses, which enable graduates to move from science or arts learning at university to the level of competence needed for foundation year work in medicine. They can also concentrate on developing professional study skills rather than acquiring tertiary study skills.
Although cost comparisons between graduate and undergraduate courses are difficult, graduates are probably more likely to complete the course, adds Professor Peile. US data also indicate that older graduates practice more readily in underserved areas and are more likely to work in primary care, while data from Australia suggests that graduate entry schemes better prepare doctors for the workplace.
A change to a single system of graduate entry medical schools in the UK should attract mature learners with high levels of motivation, independence of outlook, and orientation towards hard work. Graduate entrants have the additional maturity and strengthened interpersonal skills necessary to provide the diverse multiskilled workforce needed for the future, he concludes.
But Charles George, Chair of the Board of Science and Education at the British Medical Association, argues that there is insufficient evidence to make this a criterion of entry.
We do not need to modify the current system by restricting entry to graduates, he says. It would be discriminatory to school leavers and to mature non-graduates to limit medical training to people who already have a degree in the absence of any convincing evidence of benefit.
School leavers are intelligent, multitalented, committed, and come with excellent study skills, and there is no evidence that graduate entrants make better doctors, he adds.
In fact, a study from New South Wales found no significant differences between school leavers and graduate entrants in terms of academic performance or in career positions obtained after qualifying.
Although graduate entrants increase the diversity of our future doctors, there is insufficient evidence to make this a universal criterion for entry. Finally, we should not forget that graduate and mature entrants are subject to additional stresses, such as balancing commitments and financial pressures, he concludes.
Contacts:
Ed Peile, Professor of Medical Education, Institute of Clinical Education, Medical School, University of Warwick, Coventry, UK
Email: ed.peile{at}warwick.ac.uk
Charles George, Chair, Board of Science and Education, British Medical Association, London, UK
Email: charles_george{at}btinternet.com
(3)
GP targets are not meeting patients' needs
(Analysis: Measuring performance and missing the point?)
http://www.bmj.com/cgi/content/short/335/7629/1075
GP performance targets could be leading to lower levels of health care for those who need it most, argue experts in this week's BMJ.
General practice in the UK has the largest healthcare pay for performance programme in the world – the quality and outcomes framework (QOF). Practices earn points for the services they provide and these points attract financial resources into the practice.
The system has been hailed as a success for quality of care. But, while there have undoubtedly been useful achievements, Dr Iona Heath and colleagues warn that the system may not be meeting patient's needs.
Clinical care needs to be tailored to individual patients rather than using a mechanistic approach, they say. Yet they believe that the quality and outcomes framework diminishes the responsibility of doctors to think, to the potential detriment of patients, and encourages a focus on points scored, threshold met, and income generated.
The framework also needs to include clinically important outcomes, rather than concentrating on treatment processes, they add.
One of the aims of the framework is to tackle health inequalities but they warn that it has the potential to work in the opposite direction.
For example, marginalised and socially disadvantaged people are more likely to be listed as exceptions from quality framework payments and, once given that status, are at risk of receiving proportionally less attention.
In addition, as people living in deprived areas are sicker, more effort will be needed for doctors to reached fixed targets. Working in poorer areas therefore becomes less desirable, further reducing quality of care or even making care difficult to find.
Furthermore, there is evidence that payment for performance systems reward already high achievers and penalise low achievers and so exacerbate inequalities, they write.
Until the increase in process is translated into tangible outcomes, such as diabetes complication rates or incidence of heart attack or smoking related deaths, the benefits and cost effectiveness of the exercise cannot be established, they say.
Outcomes are much more difficult to measure than processes, especially at the level of individual practices, but the heightened emphasis on processes brought about by the framework should not be allowed to distract from the fundamental aims of medical care, they conclude.
Contacts:
Iona Heath, General Practitioner, Caversham Group Practice, London, UK
Email: iona.heath@dsl.pipex.com
(4) Doctors challenge NICE guidelines on heart drug
(Editorial: Rate control in permanent atrial fibrillation)
http://www.bmj.com/cgi/content/short/335/7629/1057
Doctors in this week's BMJ argue that new NICE guidelines on the use of digoxin, a drug used to slow heart rate in patients with irregular heart rhythm (atrial fibrillation), are inconsistent with the evidence.
Atrial fibrillation occurs when the electrical signals which keep the heart pumping, become disturbed. It is the most common heart rhythm problem especially in elderly people.
In June 2006, the UK National Institute for Health and Clinical Excellence (NICE) published new guidelines for control of heart rate in people with chronic atrial fibrillation. The guidelines depart from historical practice by recommending that instead of digoxin, two other types of drug (beta-blockers or calcium antagonists) should be the preferred initial treatment.
US guidelines also recommend the use of beta-blockers or calcium antagonists alone to control heart rate.
But two doctors at the Royal Hallamshire Hospital in Sheffield warn that it is safest to start treatment with digoxin first.
They reviewed 57 studies, including 25 randomised controlled trials, assessing digoxin, beta-blockers, calcium antagonists, and combinations for heart rate control in chronic atrial fibrillation.
They found little evidence that single treatment (monotherapy) with beta-blockers or calcium antagonists improves exercise tolerance compared with digoxin. On the contrary, there is clear evidence that when beta-blockers are used alone, exercise capacity may worsen, especially in people with a history of heart failure.
Similarly, little evidence exists that monotherapy with these drugs improves heart rate control at rest and during exercise compared with digoxin alone. Benefits on heart rate variability, together with improved exercise tolerance, have only been shown with the combination of digoxin and a beta-blocker or calcium antagonist, they say.
"We believe that the combination of digoxin and a beta-blocker or calcium antagonist should be recommended as first line management and we would emphasise that it is safest to start treatment with digoxin first," they conclude.
Contacts:
Theodora Nikolaidou, Research Fellow, Royal Hallamshire Hospital, Sheffield, UK
Email: nikolaidou{at}btinternet.com
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