- Email: [email protected]
Cardiology
1215
Would this proposal increase medical negligence litigation and encourage defensive practices? Since the proposal does not remove the need to prove fault as well as causation the success rate of plaintiffs seems unlikely to change, so anxieties of increased risk of suits bringing with it the increased chance of defensive medicine seem
unfounded.
Many doctors believe that they should be beyond the clutch of negligence litigation, which is damaging to patient/doctor relationships and trust. However, they will also recognise that when a patient is injured as a result of negligent treatment he or she is entitled to compensation. If the proposal really will provide better protection for those damaged by negligent services the profession should support it. However, my view remains that compensation without the need to prove fault is the best option. It is a pity that the European Commissioners did not have the courage of their original convictions. Which medical services qualify as "commercial" for the purposes of the proposed directive is uncertain. The British Government, having circulated interested parties, is considering its response. Diana Brahams
30%. The majority used no method of contraception at their first intercourse. Fortunately, however, the data do show that teenage use of condoms doubled in the 1980s. The meeting, jointly held with the Society for Pediatric Research and Ambulatory Pediatric Society, brought 4000 physicians and nurses to New Orleans during April 29-May 2. The concurrent sessions and posters covered many topics, from the risk of neural tube defects when women use electric blankets or hot tubs in early pregnancy (there is evidence of a rise) to rotavirus in day-care centres (one polymerase chain reaction study showed that 44% of toys carried the virus), and accidental child shootings in Chicago (4 children were killed and 15 had serious injuries: only 3 gun owners were charged and the total fines were$150). In a bold effort to keep the various parts of the paediatric universe in focus, Etienne-Emile Baulieu of Laboratoire Hormones, Bicetre, France, was asked to talk about RU 486 and early abortion, or "contragestational" procedures. There was a small protest outside the conference hall, but the Councils of the American Pediatric Society and the Society for Pediatric Research passed a resolution to make RU 486 available for further research and use as medically indicated.
Malcolm Potts
Conference The paediatric universe "The Hubble space telescope is perfect, but the universe is out of focus!", quipped William Foege, addressing the 101st meeting of the American Pediatric Society. In fact, the meeting went a long way towards bringing into focus the many perspectives characterising the health and welfare of children. In the late nineteenth and early twentieth centuries, American paediatricians were an activist specialty group concerned with public health issues. More recently, professional meetings have been dominated by high technology. In her presidential address, Mary Ellen Avery brought the two perspectives back into a thoughtful and wise focus. A pioneer in the study of lung surfactants, Dr Avery discussed the problem "How Small" and the intensive care of infants born at less than 28 weeks’ gestation and the imperative to reduce, through antenatal care and counselling, the prematurity rate in the USA. She also discussed "How Many", the "right of every child to be wanted" and the need for family planning. Bringing paediatric care and socioeconomic factors into focus at the same times was also the theme of other presentations. Dr Foege, director of the Carter Center of Emory University, Atlanta, celebrated the success of child survival (today 80% of the world’s children are immunised and one million lives are saved annually by oral rehydration). But it was pointed out that incomes are falling in many parts of Africa, and the infant mortality rate has stopped declining in over 20 countries. All speakers agreed that family planning services must be expanded to improve the socioeconomic environment; moreover, the optimum timing and number of births can directly reduce infant and child deaths. One senior National Institutes of Health researcher confessed that she was sometimes professionally "embarrassed to travel overseas" because the USA had such a dismal ranking in family planning: 50% of all pregnancies in the country are unplanned. In 1980, 10% of 16-year-old girls had made their sexual debut, but by 1990 it was over
Cardiology During May 1-3 Glasgow extended a warm failte to the 800 or so people who attended the British Cardiac Society’s annual meeting. Some of the most interesting presentations came from the former European City of Culture and its ancient rival, Edinburgh. The rate of coronary angiography relative to the prevalence of coronary artery disease in Glasgow was examined according to social class. Standardised mortality ratio (SMR) for coronary heart disease correlates closely with social deprivation score (SDS). For women with the highest SDS of 7, the predicted coronary angiography rate, adjusted for SMR, was 3-3 per 1000, whereas the actual rate was 2-7 per 1000 (83% of predicted). For a SDS of 1, the respective figures were 0-9 and 1 -7—ie, 200% of predicted. Similar trends were seen for men. Coronary angiograms done in the private sector were not included, which can only strengthen these thoughtprovoking findings. In Scotland’s capital, the epidemic of HIV infection has been exercising the minds of the cardiologists amongst others. In a prospective echocardiographic