- Email: [email protected]
Acronym mania
CORRESPONDENCE
the investigators explaining our reason not to publish their letter. The use of the term Taiwan, China by WHO and its secretariat is based on a resolution adopted by its member states at the 25th World Health Assembly in 1972 (resolution WHA25:1). Other more appropriate forums already exist for the discussion of the merit and consequences of this resolution. We do, however, welcome debate on issues of international public-health interest and our letters section is open for scientific comments from throughout the world on reports we have published. Hooman Momen Bulletin of the World Health Organization, CH 1211 Geneva, Switzerland (e-mail: [email protected])
Funding for the National Health Service Sir—The UK government is pounding the National Health Service (NHS) with new funding that will result in nearly 10% of gross domestic product being spent on health care in 5 years.1,2 Although many welcome these increases, there is a risk that the NHS may be killed by kindness. Spending increases create higher expectations for quality and access from the public, and from professionals for better pay, conditions, infrastructure, and equipment. However, supply creates its own demand and more spending reveals previously unmet demands in an increasingly medicalised society. In continental Europe, higher expenditure is still clearly accompanied by dissatisfaction with local services.3 International experience shows that there is no level of expenditure at which all public and professional expectations can be met. More investment in the NHS will only efficiently produce health gains if it is carefully targeted at interventions of proven cost-effectiveness. Ideally priorities, assessed by evidence of relative cost-effectiveness, should be set across the whole of health-related activity (National Service Frameworks, waiting times, National Institute for Clinical Excellence, and the myriad of other government priorities). Even if this was done, not all demand will be met. If priorities were pursued efficiently, however, there are severe capacity constraints that create pay and price inflation (eg, agency nursing costs). There is a risk that much of the new funding will evaporate into higher pay with little effect on volume and quality.
576
Increases in the supply of labour and beds by overseas recruitment, private contracting, and fining local authorities that do not meet delayed discharge targets may also be inflationary and ameliorate capacity issues only slightly in the short term. The huge investment in medical care compared with that in population health-improving strategies is a wasted opportunity, since investing outside the NHS may be more cost effective. Investment in education raises lifetime earnings, which is associated with reductions in smoking and the adoption of other behaviours conducive to health. Similarly, the reduction of poverty leads to investments in human capital and behaviour changes that improve the long-term health of the poor and their children and helps reduce inequalities in health.4 The current redisorganisation of the NHS structures supposedly supports the funding increases. These changes are expensive, have used scarce managerial effort much needed to accelerate service change, and are evidence-free. These policy-making characteristics have plagued the NHS for decades despite advocacy of cautious evidence-based reform.5 Difficulties in policy implementation may panic the government into more initiatives which create an even more bloated and invasive regulatory structure of uncertain effect and cost. Such action will precipitate calls for the dismantling of the NHS, which would fragment the funding and provision of care and redistribute resources to richer patients and richer providers. This effect is not presumably the intention of the government but may be the result of its reckless neglect of evidence and reality. Most in the NHS will strive to avoid this outcome. *Alan Maynard, Trevor Sheldon York Health Policy Group, Department of Health Sciences, University of York, York YO10 5DD, UK (e-mail: [email protected]) 1
2
3
4
5
Delivering the NHS plan—next steps for investment; next steps for reform, Cmnd 5503. London: Department of Health, 2002. Ashraf H. UK budget commits to rebuild national health service. Lancet 2002; 359: 271. Dixon A, Mossialos E, eds. Health care systems in eight countries: trends and challenges, commissioned by the Health Trends Review (the Wanless report group). London: HM Treasury, 2002. Chalmers I, Sheldon T, Rounding C, eds. Evidence from systematic reviews of research relevant to implementing the ‘wider public health agenda’. York: University of York NHS Centre for Reviews and Dissemination, 2000. Maynard A, Sheldon T. Time to turn the tide. Health Service J 1997; 107: 24–26.
