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FENOTEROL
971 WHO NEEDS INTENSIVE CARE?
Notes and News FENOTEROL THE New Zealand Department of Health has issued a "dear doctor" letter in response to the article that begins this week’s Lancet. It says: "...The Department and the Medicines Adverse Reactions Committee have sought and received advice from a number of experts. This is conflicting and the situation may not be clarified for some time. The articles does suggest that there may be an increased risk of death from asthma in patients prescribed fenoterol by aerosol who have severe disease, or who also use oral steroids. In these circumstances it would be prudent to consider whether the use of fenoterol in such patients should be modified. Practitioners are advised to take this into account when prescribing for these groups. At this stage there is insufficient reason to withdraw fenoterol from the market. The department is considering ways of following up the possible relationship between asthma deaths and the use of fenoterol." The message ends with a reminder of the value of comprehensive management plans for asthmatics, which depend upon skilful use of a peak flow meter by the patient.
TOBACCO WATCHDOG STILL PUFFING AWAY IN the past year the Committee for Monitoring Agreements on Tobacco Advertising and Sponsorship (COMATAS) has received far fewer complaints about advertising than in the previous year (65 items, compared with 172 last year), and only 7 of these were found to be in breach of the voluntary agreement between the Government and the tobacco industry. Good news, one might think; but a letter, included in the committee’s second report,l from the chairman of COMATAS, Sir Peter Lazarus, to the Secretary of State for Health tells a rather different story. Sir Peter speculates that one reason for the drop in the number of complaints is that the "professional critics" have appreciated that many of the advertisements about which they would like to complain do not fall within the terms of the agreement. He records that "for hanging signs in particular, but also to an unacceptable extent for fascia boards, there is still too high a proportion of pre-1983 advertisements [excluded from the agreement] without any [health] warning". The chairman could also have drawn attention to another anomaly: static advertisements for cigarettes and hand-rolling tobacco are banned near schools and playgrounds, but by four o’clock in the afternoon the playgrounds are deserted and the children have swarmed over to the local sweet shop, where there are no such restrictions. Sir Peter knows that the restrictions need to be extended, but his committee has failed to gain the cooperation of the tobacco industry. The Government announced last year that the voluntary agreements on advertising and sports sponsorship by tobacco companies were to be renegotiated, and Sir Peter generously takes the view that the industry is unwilling to discuss with his committee items that might be on the Department of Health’s "shopping list" because it fears that voluntary concessions made now would disadvantage the industry in the negotiations. Sir Peter says he had been led to believe that there would be an early start to the negotiations but that "no visible progress had been made with the negotiations over the whole of the past year". The list of young women’s magazines which, under the terms of the voluntary agreement, should not carry advertisements for cigarettes and hand-rolling tobacco, has been amended since the first COMATAS report was published last year. Car and Girl about Town have been removed because neither has a total female readership of more than 200 000. But Mother, having over 33% of its readers in the age-group 15-24 as well as a total of more than 200 000 female readers, has been added to the list.
1. Second report of the Committee for Monitoring Agreements on Tobacco Advertising and Sponsorship. Department of Health. London. HM Stationery Office. 1989. £3.20. ISBN 0-113212259.