study of 74 HIV-infected patients, 7 (9-5%) were found to have global left-ventricular dysfunction; a further 5 patients (6-8%) had left-ventricular dilatation. Isolated right-ventricular dilatation was seen in 7 patients (9-5%), all of whom were intravenous drug abusers. This study shows that HIV infection is associated with a high prevalence of dilated cardiomyopathy. As the number of patients with this illness increases and other causes of morbidity and mortality, such as secondary infection, become less of a problem because of effective treatment, cardiac disease due to HIV may become familiar to all cardiologists. In another ancient seat of learning south of the border surgeons and anaesthetists have altered their practices to transfer post-bypass patients from theatre to a three-bedded recovery area rather than to an intensive-care unit (ICU). Most of the patients are extubated in the recovery area within 2 hours (instead of being ventilated overnight) and
1216
subsequently transferred to the ward. ICU is a major, if the major, contributor to the cost of cardiac surgery; availability of ICU beds is also the limiting factor for the number of cases operated upon. Staffing an ICU in Oxford
are
not
needs 7-3 recovery
per bed, whereas the cardiac surgery (CSRA) requires 4-6 nurses per bed. The
nurses
area
Oxford cardiac surgeons believe that the CSRA has enabled them to increase their case-load considerably despite the usual budgetary limitations. Finally, an example of how audit worked to the patients’ advantage came from a retrospective audit of coronary care in Plymouth, which showed that a low proportion of patients aged over 64 years received thrombolytic therapy. Guidelines for thrombolysis were reiterated and nursing staff were instructed to question the action of junior medical staff when thrombolytics were not prescribed. A second prospective audit showed a significant increase in proportion receiving thrombolytic therapy-from 12% to 46%.
A correspondent
Noticeboard Global demography The first half of 1991 has seen an accelerating number of natural and man-made catastrophes. Food production and income are falling in many nations and 36 countries will not be able to feed themselves by the end of the decade. The UN has just revised its best estimates for global population upwards; by the year 2001 the total will be 6.4 billion. The State of World Population 19911 presents the United Nations Population Fund (LJNFPA) summary of global demographic problems and the Fund’s vision of solutions. It is a business-like and balanced document that does not judge the magnitude of contemporary population growth, while underscoring the successes achieved with family planning in the developing world. In East Asia, for example, the number of births per woman has fallen from 6.1in 1960-65 to 2-7 in 1985-90. Of the several interactions between family planning and development covered in the report, one of the most impressive is the positive linkage between family planning and the welfare of women: the daughters of small families are more likely to enter and stay in school, and literate mothers have smaller families than those who have not had the opportunity of education. Dr Nafis Sadik, Executive Director of the UNFPA, is optimistic in opening the report with the statement, "Targets in fertility and family planning for the end of the decade are for the first time part of international development strategies". This statement may sound like bureaucratic rhetoric but it is a realistic assertion and response to population issues. The graphs in the report show how the proportion of women in developing countries wanting no more children has risen, and how desired family size has fallen. In virtually every country the demand for family planning outstrips the services. To achieve targets for the year 2000 the number of couples using contraceptives in developing countries needs to rise from today’s 381 million to 567 million by the end of the decade; in terms of "contraceptive prevalence" the rise need only be from 51 % to 59%. Moreover, family programmes have the support of political and social leaders. The programmes have been well managed and the report gives examples of the ideas used in the distribution of contraceptives. Grenada may have no Virgin Megastore, but a guitar maker’s workshop serves just as well. And sales at Nigeria’s market stalls show not only that distribution there is better than through the family planning association, but also how branded products, promoted by an advertising jungle, outsold unbranded and unpromoted ones. Contraceptive supplies alone will cost US$600 million a year, and family planning services in total could
billion annually (double today’s expenditure) by the end of the decade. Most of this money will come directly from consumers themselves and from the tax revenue of Third World nations, but first-world donors will also need to increase their support (currently just over US$600 million a year) to several billion a year. For many people billions of dollars and billions of people appear cost US$9
mind-boggling figures representing an overwhelming problem requires unobtainable sums of money to solve. In reality, population trends are well understood, proven solutions exist, and the costs are trivial at a global level. For comparison, Philip Morris, the US tobacco conglomerate, has an annual advertising budget of US$2 billion, while the industrialised nations spend US$2 billion a day on defence. as
that
1. Sadik N. The State of World Population,
1991. New York: United Nations Population
Fund. 1991. Pp 48.
Are
patients satisfied?