Acronym mania Sir—In the self-proclaimed era of evidence-based medicine, the randomised clinical trial is touted as the gold standard of evidence. These trials were originally named in such a way as to convey to readers not in the know the actual purpose or subject of the trial, such as, for example, the University Group Diabetes Program. The abbreviation for this particular study title (UGDP) was unpronounceable, meant nothing in English, or in the 174 other languages currently in use, but did correctly identify the study and its purpose. To start with, I think some trial titles coincidentally abbreviated into acronyms, several of which were actually quite catchy, such as TIMI (Thrombolysis In Myocardial Infarction). Other acronyms were made up from words that even reflected the purpose of the study, such as DIG (Digitalis Investigation Group). Acronyms for trial names have proliferated more rapidly than smoothmuscle cells after balloon angioplasty, and in no specialty more notably than in cardiology. Some disturbing trends have become apparent, however. Rather than clarifying the nature or purpose of the study, the acronyms seem to be simply attempting to portray an attribute of the principal investigator (RESOLVD) or a quest for knowledge (PURSUIT), to idealise the goals of science (AFFIRM), or to affirm the pursuit of a higher ideal (PEACE). Furthermore, in their quest to achieve the Simply Perfect Latest Acronym Title (SPLAT) the trialists responsible for naming these studies defy all rules of language and syntax (as well as the actual conventions for creating an acronym) simply to come up with the cleverest study title, a process I consider an ABOMINATION (Arty But cOntorted Manoeuvre that IgNores All reason To Invent a wOnderful Name). The Oxford English Dictionary defines an acronym as a word formed from the initial letters of other words. I propose that if a study is to be referred to by an acronym, its title should first and foremost actually describe the study in proper and conventional English, so there might be some hope that the rest of us can guess the nature of the study. To avoid illegal acronyms, perhaps they should be comprised of the initial letters of the key words in the name. Otherwise I would expect the trial to be relegated to the TRASH (Trials Rejected for Acronyms we Simply Hate). Ellis W Lader Mid-Valley Cardiology, 456 Washington Avenue, Kingston, NY 12401, USA (e-mail: [email protected])
THE LANCET • Vol 360 • August 17, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
the investigators explaining our reason not to publish their letter. The use of the term Taiwan, China by WHO and its secretariat is based on a resolution adopted by its member states at the 25th World Health Assembly in 1972 (resolution WHA25:1). Other more appropriate forums already exist for the discussion of the merit and consequences of this resolution. We do, however, welcome debate on issues of international public-health interest and our letters section is open for scientific comments from throughout the world on reports we have published. Hooman Momen Bulletin of the World Health Organization, CH 1211 Geneva, Switzerland (e-mail: [email protected])
Funding for the National Health Service Sir—The UK government is pounding the National Health Service (NHS) with new funding that will result in nearly 10% of gross domestic product being spent on health care in 5 years.1,2 Although many welcome these increases, there is a risk that the NHS may be killed by kindness. Spending increases create higher expectations for quality and access from the public, and from professionals for better pay, conditions, infrastructure, and equipment. However, supply creates its own demand and more spending reveals previously unmet demands in an increasingly medicalised society. In continental Europe, higher expenditure is still clearly accompanied by dissatisfaction with local services.3 International experience shows that there is no level of expenditure at which all public and professional expectations can be met. More investment in the NHS will only efficiently produce health gains if it is carefully targeted at interventions of proven cost-effectiveness. Ideally priorities, assessed by evidence of relative cost-effectiveness, should be set across the whole of health-related activity (National Service Frameworks, waiting times, National Institute for Clinical Excellence, and the myriad of other government priorities). Even if this was done, not all demand will be met. If priorities were pursued efficiently, however, there are severe capacity constraints that create pay and price inflation (eg, agency nursing costs). There is a risk that much of the new funding will evaporate into higher pay with little effect on volume and quality.
