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(2) "DO
NOT RESUSCITATE" DECISIONS
DISCRIMINATORY
AND PREJUDICIAL
(3) VIAGRA
IS COST EFFECTIVE AND SHOULD BE
MORE WIDELY
AVAILABLE
(4) SPEED
LIMIT MUST BE REDUCED TO PREVENT
"UNACCEPTABLE"
LEVELS OF PEDESTRIAN
DEATHS
(5) INEQUALITY
- IT'S NOT ALL JUST IN THE HEAD
(1) CHANGING TO
A NEW OPERATION IN YOUNG
BABIES MAY COST LIVES WHILE SURGICAL
TEAMS LEARN THE NEW TECHNIQUE
(Scientific, ethical, and logistical
considerations in introducing
a new operation: a retrospective
cohort study from paediatric
cardiac surgery)
http://bmj.com/cgi/content/full/320/7243/1168
Research in this week's BMJ says that deaths
soon after a
new operation in new born babies can exceed
deaths
expected after a more established procedure,
particularly
when the new operation is first introduced.
This need not
mean that either the surgery or the surgical
team are unsound,
concludes the research, but that safeguards
should be in place
to minimise the risk to patients.
Researchers say that doctors and relatives
need to accept
both the risk implications of the change
over period and that
operations can differ in their profiles
of early and late hazard.
Bull and colleagues from Great Ormond Street
Hospital,
London, reviewed the initial impact on
death rates of a new
surgical technique for congenital heart
disease that is now
taken for granted. They reviewed the outcome
of 325 babies
with transposition of the great arteries
before during and after
their treatment was changed from the Senning
operation to
the Arterial Switch surgery between 1978
and 1998. The
"new" operation involved more difficult
surgery on younger
babies of less than three weeks old, with
greater short term
risks, but anticipated greater long term
benefits.
The results showed that early deaths were
lower in 1998 with
the Switch operation than in 1978 with
the Senning
procedure. However, while arterial Switch
was gradually
being adopted between 1986 and 1992, death
rates were
higher among those patients scheduled
for Switch than among
those scheduled for the Senning operation.
But follow up has
shown that premature deaths later in life
have been more
common after the older Senning procedure
as had been
predicted at the time the new operation
was first offered.
The authors say that in children's surgery
in particular,
doctors often have to make recommendations
that aim to
improve life expectancy when there is
only scant evidence
about later risks of treatment. This means
that every effort
must be made to minimise the early risk
to patients and to
explain the aims of treatment and the
hazards and
uncertainties involved to the relatives.
Contact:
Dr Catherine Bull, Cardiothoracic Unit,
Great Ormond Street
Hospital, London.
Email: C.Bull@gosh-tr.nthames.nhs.uk
(2) "DO NOT RESUSCITATE"
DECISIONS
DISCRIMINATORY AND PREJUDICIAL
(Do not resuscitate decisions: flogging
dead horses or a
dignified death? [Editorial])
http://bmj.com/cgi/content/full/320/7243/1155
Evidence suggests that doctors may be using
"do not
resuscitate" orders to uphold their own
prejudices and this
reduces quality of care, writes Shah Ebrahim
from the
University of Bristol's Department of
Social Medicine, in this
week's BMJ.
Citing research published in America, Professor
Ebrahim
writes that over two thirds of patients
with "do not
resuscitate" (DNR) orders have not been
involved in making
these decisions. And DNR patients are
30 times more likely
to die than other patients, irrespective
of the severity of their
illness or other risk factors, he says.
US data show that DNR
orders tend to be used for patients who
are black, alcoholic,
non-English speakers, or who have HIV.
This suggests,
writes Professor Ebrahim, that doctors
operate on
stereotypes of whose life is worth saving.
In the UK guidance from the BMA, the Resuscitation
Council
and the Royal College of Nursing is regularly
flouted, and
ageism is alive and well in the NHS when
it comes to DNR,
contends professor Ebrahim. Audit and
education over the
past 30 years have done little to stem
prejudice in the health
service against the elderly, he says.
Legislation outlawing the
practice looks to be the only solution,
he concludes.
Contact:
Professor Shah Ebrahim, Department of Social
Medicine,
University of Bristol.
Email: shah.ebrahim@bristol.ac.uk
(3) VIAGRA IS
COST EFFECTIVE AND SHOULD BE
MORE WIDELY AVAILABLE
(Cost utility analysis of sildenafil
compared with
papaverine-phentolamine injections)
http://bmj.com/cgi/content/full/320/7243/1165
(Valuing the effects of sildenafil
in erectile dysfuntion
[Editorial])
http://bmj.com/cgi/content/full/320/7243/1156
Viagra (sildenafil) is cost effective and
should be more widely
available on prescription, contends a
cost-benefit analysis in
this week's BMJ.
Stolk and colleagues from the Institute
for Medical
Technology Assessment in Rotterdam, The
Netherlands,
compared the costs and effects of Viagra
pills with injections
used once a week for the treatment of
erectile dysfunction
over a projected period of five years.
