Press releases Monday 24 January to Friday 28 January 2011

Please remember to credit the BMJ as source when publicising an article and to tell your readers that they can read its full text on the journal's website (http://www.bmj.com).

• (1) GPs pay for performance targets on blood pressure have no impact
• (2) Government's "nudge" approach may struggle to make an impression, warn experts
• (3) Expert questions Lansley's key arguments for NHS reform
• (4) Deaths from IVF are rare but relevant
• (5) Marriage is good for physical and mental health

(1) GPs pay for performance targets on blood pressure have no impact

(Research: Effect of pay for performance on the management and outcomes of hypertension in the United Kingdom: interrupted time series study)
http://www.bmj.com/cgi/doi/10.1136/bmj.d108
(Editorial: Primary prevention of cardiovascular disease)
http://www.bmj.com/cgi/doi/10.1136/bmj.d201

Targets set for GPs to improve the care of patients with high blood pressure have had no impact, according to a new study published on bmj.com today.

Researchers found that nationally set targets in the UK, that have financial rewards for GPs if they are met, have made no discernible difference to improving care and outcomes for patients with hypertension (high blood pressure).

Around half of people aged over 50 have hypertension, which is one of the most treatable, but undertreated cardiovascular risk factors.

The Quality and Outcomes Framework (QOF) for general practice is a voluntary system of financial incentives, which has been in place since 2004 and part of this programme includes specific targets for GPs to demonstrate high quality care for patients with hypertension and other diseases.

The UK National Health Service committed £1.8bn (€2.1bn; $2.8bn) in funding to the programme. Yet, to date, there is little evidence of the effectiveness of pay for performance targets.

A team of international researchers from the UK, USA, and Canada set out to assess the impact of the targets on quality of care and outcomes among UK patients with hypertension.

They studied data from The Health Improvement Network (THIN), a large database of primary care records from 358 UK general practices.

They found there were 470,725 patients diagnosed with hypertension between January 2000 and August 2007.

They looked at various measures including blood pressures over time; rates of blood pressure monitoring, blood pressure control and treatment intensity at monthly intervals three years before and four years after the introduction of the targets; and hypertension outcomes as well as illnesses.

Analysis showed that even after allowing for secular trends, there was no change in blood pressure monitoring, blood pressure control, or treatment intensity that could be attributed to the QOF targets.

There was a decline in the proportion of patients receiving no medicines or only a single medicine, at the same time as a rise in numbers of patients receiving combination therapy with two or three plus medications.

The researchers found, however, that the QOF targets were not associated with any change to these trends in medication prescribing.

Similarly, there was no identifiable impact from the targets on the cumulative incidence of stroke, heart attacks, renal failure, heart failure or mortality in both patients who had started treatment before 2001 and another sub-group of patients whose treatment had started close to the first QOF interventions.

The quality of care for hypertension, such as blood pressure monitoring and treatment intensification, was already improving before the QOF began, said the researchers.

They conclude: "The programme's lack of effect may be explained in part by performance targets that were set too close to existing practice. To stimulate further improvement in hypertension care in the UK, it may be necessary to implement other evidence based interventions on a large scale."

Two linked analysis articles look at what measures of preventing cardiovascular disease are the most efficient and cost effective, while an editorial suggests that the current model in the UK is not necessarily the right one or the only one.

Contacts:
Research: Professor Stephen Soumerai, Harvard Medical School AND Harvard Pilgrim Health Care Institute, Boston, MA, USA
Email: stephen_soumerai@hms.harvard.edu
Editorial: Professor John Reckless, Honorary Consultant Endocrinologist, Royal United Hospital, Bath, UK
Email: mpsjpdr@bath.ac.uk

(2) Government's "nudge" approach may struggle to make an impression, warn experts

(Analysis: Judging nudging: can nudging improve population health?)
http://www.bmj.com/cgi/doi/10.1136/bmj.d228
(Editorial: One nudge forward, two steps back)
http://www.bmj.com/cgi/doi/10.1136/bmj.d401

The government's "nudge" approach to public health may struggle to make much impression on improving population health, warn experts on bmj.com today.

An accompanying editorial argues that the notion of nudging adds nothing to existing approaches and risks wasting resources.

