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Press releases Saturday 3 December 2005

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 web site (http://bmj.com).

(1) CANNABIS ALMOST DOUBLES RISK OF FATAL CRASHES

(2) NO EVIDENCE THAT COX-2 INHIBITORS PROVIDE GREATER STOMACH PROTECTION

(3) GOVERNMENT REFORMS MAY BRING AN END TO FREE HEALTHCARE

(4) DOES THE DISTRICT GENERAL HOSPITAL HAVE A FUTURE?

(5) FOOD SUBSIDIES ARE DAMAGING HEALTH

(1) CANNABIS ALMOST DOUBLES RISK OF FATAL CRASHES

Online First
(Cannabis intoxication and fatal road crashes in France: population based case-control study)
http://bmj.bmjjournals.com/cgi/rapidpdf/bmj.38648.617986.1F

Driving under the influence of cannabis almost doubles the risk of a fatal road crash, finds a study published online by the BMJ today. However its share in fatal crashes is significantly lower than those involving alcohol.

The study took place in France and involved 10,748 drivers who were involved in fatal crashes from October 2001 to September 2003. All drivers underwent compulsory tests for drugs and alcohol.

A total of 681 drivers tested positive for cannabis (7%) and 2096 for alcohol (21.4%), including 285 for both (2.9%). Men were more often involved in crashes than women, and were also more often positive for both cannabis and alcohol, as were the youngest drivers, and users of mopeds and motorcycles.

The risk of being responsible for a fatal crash increased as the blood concentration of cannabis increased (known as a dose effect). The odds increased from 1.9 at a concentration of 0-1 ng/ml to 3.1 at or above 5 ng/ml. These effects were adjusted for alcohol and remained significant when also adjusted for other factors.

These results give credence to a causal relationship between cannabis and crashes, say the authors.

Samples show that the prevalence of cannabis (2.9%) within the driving population is similar to that for alcohol (2.7%) at or above 0.5 g/l, they add. However, in France, its share in fatal crashes is significantly lower than that associated with alcohol (2.5% compared with 29% for alcohol).

Contacts:

Bernard Laumon, Senior Researcher, French National Institute for Transport and Safety Research (INRETS), Bron Cedex, France
Email: bernard.laumon@inrets.fr

Jean-Louis Martin, Senior Researcher, INRETS Universite Claude Bernard, Lyon, France
Email: jean-louis.martin@inrets.fr

(2) NO EVIDENCE THAT COX-2 INHIBITORS PROVIDE GREATER STOMACH PROTECTION

(Risk of adverse gastrointestinal outcomes in patients taking cyclo-oxygenase-2 inhibitors or conventional non-steroidal anti-inflammatory drugs: population based nested case-control analysis)
http://bmj.com/cgi/content/full/331/7528/1310

There is no evidence to back up claims that the new generation of anti-inflammatory drugs (COX-2 inhibitors) are less harmful to the stomach lining than many traditional anti-inflammatory drugs, concludes a study in this week’s BMJ.

These drugs were specifically designed to provide pain relief without the serious gastrointestinal side effects associated with the traditional non-steroidal anti-inflammatory drugs.

Researchers at the University of Nottingham identified patients from 367 UK general practices with a first ever diagnosis of an upper gastrointestinal event (stomach ulcer or bleed). Each case was matched with up to 10 control patients.

Prescriptions for anti-inflammatory drugs and aspirin issued in the three years before the study were identified for both cases and controls.

Of 9407 cases, 45% had been prescribed a conventional non-steroidal anti-inflammatory drug (NSAID) in the previous three years and 10% had been prescribed a COX-2 inhibitor. Of 88,867 controls, 33% had been prescribed an NSAID and 6% had been prescribed a COX-2 inhibitor.

Increased risks of adverse gastrointestinal events were associated with current use of COX-2 inhibitors and with conventional non-steroidal anti-inflammatory drugs. Risks were reduced after adjusting for other factors, but remained significantly increased for naproxen, diclofenac, and rofecoxib, but not for current use of celecoxib.

The use of ulcer healing drugs reduced the risk with all groups of non-steroidal anti-inflammatory drugs, although for diclofenac the increased risk remained significant.

Evidence of enhanced gastrointestinal safety with any of the new cyclo-oxygenase-2 inhibitors compared with non-selective non-steroidal anti-inflammatory drugs is lacking, say the authors.

These results suggest that COX-2 inhibitors may not be as safe as originally thought, although a possible confounding effect cannot be ruled out, they conclude.

Contact:

Julia Hippisley-Cox, Professor of Clinical Epidemiology and Clinical Practice, University of Nottingham, Nottingham, UK
Email: julia.hippisley-cox@nottingham.ac.uk

(3) GOVERNMENT REFORMS MAY BRING AN END TO FREE HEALTHCARE

(Should the NHS follow the American way?)
http://bmj.com/cgi/content/full/331/7528/1328

The Government’s current NHS reform programme could lead to patients being charged for access to healthcare, argues a paper in this week’s BMJ.