The authors used
clinical results from a large published
trial, graded evaluations
from 169 randomly selected members of
the general public,
and measured medical treatment, and societal
costs to
calculate the cost per quality adjusted
life year (QALYs).
Treatment with Viagra was more expensive
than treatment
with injections, especially if used more
than once a week. But
viagra produced more QALYs, partly because
more people
are treated with it than with injections.
Altogether, the ratio of
cost to usefulness "cost utility ratio"
worked out at £3639 for
the first year of life gained, becoming
less expensive each
successive year. This, say the authors,
is well within the
accepted limits for such a ratio, usually
put at between £8000
and £25,000. And, they add, less
than the ratios for breast
screening at almost £7000 per QALY
and kidney
transplantation at almost £5000
per QALY.
An accompanying editorial, however, by
Nick Freemantle, of
the Medicines Evaluation Group at the
University of York,
suggests that using QALYs to assess cost
effectiveness is
essentially flawed, because the method
relies on too many
assumptions and, in this context, is not
comparing like with
like. He points out that in the UK, the
National Institute for
Clinical Excellence (NICE) has not yet
decided to use
QALYs to inform its recommendations. Simply
assessing
each treatment on merit and making recommendations
on the
basis of clinical effectiveness and cost
is a more honest and
transparent approach, he suggests.
Contacts:
Dr Elly Stolk, Institute for Medical Technology
Assessment,
Erasmus University, Rotterdam, The Netherlands.
Email: stolk@bmg.eur.nl
Dr Nick Freemantle, Centre for Health Economics,
University of York.
Email: nf2@york.ac.uk
(4) SPEED LIMIT
MUST BE REDUCED TO PREVENT
"UNACCEPTABLE" LEVELS OF PEDESTRIAN
DEATHS
(Reducing the speed limit to 20 mph
in urban areas
[Editorial])
http://bmj.com/cgi/content/full/320/7243/1160
Speeding kills around 1200 people on UK
roads every year:
140 of those deaths are child pedestrians.
If any impact is to
be made on these "unacceptable" figures,
speed limits in
built-up areas must be reduced to 20 miles
per hour, argues
Paul Pilkington, public health specialist
for the South West
Region, in this week's BMJ.
Almost three quarters of motorists exceed
the current 30 mph
(48kph) urban speed limit, and two thirds
of all serious or
fatal accidents happen in areas with the
30 mph limit,
contends Mr Pilkington. He provides plenty
of evidence to
show that lower speeds can cut deaths
and the number of
traffic accidents by around two thirds.
Experiments in the UK
and in Europe using the lower 20 mph speed
limit have
shown dramatic falls not only in the number
of casualties, but
also in air and noise pollution. Mr Pilkington
says that there is
also mounting evidence of public support
for such a move.
But he cautions that decisions to lower
speed limits should
not be arbitrary or driven by political
motives. Rather, they
should be "based on sound, established
road safety
principles," as recommended by the Association
of British
Drivers, and should be accompanied by
more stringent
attitudes to driving offences in the law
courts.
Contact:
Paul Pilkington, London School of Hygiene
and Tropical
Medicine, London.
Email: paul.pilkington@lshtm.ac.uk
(5) INEQUALITY - IT'S NOT ALL JUST IN THE HEAD
(Income inequality and mortality:
importance to health of
individual income, psychosocial
environment, or material
conditions)
http://bmj.com/cgi/content/full/320/7243/1200
Policies to reduce inequalities in health
should not confuse the
structural causes of inequality with their
subjective
consequences, says an article in this
week's BMJ.
Lynch and colleagues from the Universities
of Michigan and
Bristol analysed the evidence for a link
between income
inequalities and health using three different
published
interpretations: differences in individual
income; psychosocial
environmental factors; and neo-material
considerations.
The authors use the metaphor of plane travel:
a psychosocial
interpretation holds that Economy class
travellers have worse
health after a flight than First class
travellers because of the
negative emotions engendered from knowing
that the First
class passengers are having a better time
of it; abolishing the
different classes of travel would solve
the problem. The
neo-material approach holds that Economy
travellers have
worse health simply because they have
cramped seats and
can't sleep; upgrading conditions in Economy
class would
take care of that.
Although psychosocial factors cannot be
dismissed, conclude
the authors, it is hard to see how these
could inform public
policy to reduce health inequalities.
But a combination of
income differentials and material conditions
recognises the
impact of political and economic processes
on individual
income and subsequently on personal and
public resources,
such as healthcare, education, social
welfare and working
conditions. The authors conclude that
strategies to ensure
more equitable distribution of public
and private resources
would do most to reduce health inequalities
and improve
public health in rich and poor nations
alike.
Contact:
Professor John Lynch, Department of Epidemiology,
School
of Public Health, University of Michigan,
USA.
Email: jwlynch@sph.umich.edu
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