THERE is a serious lack of evidence about the costs and benefits of intensive care in the UK, according to a new report from the King’s Fund.The multidisciplinary panel that prepared the report concluded that this deficiency has resulted in part from uncertainty about who is responsible for organising and managing intensive care and the consequent failure to collect data about activity and outcomes. The report recommends that economic evaluation of intensive care should be given urgent attention and that each intensive care unit (ICU) should identify someone responsible for: (i) ensuring that the unit has written guidelines on clinical policy; (ii) ensuring that these policies are implemented; (iii) collecting and evaluating data on the clinical outcome and costs, in general and in the care of individual patients; and (iv) coordinating the clinical care of individual patients. The person responsible need not necessarily be the same in each case, says the panel; and since conflicts may still arise despite clinical guidelines, an independent mechanism for their resolution should be available. The panel, chaired by Dr John Ledingham, was concerned not only about the costs and benefits of treating the complex illnesses that afflict the majority of patients admitted to ICUs but also about the ill-effects that may arise from such treatment. These include the patient’s loss of dignity, privacy, and autonomy and the perception (well founded or not) that some procedures do more harm than good. Though relevant to all medical practice, these issues were considered to be particularly important in the case of intensive care because of the high costs of treatment. The panel therefore set out to consider: whether there was scientific evidence that ICUs caused a reduction in mortality and morbidity; what criteria should be set for admission to and discharge from ICUs; which classes of patients were likely to benefit most from which procedures carried out in ICUs; for what extra cost was therapeutic benefit gained by using intensive care; and what scale of provision (whether a large multispecialty unit or small subspecialty units) was needed in the National Health Service. Despite a review of the published literature on ICUs, evidence from two surveys and from papers prepared by experts in the use of intensive care, and the panel members’ own considerable experience, the panel had insufficient evidence to carry out its original intention of producing a consensus statement, and it decided instead to publish a report summarising the present state of knowledge about intensive care, highlighting the absence of evidence and calling for a substantial programme of research. The panel recommends that intensive care should be provided for patients with potentially recoverable diseases and for those for whom the prognosis is uncertain, but that it should not be provided for patients who are expected to die shortly whatever is done. It may also be appropriate, the panel suggests, to admit potential organ donors (ie, patients who fulfil the criteria of brainstem death) because of the procedures needed to keep the organs in good condition. Disagreements about what constitutes benefit for individual patients are common, and the panel rejects the hippocratic view (endorsed by the British Medical Association and the American Medical Association) that "the physician should benefit the patient according to his/her ability and judgement" because it depends solely on the doctor’s subjective assessment. The panel prefers a more objective judgment (unless the patient expresses a competent and informed wish for an alternative course). In the panel’s view, the ability to provide more accurate prognosis-for instance, by using severity of disease scores such as APACHE II-would avoid some of the conflicts about potential benefit. The panel suggests that "selection for intensive care should be based on broad concepts of prognosis derived from statistical analysis of comparable cohorts of patients backed up by sound clinical trials." However, it finds that such data are "sadly deficient" in the UK.
1
Intensive care in the United Kingdom: report from the King’s Fund Panel Anaesthesia 1989; 44: 428-31 Single copies are available at no charge from the King’s Fund Forum, 126 Albert Street, London NW1 7NF
Notes and News FENOTEROL THE New Zealand Department of Health has issued a "dear doctor" letter in response to the article that begins this week’s Lancet. It says: "...The Department and the Medicines Adverse Reactions Committee have sought and received advice from a number of experts. This is conflicting and the situation may not be clarified for some time. The articles does suggest that there may be an increased risk of death from asthma in patients prescribed fenoterol by aerosol who have severe disease, or who also use oral steroids. In these circumstances it would be prudent to consider whether the use of fenoterol in such patients should be modified. Practitioners are advised to take this into account when prescribing for these groups. At this stage there is insufficient reason to withdraw fenoterol from the market. The department is considering ways of following up the possible relationship between asthma deaths and the use of fenoterol." The message ends with a reminder of the value of comprehensive management plans for asthmatics, which depend upon skilful use of a peak flow meter by the patient.
TOBACCO WATCHDOG STILL PUFFING AWAY IN the past year the Committee for Monitoring Agreements on Tobacco Advertising and Sponsorship (COMATAS) has received far fewer complaints about advertising than in the previous year (65 items, compared with 172 last year), and only 7 of these were found to be in breach of the voluntary agreement between the Government and the tobacco industry. Good news, one might think; but a letter, included in the committee’s second report,l from the chairman of COMATAS, Sir Peter Lazarus, to the Secretary of State for Health tells a rather different story. Sir Peter speculates that one reason for the drop in the number of complaints is that the "professional critics" have appreciated that many of the advertisements about which they would like to complain do not fall within the terms of the agreement. He records that "for hanging signs in particular, but also to an unacceptable extent for fascia boards, there is still too high a proportion of pre-1983 advertisements [excluded from the agreement] without any [health] warning". The chairman could also have drawn attention to another anomaly: static advertisements for cigarettes and hand-rolling tobacco are banned near schools and playgrounds, but by four o’clock in the afternoon the playgrounds are deserted and the children have swarmed over to the local sweet shop, where there are no such restrictions. Sir Peter knows that the restrictions need to be extended, but his committee has failed to gain the cooperation of the tobacco industry. The Government announced last year that the voluntary agreements on advertising and sports sponsorship by tobacco companies were to be renegotiated, and Sir Peter generously takes the view that the industry is unwilling to discuss with his committee items that might be on the Department of Health’s "shopping list" because it fears that voluntary concessions made now would disadvantage the industry in the negotiations. Sir Peter says he had been led to believe that there would be an early start to the negotiations but that "no visible progress had been made with the negotiations over the whole of the past year". The list of young women’s magazines which, under the terms of the voluntary agreement, should not carry advertisements for cigarettes and hand-rolling tobacco, has been amended since the first COMATAS report was published last year. Car and Girl about Town have been removed because neither has a total female readership of more than 200 000. But Mother, having over 33% of its readers in the age-group 15-24 as well as a total of more than 200 000 female readers, has been added to the list.
