Access to emergency care in Palestinian West Bank

Editor—I peer review papers for some less prestigious journals: here are some observations on the paper by Rytter et al on the effects of armed conflict on access to emergency health care in the Palestinian West Bank.¹

Was this week and were these hospitals representative? Were hospitals chosen as likely to yield anticipated results (selection bias)? Was hospital admission more likely to stimulate recall of delay than non-admission (recall bias)? When were questions about delay asked—and, critically, how were questions phrased?

Could patients assessed as delayed by conflict have been delayed for other reasons (misclassification)? How were data obtained? What intermediaries were there between researcher and source—for example, interpreters? Was awareness of research objectives by interviewees or others likely to bias outcome? Could more serious illness implicit in admission have contributed to delay (confounding)? Were patients complaining of delay preferentially admitted to hospital? Were the baseline medical conditions different between the groups and did this account for differences in admission rates? Incidentally, were patient consent and ethics committee approval for access to data needed and obtained?

“Delay” resulted in a difference in median speed of 2.5 km/h. What was the effect on the time taken to reach hospital? The authors assume that a reported delay significantly affected journey time, which damaged health. The facts available to the authors may support their conclusions—or perhaps they just support their preconceptions. They have not provided information in a way that allows the reader to judge.

As distinct from the paper's stated conclusion, the higher admission rate suggests that reported delays (not, as stated, restrictions in access) influence hospital admission rates (not, as stated, the severity of the medical conditions).

It is laudable that socially aware undergraduates undertake and publish research but it is incumbent on journal editors to maintain appropriate standards.