To help health authorities assess patients’ satisfaction with the service they receive, the Audit Commission asked the Health Services Research Unit of the London School of Hygiene and Tropical Medicine to develop a questionnaire for use by health service managers and clinicians. Three questionnaires for assessing views on surgery-before surgery, and at one week and one month postoperatively-were field tested.! The field trials showed that only one questionnaire,2 with variants for adults and for parents of children undergoing operations, is needed. At least 350 questionnaires should be sent out in any survey to obtain the 200 responses necessary for a statistically valid analysis. They are best sent out to arrive about 3 weeks after the operation. The Commission has also prepared a computer disk2 containing ready-formatted files for entering or tabulating data from the questionnaires. In addition, it has asked the Health Services Research Unit to assemble a national database of the results of surveys using the questionnaires, so that comparative data are available and more detailed analyses will be possible. 1. Audit Commission for Local Authorities and the National Health Service m England and Wales. Measuring quality the patient’s view of day surgery. London: HM Stationery Office. 1991. Pp 19. £5. ISBN 0118860569.
2. Available, with computer disk, from Publications Section, Audit Commission, Nicholson House, Lime Kiln Close, Stoke Gifford, Bristol BS12 6SU
Environmentally friendly NHS The National Health Service, which is the largest employer in the enormous potential for contributing to a cleaner environment. The measures that health authorities can take were discussed at a meeting held in Oxford a year ago (see Lancet 1990, 335: 783). Last week, at another NHS Greening Conference (in Southsea), the Government’s commitment to helping the health service to reduce environmental pollution was emphasised by Mr Stephen Dorrell, Parliamentary Secretary for Health, who announced that the Government will provide funds to help the Centre for Greening the NHS to produce a workbook on good practice in environmental protection for health authorities. The centre, based at the Radcliffe Infirmary, Oxford, was set up after the Oxford conference, and aims to coordinate efforts to clean up the environment through projects with other organisations (eg, the British Institute of Radiology and the Royal College of General Practitioners); through its newsletter, which is being produced with money from the King’s Fund and which will be launched next month; and through seminars. Mr Dorrell also called on the health authorities to use their vast purchasing power to stimulate demand for environmentally friendly products. Other steps that the Government is taking include: the issue of guidance on waste management; the production of a manual on implementing smoking policies in health care facilities to be distributed later this year; completing the changeover to unleaded fuel for NHS vehicles by 1992/93; and the setting of a target saving in energy of 15% within the NHS over the next 5 years. Since 1977/78 there has been a 30% reduction in total energy
UK, has
Would this proposal increase medical negligence litigation and encourage defensive practices? Since the proposal does not remove the need to prove fault as well as causation the success rate of plaintiffs seems unlikely to change, so anxieties of increased risk of suits bringing with it the increased chance of defensive medicine seem
unfounded.
Many doctors believe that they should be beyond the clutch of negligence litigation, which is damaging to patient/doctor relationships and trust. However, they will also recognise that when a patient is injured as a result of negligent treatment he or she is entitled to compensation. If the proposal really will provide better protection for those damaged by negligent services the profession should support it. However, my view remains that compensation without the need to prove fault is the best option. It is a pity that the European Commissioners did not have the courage of their original convictions. Which medical services qualify as "commercial" for the purposes of the proposed directive is uncertain. The British Government, having circulated interested parties, is considering its response. Diana Brahams
30%. The majority used no method of contraception at their first intercourse. Fortunately, however, the data do show that teenage use of condoms doubled in the 1980s. The meeting, jointly held with the Society for Pediatric Research and Ambulatory Pediatric Society, brought 4000 physicians and nurses to New Orleans during April 29-May 2. The concurrent sessions and posters covered many topics, from the risk of neural tube defects when women use electric blankets or hot tubs in early pregnancy (there is evidence of a rise) to rotavirus in day-care centres (one polymerase chain reaction study showed that 44% of toys carried the virus), and accidental child shootings in Chicago (4 children were killed and 15 had serious injuries: only 3 gun owners were charged and the total fines were$150). In a bold effort to keep the various parts of the paediatric universe in focus, Etienne-Emile Baulieu of Laboratoire Hormones, Bicetre, France, was asked to talk about RU 486 and early abortion, or "contragestational" procedures. There was a small protest outside the conference hall, but the Councils of the American Pediatric Society and the Society for Pediatric Research passed a resolution to make RU 486 available for further research and use as medically indicated.