Theresa Marteau, Director of the Behaviour and Health Research Unit at Cambridge University (the Department of Health Policy Research Unit on Behaviour and Health), and colleagues ask whether the concept stands up to scientific scrutiny as a basis for improving population health.

Nudging involves altering environments to prompt healthier behaviour, without banning particular choices or using financial incentives.

The concept of nudging people towards healthier behaviour has captured the imagination of the public, researchers, and policy makers, say the authors. Its appeal lies in the seemingly simple, low cost solutions that can be applied to a wide array of problems, and there is some evidence that it can work.

For example, putting yellow duct tape across the width of supermarket trolleys with a sign requesting shoppers to place fruit and vegetables in front of the line doubled fruit and vegetable purchasing, and placing fruit by the cash register increased the amount of fruit bought by school children at lunchtime by 70%.

However, they argue that, "at present, the evidence to support the view that nudging alone can improve population health is weak." They also point out that nudging has the potential to generate harms as well as benefits, particularly if an emphasis on nudging results in a neglect of other, potentially more effective interventions.

Nudging is often used very effectively by industry to prompt unhealthy behaviour, for example in the marketing of food and alcohol.

The authors argue that effective nudging "may require legislation, either to implement healthy nudges . . . or to prevent unhealthy nudges from industry."

The authors argue that research is needed to determine the effectiveness and cost effectiveness of nudging and related ideas. Currently there is precious little good science on which to build practical examples which would work.

They conclude: "Without regulation to limit the potent effects of unhealthy nudges in existing environments shaped largely by industry, nudging towards healthier behaviour may struggle to make much impression on the scale and distribution of behaviour change needed to improve population health to the level required to reduce the burden of chronic disease in the UK and beyond."

In an editorial, Chris Bonell and colleagues at the London School of Hygiene and Tropical Medicine also question whether it is clear what is meant by nudging and whether it really offers anything new, and warn that "little progress will be made if public health policy is made largely on the basis of ideology and ill defined notions that fail to deal with the range of barriers to healthy living."

A blog by BMJ News Editor, Annabel Ferriman, argues that the Conservatives have invented the nudge as a new way of encouraging people to live in a healthy way, and asks: can you tell your nudge from your nanny?

Contacts:
Analysis: Theresa Marteau, Director, Behaviour and Health Research Unit, University of Cambridge Institute of Public Health, Cambridge, UK
Email: theresa.marteau@medschl.cam.ac.uk
Editorial: Chris Bonell, Senior Lecturer in Social Science & Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
Email: chris.bonell@lshtm.ac.uk

(3) Expert questions Lansley's key arguments for NHS reform

(Data briefing: Does poor health justify NHS reform?)
http://www.bmj.com/cgi/doi/10.1136/bmj.d566

England's health secretary Andrew Lansley has said that his reforms for the NHS are needed because the country's health outcomes are among the poorest in Europe. But in an article published on bmj.com today, John Appleby, Chief Economist at the King's Fund, reviews the data and finds the UK in better health than Lansley suggests.

It has been claimed that despite spending the same on health care, we suffer twice the rate of deaths from heart disease than France, says Appleby.

The latter is true, but what this claim doesn't show is that the UK has actually had the largest fall in heart attack deaths between 1980 and 2006 of any European country. And if trends over the last thirty years continue, the UK will have a lower death rate than France as soon as 2012, he writes.

These trends have been achieved not only with a slower rate of growth in health care spending in the UK compared with France, but at lower levels of spending every year for the last half century, he adds.

Our apparently poor comparison with other countries on cancer deaths has also been a key argument for reforming the NHS, says Appleby.

He points out that cancer outcomes in this country are improving, although comparisons are not straightforward and some of the data often cited should be treated with caution.

Breast cancer deaths in the UK have fallen by 40 per cent over the last two decades to virtually close the gap with France.

Again, if trends continue, it is likely that the UK will have lower death rates than France in just a few years, he says.

And despite headlines that the UK is the 'sick man of Europe', trends actually show improvements in survival rates for the UK, he adds.

Appleby says: "Comparing health outcomes across countries is complex and not simply down to healthcare spending, but these trends must challenge one of the government's key justifications for reforming the NHS."

