Releases Saturday 12 July 2003
No 7406 Volume 327

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(1) Women need better information about breast screening

(2) Homeless people are more likely to die early

(3) Virtual consultations are not cost effective

(4) Are smoke free hospitals unethical?


(1) Women need better information about breast screening

(Women need better information about routine
mammography)
http://bmj.com/cgi/content/full/327/7406/101

Information about breast screening must be improved if
women are to fully understand both the benefits and the
potential harms in order to make an informed choice, argue
researchers in this week's BMJ.

Although breast screening is well established in the United
Kingdom and elsewhere, its value continues to be debated.
Estimates of the effect of screening on breast cancer deaths
vary widely, and women are given limited information in
terms that are often hard to understand.

As a result, harms are often dismissed as a price worth
paying for the perceived general good and few people
appreciate that screening contributes to the rise in incidence
of breast cancer, write the authors.

Tensions exist between the demands of the screening
industry's "pursuit of good uptake" and properly promoting
informed choice for citizens as required by the GMC
guidelines, they add. Although much research has been
done, so far there has been negligible improvement in NHS
screening leaflets and public misconceptions.

The focus of research into screening programmes should
not be to improve uptake but to develop flexible decision
aids to meet women's desires for balanced information.

It is unacceptable that women taking tests continue to suffer
damage and regret because they found out the harms of
screening from experience. Unless women are able to make
true informed choices, funding for the service will continue
to be questioned, they conclude.

Contact:

Hazel Thornton, Honorary Visiting Fellow, Department of
Epidemiology and Public Health, University of Leicester,
UK 
Email: hazelcagct{at}aol.com


(2) Homeless people are more likely to die early

(10 year follow up study of mortality among users of hostels
for homeless people in Copenhagen)
http://bmj.com/cgi/content/full/327/7406/81

Homeless people staying in hostels are four times more
likely to die early than people in the general population,
claim researchers in this week's BMJ.

The study involved over 750 people staying in two hostels
for the homeless in Copenhagen in 1991. Some were
interviewed about several aspects of their lives including
upbringing, family background, education, and psychiatric
treatment.

Mortality was higher in the younger age groups (15-34
years) and among homeless women. The highest mortality
was among homeless people staying only a short time at a
hostel or staying more than once during 1991, showing that
this transient population is the most vulnerable and has the
highest risk of early death, say the authors.

Other predictors of early death included adverse childhood
experiences, such as death of the father, and misuse of
alcohol and drugs.

Outreach and case management techniques can improve
the standards of daily living for homeless people, add the
authors. The prevention of social exclusion should start
early in life.

Contact:

Merete Nordentoft, Consultant, Department of Psychiatry,
Bispebjerg Hospital, Copenhagen, Denmark
Email: merete.nordentoft{at}dadlnet.dk


(3) Virtual consultations are not cost effective

(Virtual outreach: economic evaluation of joint
teleconsultations for patients referred by their general
practitioner for a specialist opinion)
http://bmj.com/cgi/content/full/327/7406/84

Virtual consultations between doctors and patients cost the
NHS more than standard outpatient appointments, but are
slightly less time consuming and cheaper for patients,
conclude researchers in this week's BMJ.

A videoconferencing link was set up at two hospitals and
29 general practices in the UK to allow consultations
between the general practitioner, present with the patient in
the practice, and consultants in the hospital.

A total of 1,051 patients were allocated to virtual outreach
consultations and 1,043 to standard outpatient
appointments.

Over six months, costs were greater for the virtual outreach
consultations (£724 per patient) than for conventional
outpatient appointments (£625 per patient). Patients
attending a teleconsultation incurred significantly lower
transport costs and less time off work than those attending
conventional outpatient appointments, although the cost
difference (£3) was relatively small.

Considering total costs, widespread adoption of virtual
outreach cannot be justified on economic grounds, say the
authors although the use of patient selection in certain
specialties could improve its relative cost effectiveness.
Furthermore, a six-month follow up period may have been
too short to detect all 'downstream' savings and improved
patient satisfaction was not taken into account.

"We may therefore have underestimated the beneficial
consequences of virtual outreach," they conclude.

Contact:

Paul Jacklin, Research Felow (health economics),
Department of Public Health Policy, London School of
Hygiene and Tropical Medicine, London,
Email: paul.jacklin{at}lshtm.ac.uk


(4) Are smoke free hospitals unethical?

(Letter: Smoke free hospitals)
http://bmj.com/cgi/content/full/327/7406/104

A recent editorial attacked a decision by the Royal Victoria
Hospital in Belfast to build seven smoking rooms for
patients and staff. In response, a letter in this week's BMJ
argues that smoke free hospitals are unethical.

To bar smoking for patients with smoking related diseases
seems reasonable, but to coerce smokers who happen to
be in hospital with an unrelated condition into accepting
smoke free behaviour as a condition of their care may be
questionable, writes Stephen Head, a general practitioner
from Nottinghamshire.

When patients have no prospect of benefit from smoking
cessation, and enforced abstention aggravates their existing
distress, they are being managed unethically, he says. Their
best interests as a patient (which should be the medical
profession's prime concern) are being subjugated to a
broader policy that does them harm.

He describes the case of terminally ill patient, whose last
days in hospital were made worse for nicotine withdrawal.
Another declined admission because he would have to give
up "his one remaining pleasure."

Such cases should not blunt the public health message. But
making their last days more distressing than they would
otherwise have been reflects an uncritical policy
enforcement that adds a cruel and condescending twist to
how doctors and health managers, as much as the
international tobacco industry, are able to create smoking
related suffering, he concludes.

Contact:

Stephen Head, General Practice Principal, Newark,
Nottinghamshire, UK 
Email: shead{at}doctors.org.uk BMJ -- Press Releases