Malcolm Potts
Conference The paediatric universe "The Hubble space telescope is perfect, but the universe is out of focus!", quipped William Foege, addressing the 101st meeting of the American Pediatric Society. In fact, the meeting went a long way towards bringing into focus the many perspectives characterising the health and welfare of children. In the late nineteenth and early twentieth centuries, American paediatricians were an activist specialty group concerned with public health issues. More recently, professional meetings have been dominated by high technology. In her presidential address, Mary Ellen Avery brought the two perspectives back into a thoughtful and wise focus. A pioneer in the study of lung surfactants, Dr Avery discussed the problem "How Small" and the intensive care of infants born at less than 28 weeks’ gestation and the imperative to reduce, through antenatal care and counselling, the prematurity rate in the USA. She also discussed "How Many", the "right of every child to be wanted" and the need for family planning. Bringing paediatric care and socioeconomic factors into focus at the same times was also the theme of other presentations. Dr Foege, director of the Carter Center of Emory University, Atlanta, celebrated the success of child survival (today 80% of the world’s children are immunised and one million lives are saved annually by oral rehydration). But it was pointed out that incomes are falling in many parts of Africa, and the infant mortality rate has stopped declining in over 20 countries. All speakers agreed that family planning services must be expanded to improve the socioeconomic environment; moreover, the optimum timing and number of births can directly reduce infant and child deaths. One senior National Institutes of Health researcher confessed that she was sometimes professionally "embarrassed to travel overseas" because the USA had such a dismal ranking in family planning: 50% of all pregnancies in the country are unplanned. In 1980, 10% of 16-year-old girls had made their sexual debut, but by 1990 it was over
Cardiology During May 1-3 Glasgow extended a warm failte to the 800 or so people who attended the British Cardiac Society’s annual meeting. Some of the most interesting presentations came from the former European City of Culture and its ancient rival, Edinburgh. The rate of coronary angiography relative to the prevalence of coronary artery disease in Glasgow was examined according to social class. Standardised mortality ratio (SMR) for coronary heart disease correlates closely with social deprivation score (SDS). For women with the highest SDS of 7, the predicted coronary angiography rate, adjusted for SMR, was 3-3 per 1000, whereas the actual rate was 2-7 per 1000 (83% of predicted). For a SDS of 1, the respective figures were 0-9 and 1 -7—ie, 200% of predicted. Similar trends were seen for men. Coronary angiograms done in the private sector were not included, which can only strengthen these thoughtprovoking findings. In Scotland’s capital, the epidemic of HIV infection has been exercising the minds of the cardiologists amongst others. In a prospective echocardiographic study of 74 HIV-infected patients, 7 (9-5%) were found to have global left-ventricular dysfunction; a further 5 patients (6-8%) had left-ventricular dilatation. Isolated right-ventricular dilatation was seen in 7 patients (9-5%), all of whom were intravenous drug abusers. This study shows that HIV infection is associated with a high prevalence of dilated cardiomyopathy. As the number of patients with this illness increases and other causes of morbidity and mortality, such as secondary infection, become less of a problem because of effective treatment, cardiac disease due to HIV may become familiar to all cardiologists. In another ancient seat of learning south of the border surgeons and anaesthetists have altered their practices to transfer post-bypass patients from theatre to a three-bedded recovery area rather than to an intensive-care unit (ICU). Most of the patients are extubated in the recovery area within 2 hours (instead of being ventilated overnight) and
1216
subsequently transferred to the ward. ICU is a major, if the major, contributor to the cost of cardiac surgery; availability of ICU beds is also the limiting factor for the number of cases operated upon. Staffing an ICU in Oxford
are
not
needs 7-3 recovery
per bed, whereas the cardiac surgery (CSRA) requires 4-6 nurses per bed. The
nurses
area
Oxford cardiac surgeons believe that the CSRA has enabled them to increase their case-load considerably despite the usual budgetary limitations. Finally, an example of how audit worked to the patients’ advantage came from a retrospective audit of coronary care in Plymouth, which showed that a low proportion of patients aged over 64 years received thrombolytic therapy. Guidelines for thrombolysis were reiterated and nursing staff were instructed to question the action of junior medical staff when thrombolytics were not prescribed. A second prospective audit showed a significant increase in proportion receiving thrombolytic therapy-from 12% to 46%.