Contact:
Press Office, King's Fund, London, UK
Email: mediaoffice@kingsfund.org.uk

(4) Deaths from IVF are rare but relevant

(Editorial: Adverse outcomes from IVF)
http://www.bmj.com/cgi/doi/10.1136/bmj.d436

Although still rare, maternal deaths related to in vitro fertilisation (IVF) are a key indicator of risks to older women, those with multiple pregnancy and those with underlying disease, warn experts in an editorial published on bmj.com today.

Dr Susan Bewley and colleagues argue that serious adverse outcomes related to IVF treatment, such as ovarian hyperstimulation sydrome (a complication caused by some fertility drugs), should be systematically reported so that lessons can be learnt and appropriate action taken.

In 1991, the first published report of a maternal death related to IVF predicted that rates would rise with increasing use of assisted reproductive technologies as a result of pregnancies at an older age, multiple pregnancies, and pre-eclampsia.

A recent study from the Netherlands also showed convincingly that overall mortality in IVF pregnancies was higher than the maternal mortality rate in the general population in the Netherlands (there were about 42 mothers' deaths per 100,000 IVF pregnancies compared to 6 deaths per 100,000 pregnancies overall), a fact confirmed from results in the UK.

The last UK Confidential Enquiry into Maternal Death recorded four deaths directly related to IVF via ovarian hyperstimulation syndrome and three deaths related to multiple pregnancy after IVF.

Thus, more deaths were related to ovarian hyperstimulation syndrome than to abortion (two) despite many fewer IVF procedures (for example, there were 48,829 IVF cycles v 198,500 abortions in the UK in 2007), say the authors. They also warn that IVF associated maternal deaths may be underestimates as confidentiality restrictions under the Human Fertilisation Act preclude accurate data.

The global industry has operated on an assumption that women undergoing assisted reproduction are healthier than average thus ensuring safer pregnancies, but the maternal mortality figures suggests otherwise, they argue.

Even though IVF pregnancy in the UK is still very safe, they add, deaths may reflect a far greater burden of severe adverse morbidity.

They believe that better information about the risks of fertility treatment is needed, better identification of high risk women, and more single embryo transfer as the norm to prevent death and disability.

"More stringent attention to stimulation regimens, pre-conceptual care, and pregnancy management is needed so that maternal death and severe morbidity do not worsen further," they conclude.

Contact:
Susan Bewley, Consultant Obstetrician, Guy's and St Thomas' NHS Foundation Trust, London, UK
Email: susan.bewley@gstt.nhs.uk

(5) Marriage is good for physical and mental health

(Student BMJ editorial: Are relationships good for you?)
http://student.bmj.com/student/view-article.html?id=sbmj.d404

The 'smug marrieds' may have good reason to feel pleased with themselves as experts today confirm that long-term committed relationships are good for mental and physical health and this benefit increases over time.

In an editorial published by student BMJ, David and John Gallacher from Cardiff University say that on average married people live longer. They say that women in committed relationships have better mental health, while men in committed relationships have better physical health, and they conclude that "on balance it probably is worth making the effort."

Men's physical health probably improves because of their partner's positive influence on their lifestyle and "the mental bonus for women may be due to a greater emphasis on the importance of the relationship", they write.

But the journey of true love does not always run smoothly, maintain the authors, pointing to evidence that relationships in adolescence are associated with increased adolescent depressive symptoms.

And not all relationships are good for you, they add, referring to evidence that single people have better mental health than those in strained relationships.

They also confirm that breaking up is hard to do, saying "exiting a relationship is distressing" and divorce can have a devastating impact on individuals. Having numerous partners is also linked with a risk of earlier death.

They conclude that while relationship failures can harm health this is not a reason to avoid them. A good relationship will improve both physical and mental health and perhaps the thing to do is to try to avoid a bad relationship rather than not getting into a relationship at all.

Contact:
John Gallacher, Reader, Department of Primary Care and Public Health, School of Medicine, Cardiff University, Wales, UK
Email: gallacher@cf.ac.uk

Emma Dickinson
Tel: +44 (0)20 7383 6529
Email: edickinson@bma.org.uk

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