1. Second report of the Committee for Monitoring Agreements on Tobacco Advertising and Sponsorship. Department of Health. London. HM Stationery Office. 1989. £3.20. ISBN 0-113212259.
THERE is a serious lack of evidence about the costs and benefits of intensive care in the UK, according to a new report from the King’s Fund.The multidisciplinary panel that prepared the report concluded that this deficiency has resulted in part from uncertainty about who is responsible for organising and managing intensive care and the consequent failure to collect data about activity and outcomes. The report recommends that economic evaluation of intensive care should be given urgent attention and that each intensive care unit (ICU) should identify someone responsible for: (i) ensuring that the unit has written guidelines on clinical policy; (ii) ensuring that these policies are implemented; (iii) collecting and evaluating data on the clinical outcome and costs, in general and in the care of individual patients; and (iv) coordinating the clinical care of individual patients. The person responsible need not necessarily be the same in each case, says the panel; and since conflicts may still arise despite clinical guidelines, an independent mechanism for their resolution should be available. The panel, chaired by Dr John Ledingham, was concerned not only about the costs and benefits of treating the complex illnesses that afflict the majority of patients admitted to ICUs but also about the ill-effects that may arise from such treatment. These include the patient’s loss of dignity, privacy, and autonomy and the perception (well founded or not) that some procedures do more harm than good. Though relevant to all medical practice, these issues were considered to be particularly important in the case of intensive care because of the high costs of treatment. The panel therefore set out to consider: whether there was scientific evidence that ICUs caused a reduction in mortality and morbidity; what criteria should be set for admission to and discharge from ICUs; which classes of patients were likely to benefit most from which procedures carried out in ICUs; for what extra cost was therapeutic benefit gained by using intensive care; and what scale of provision (whether a large multispecialty unit or small subspecialty units) was needed in the National Health Service. Despite a review of the published literature on ICUs, evidence from two surveys and from papers prepared by experts in the use of intensive care, and the panel members’ own considerable experience, the panel had insufficient evidence to carry out its original intention of producing a consensus statement, and it decided instead to publish a report summarising the present state of knowledge about intensive care, highlighting the absence of evidence and calling for a substantial programme of research. The panel recommends that intensive care should be provided for patients with potentially recoverable diseases and for those for whom the prognosis is uncertain, but that it should not be provided for patients who are expected to die shortly whatever is done. It may also be appropriate, the panel suggests, to admit potential organ donors (ie, patients who fulfil the criteria of brainstem death) because of the procedures needed to keep the organs in good condition. Disagreements about what constitutes benefit for individual patients are common, and the panel rejects the hippocratic view (endorsed by the British Medical Association and the American Medical Association) that "the physician should benefit the patient according to his/her ability and judgement" because it depends solely on the doctor’s subjective assessment. The panel prefers a more objective judgment (unless the patient expresses a competent and informed wish for an alternative course). In the panel’s view, the ability to provide more accurate prognosis-for instance, by using severity of disease scores such as APACHE II-would avoid some of the conflicts about potential benefit. The panel suggests that "selection for intensive care should be based on broad concepts of prognosis derived from statistical analysis of comparable cohorts of patients backed up by sound clinical trials." However, it finds that such data are "sadly deficient" in the UK.
1
Intensive care in the United Kingdom: report from the King’s Fund Panel Anaesthesia 1989; 44: 428-31 Single copies are available at no charge from the King’s Fund Forum, 126 Albert Street, London NW1 7NF