576
Increases in the supply of labour and beds by overseas recruitment, private contracting, and fining local authorities that do not meet delayed discharge targets may also be inflationary and ameliorate capacity issues only slightly in the short term. The huge investment in medical care compared with that in population health-improving strategies is a wasted opportunity, since investing outside the NHS may be more cost effective. Investment in education raises lifetime earnings, which is associated with reductions in smoking and the adoption of other behaviours conducive to health. Similarly, the reduction of poverty leads to investments in human capital and behaviour changes that improve the long-term health of the poor and their children and helps reduce inequalities in health.4 The current redisorganisation of the NHS structures supposedly supports the funding increases. These changes are expensive, have used scarce managerial effort much needed to accelerate service change, and are evidence-free. These policy-making characteristics have plagued the NHS for decades despite advocacy of cautious evidence-based reform.5 Difficulties in policy implementation may panic the government into more initiatives which create an even more bloated and invasive regulatory structure of uncertain effect and cost. Such action will precipitate calls for the dismantling of the NHS, which would fragment the funding and provision of care and redistribute resources to richer patients and richer providers. This effect is not presumably the intention of the government but may be the result of its reckless neglect of evidence and reality. Most in the NHS will strive to avoid this outcome. *Alan Maynard, Trevor Sheldon York Health Policy Group, Department of Health Sciences, University of York, York YO10 5DD, UK (e-mail: [email protected]) 1
2
3
4
5
Delivering the NHS plan—next steps for investment; next steps for reform, Cmnd 5503. London: Department of Health, 2002. Ashraf H. UK budget commits to rebuild national health service. Lancet 2002; 359: 271. Dixon A, Mossialos E, eds. Health care systems in eight countries: trends and challenges, commissioned by the Health Trends Review (the Wanless report group). London: HM Treasury, 2002. Chalmers I, Sheldon T, Rounding C, eds. Evidence from systematic reviews of research relevant to implementing the ‘wider public health agenda’. York: University of York NHS Centre for Reviews and Dissemination, 2000. Maynard A, Sheldon T. Time to turn the tide. Health Service J 1997; 107: 24–26.
Acronym mania Sir—In the self-proclaimed era of evidence-based medicine, the randomised clinical trial is touted as the gold standard of evidence. These trials were originally named in such a way as to convey to readers not in the know the actual purpose or subject of the trial, such as, for example, the University Group Diabetes Program. The abbreviation for this particular study title (UGDP) was unpronounceable, meant nothing in English, or in the 174 other languages currently in use, but did correctly identify the study and its purpose. To start with, I think some trial titles coincidentally abbreviated into acronyms, several of which were actually quite catchy, such as TIMI (Thrombolysis In Myocardial Infarction). Other acronyms were made up from words that even reflected the purpose of the study, such as DIG (Digitalis Investigation Group). Acronyms for trial names have proliferated more rapidly than smoothmuscle cells after balloon angioplasty, and in no specialty more notably than in cardiology. Some disturbing trends have become apparent, however. Rather than clarifying the nature or purpose of the study, the acronyms seem to be simply attempting to portray an attribute of the principal investigator (RESOLVD) or a quest for knowledge (PURSUIT), to idealise the goals of science (AFFIRM), or to affirm the pursuit of a higher ideal (PEACE). Furthermore, in their quest to achieve the Simply Perfect Latest Acronym Title (SPLAT) the trialists responsible for naming these studies defy all rules of language and syntax (as well as the actual conventions for creating an acronym) simply to come up with the cleverest study title, a process I consider an ABOMINATION (Arty But cOntorted Manoeuvre that IgNores All reason To Invent a wOnderful Name). The Oxford English Dictionary defines an acronym as a word formed from the initial letters of other words. I propose that if a study is to be referred to by an acronym, its title should first and foremost actually describe the study in proper and conventional English, so there might be some hope that the rest of us can guess the nature of the study. To avoid illegal acronyms, perhaps they should be comprised of the initial letters of the key words in the name. Otherwise I would expect the trial to be relegated to the TRASH (Trials Rejected for Acronyms we Simply Hate). Ellis W Lader Mid-Valley Cardiology, 456 Washington Avenue, Kingston, NY 12401, USA (e-mail: [email protected])
THE LANCET • Vol 360 • August 17, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.