This week in the BMJ
Volume 324, Number 7341, Issue of 6 Apr 2002Meningococcal C vaccination is cost effective
Meningococcal C vaccination is cost effective
The meningococcal C vaccination campaign, launched in November 1999, has rapidly reduced the incidence of serotype C meningococcal disease
in the target age groups. Using cost effectiveness analysis, Trotter
and Edmunds (p 809) estimate the cost per life saved to be £6259 and
find vaccination to be most cost effective when the incidence of the
disease is high. School based vaccination is more cost effective than
the routine vaccination of infants because delivery costs are lower and
fewer doses are required. Immunisation of infants aged under 1 year was
least cost effective, as a three dose schedule is required.
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Intensive follow up after surgery for colorectal cancer improves survival
Intensive follow up after colorectal cancer surgery is associated with
a reduction in all cause mortality. A systematic review of five trials
including 1342 patients by Renehan and colleagues (p 813) found a
9-13% reduction in mortality in trials that used computed tomography
and frequent measurements of serum carcinoembryonic antigen to follow
up patients. The authors conclude that this reduction is due to all
recurrences of cancer, and particularly isolated recurrent disease,
being detected early. This study counteracts the lack of direct
evidence for intensive follow up after initial curative treatment for
colorectal cancer.
Parents recognise benefits of postmortems
Parents who have lost a baby view the postmortem examination as a
useful and necessary tool in helping to discover the reasons why their
baby died. The most common reasons given for agreeing to a postmortem
examination were wanting more information about what had happened and
helping to improve medical knowledge and research, say Rankin and
colleagues (p 816). Parents who did not agree to a postmortem
examination felt their baby had suffered enough, but some had regrets
about their decision. One said: "Now, two years later, I would like
to know why they died," and another: "An answer may have alleviated
the burden of guilt." The authors say that all medical staff involved
in obtaining consent for postmortem examinations should be fully
trained in how to ask for parental consent, the postmortem examination
procedure, and how to explain the findings.
Visual aids help patients understand risk
Patients want more information in a more understandable format.
Decision aids such as booklets, tapes, videodiscs, interactive computer
programs, and paper based charts are tools that can easily be used to
improve communication. In their clinical review, Edwards and colleagues
(p 827) discuss how professionals can support patients in making
choices by turning raw data into more helpful information. "Framing
manipulations" of information, such as using information about
relative risk in isolation of base rates, should be avoided. Decision
aids can be useful as they often include visual presentations of risk
information and relate the information to more familiar risks.
Change in psychological agreement makes doctors unhappy
One major reason why doctors are unhappy seems to be a change in
the relationship between the profession, employers, patients, and
society, so that the job is now different to what doctors expected. Workload and pay, although important,
do not fully explain the problem. In response to Richard Smith's
editorial (BMJ 2001;322:1073-4[Full Text]), Edwards and colleagues (p
835) report on the reasons discussed at seminars on the subject of
doctors' unhappiness held in Massachusetts and London last year. They
also looked at literature from around the world. They propose that a
new agreement that is more acceptable to the profession is needed and
that clinical leaders have a crucial role in developing
it.
(Credit: PAXTON/FARROW/SPL) 
(Credit: WWW.SHOUTPICTURES.COM)
A new agreement is needed if the NHS is to reform
The implicit agreement between the government, the medical profession,
and the public (on which the NHS was established) has been undermined
over the years and needs to be updated, say Ham and Alberti (p 838).
They recommend that a new, explicit agreement is needed, based on
patients' rights, public responsibilities, greater accountability of
the medical profession, resources, partnerships, support for effective
care, and stewardship. Such an agreement can only be reached if
representatives of the medical profession, the public, and the
government trust each other and believe they are working towards common
goals. This will not be easy, they say, but it is essential to enable
the different partners to make an effective contribution to the reform
of the NHS.
(Credit: BARRY BATCHELOR/PA) 
NICE is not fulfilling its promise
The National Institute for Clinical Excellence (NICE) does not
currently fulfil its promise to give guidance on interventions of
uncertain value and provide clinical guidelines and clinical audit
packages. This is because there is ambiguity about how NICE reaches its
conclusions and uncertainty about the impact of guidance on the NHS and
about who monitors compliance. As a result, NICE's impact is uncertain
and geographical inequity in the provision of health services is likely
to persist. Dent and Sadler (p 842) consider what NICE needs to succeed
and how its chances could be improved. They conclude that there needs
to be wider debate about criteria, clarity on status, and more concise
recommendations about clinical audit methods.
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