A correspondent
Noticeboard Global demography The first half of 1991 has seen an accelerating number of natural and man-made catastrophes. Food production and income are falling in many nations and 36 countries will not be able to feed themselves by the end of the decade. The UN has just revised its best estimates for global population upwards; by the year 2001 the total will be 6.4 billion. The State of World Population 19911 presents the United Nations Population Fund (LJNFPA) summary of global demographic problems and the Fund’s vision of solutions. It is a business-like and balanced document that does not judge the magnitude of contemporary population growth, while underscoring the successes achieved with family planning in the developing world. In East Asia, for example, the number of births per woman has fallen from 6.1in 1960-65 to 2-7 in 1985-90. Of the several interactions between family planning and development covered in the report, one of the most impressive is the positive linkage between family planning and the welfare of women: the daughters of small families are more likely to enter and stay in school, and literate mothers have smaller families than those who have not had the opportunity of education. Dr Nafis Sadik, Executive Director of the UNFPA, is optimistic in opening the report with the statement, "Targets in fertility and family planning for the end of the decade are for the first time part of international development strategies". This statement may sound like bureaucratic rhetoric but it is a realistic assertion and response to population issues. The graphs in the report show how the proportion of women in developing countries wanting no more children has risen, and how desired family size has fallen. In virtually every country the demand for family planning outstrips the services. To achieve targets for the year 2000 the number of couples using contraceptives in developing countries needs to rise from today’s 381 million to 567 million by the end of the decade; in terms of "contraceptive prevalence" the rise need only be from 51 % to 59%. Moreover, family programmes have the support of political and social leaders. The programmes have been well managed and the report gives examples of the ideas used in the distribution of contraceptives. Grenada may have no Virgin Megastore, but a guitar maker’s workshop serves just as well. And sales at Nigeria’s market stalls show not only that distribution there is better than through the family planning association, but also how branded products, promoted by an advertising jungle, outsold unbranded and unpromoted ones. Contraceptive supplies alone will cost US$600 million a year, and family planning services in total could
billion annually (double today’s expenditure) by the end of the decade. Most of this money will come directly from consumers themselves and from the tax revenue of Third World nations, but first-world donors will also need to increase their support (currently just over US$600 million a year) to several billion a year. For many people billions of dollars and billions of people appear cost US$9
mind-boggling figures representing an overwhelming problem requires unobtainable sums of money to solve. In reality, population trends are well understood, proven solutions exist, and the costs are trivial at a global level. For comparison, Philip Morris, the US tobacco conglomerate, has an annual advertising budget of US$2 billion, while the industrialised nations spend US$2 billion a day on defence. as
that
1. Sadik N. The State of World Population,
1991. New York: United Nations Population
Fund. 1991. Pp 48.
Are
patients satisfied?
To help health authorities assess patients’ satisfaction with the service they receive, the Audit Commission asked the Health Services Research Unit of the London School of Hygiene and Tropical Medicine to develop a questionnaire for use by health service managers and clinicians. Three questionnaires for assessing views on surgery-before surgery, and at one week and one month postoperatively-were field tested.! The field trials showed that only one questionnaire,2 with variants for adults and for parents of children undergoing operations, is needed. At least 350 questionnaires should be sent out in any survey to obtain the 200 responses necessary for a statistically valid analysis. They are best sent out to arrive about 3 weeks after the operation. The Commission has also prepared a computer disk2 containing ready-formatted files for entering or tabulating data from the questionnaires. In addition, it has asked the Health Services Research Unit to assemble a national database of the results of surveys using the questionnaires, so that comparative data are available and more detailed analyses will be possible. 1. Audit Commission for Local Authorities and the National Health Service m England and Wales. Measuring quality the patient’s view of day surgery. London: HM Stationery Office. 1991. Pp 19. £5. ISBN 0118860569.
2. Available, with computer disk, from Publications Section, Audit Commission, Nicholson House, Lime Kiln Close, Stoke Gifford, Bristol BS12 6SU
Environmentally friendly NHS The National Health Service, which is the largest employer in the enormous potential for contributing to a cleaner environment. The measures that health authorities can take were discussed at a meeting held in Oxford a year ago (see Lancet 1990, 335: 783). Last week, at another NHS Greening Conference (in Southsea), the Government’s commitment to helping the health service to reduce environmental pollution was emphasised by Mr Stephen Dorrell, Parliamentary Secretary for Health, who announced that the Government will provide funds to help the Centre for Greening the NHS to produce a workbook on good practice in environmental protection for health authorities. The centre, based at the Radcliffe Infirmary, Oxford, was set up after the Oxford conference, and aims to coordinate efforts to clean up the environment through projects with other organisations (eg, the British Institute of Radiology and the Royal College of General Practitioners); through its newsletter, which is being produced with money from the King’s Fund and which will be launched next month; and through seminars. Mr Dorrell also called on the health authorities to use their vast purchasing power to stimulate demand for environmentally friendly products. Other steps that the Government is taking include: the issue of guidance on waste management; the production of a manual on implementing smoking policies in health care facilities to be distributed later this year; completing the changeover to unleaded fuel for NHS vehicles by 1992/93; and the setting of a target saving in energy of 15% within the NHS over the next 5 years. Since 1977/78 there has been a 30% reduction in total energy
UK, has