New ‘patient choice’ policies take no account of limited resources and funding, say the authors. Patients - ‘consumers’ in the new NHS - bear no financial responsibility for the choices they make. Primary Care Trusts (PCTs), who pay for local health services in each area, are simply picking up the bill with no control on spending.

The Government’s proposals for expanding market forces in the NHS will also be inefficient, say the authors. The aim is to drive costs down and improve quality through competition - external companies vying for NHS contracts. But prices have been fixed in advance, neutralizing the benefits of market forces.

In addition, more resources are going into the “black hole” of the hospital sector, and the way Foundation Trusts are funded heavily distorts the market.

Such a system will not be sustainable, say the authors: “We face the prospect of an NHS led totally by patients, with supply responding purely to consumer demand without any recognised cap on expenditure.” If the Government does not change tack, this “can only lead to user charges,” they warn.

Current UK policy seems based on US systems, say the authors. But these may not be transferable, particularly since organisations in the US deemed as successful models to follow, such as Kaiser Permanente, do not have to look after the range of health needs of a whole community, as the NHS does.

Instead the UK should introduce specifically-designed ‘superpractices’, family doctor surgeries expanded to include some hospital and social care services, all working together. Superpractices, servicing communities of 25-30,000 people and based on the old 'fundholding' model, would work best for controlling costs without compromising patient care, conclude the authors.

Contact:

Professor Cam Donaldson, Health Foundation Chair in Health Economics, School of Population and Health Sciences, University of Newcastle, Newcastle upon Tyne, UK
Email: cam.donaldson@ncl.ac.uk

(4) DOES THE DISTRICT GENERAL HOSPITAL HAVE A FUTURE?

(Does the district general hospital have a future? )
http://bmj.com/cgi/content/full/331/7528/1331

Government reforms are threatening the future of district general hospitals, says an expert in this week’s BMJ. Given the iconic status of hospitals in the eyes of the public, government risks huge unpopularity in dealing with the consequences.

District general hospitals have formed the backbone of NHS hospital care since the 1960s, but government reforms to increase patient choice will see these hospitals competing with other NHS hospitals, NHS treatment centres, and independent sector providers, writes Professor Chris Ham.

District general hospitals may also find themselves under pressure from the devolution of budgets to general practices and payment by results.

Taken together, these policies mean that many district general hospitals may find it difficult to sustain a full range of services and could be left providing expensive complex care.

In these circumstances, one strategy is for hospitals to compete aggressively to maintain, and if possible, increase market share. An alternative and more plausible strategy is for hospitals to reduce or cease some activities and to focus on improving productivity in areas where they have competitive advantage.

A third strategy is for hospitals to diversify into other services - for example, sub-acute and primary care.

In the NHS of the future, it is possible to envisage enhanced primary care facilities and independent sector providers acting as a one stop shop for most forms of care apart from hospital inpatient services, says the author. On a more pessimistic note, the changes could result in reduced access to services and ultimately hospital closures.

However, one thing is certain. Managing the effects of choice and competition represents a huge political challenge, he concludes.

Contact:

Professor Chris Ham, Health Service Management Centre, University of Birmingham, UK
Email: c.j.ham@bham.ac.uk

(5) FOOD SUBSIDIES ARE DAMAGING HEALTH

(Obesity, hunger, and agriculture: the damaging role of subsidies)
http://bmj.com/cgi/content/full/331/7528/1333

Overproduction of food in rich countries is fuelling health problems worldwide, argues a public health expert from Sweden in this week’s BMJ.

Globally, we are producing more food than the population needs, writes Professor Liselotte Schafer-Elinder. Subsidising overproduction in developed nations is leading to excessive consumption and obesity. It is also undermining agriculture in the developing world, hindering the eradication of hunger and poverty.

The dairy sector in the European Union is an example of how agriculture subsidies can lead to negative health effects in Europe as well as in developing countries.

Surplus milk is converted to storable products and export subsidies are granted in order to dispose of it. These undermine the milk sector in many developing countries, which has an important role in alleviating poverty and malnutrition. Surplus butter is then sold with subsidies to the food industry, which turns it into energy dense foods such as ice cream and cakes, fuelling the obesity epidemic in many developed nations.

The World Health Organisation has noted this problem. Its global strategy on diet, physical activity, and health advises member states “to take healthy nutrition into account in their agricultural policies.”

As long as the supply of energy dense foods is not reduced, the prevalence of obesity and social inequalities in health is likely to continue to increase, warns the author. As a first step to reverse this trend, agricultural market support promoting the overproduction of food has to be phased out.

But even if subsidies are phased out, global supplies will probably continue to be higher than “healthy” demand for many years to come, she adds. Therefore, as a second step, internationally binding conventions like the one on tobacco are needed.

These should include issues such as marketing of energy dense foods, availability to children, labelling, and tax and price measures.

Contact:

Liselotte Schafer Elinder, Associate Professor, Swedish National Institute of Public Health, Stockholm, Sweden (www.fhi.se)
Email: liselotte.elinder@fhi.se

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