- Email: [email protected]
Interventional cardiology in Germany
CORRESPONDENCE
Perineal repair after spontaneous vaginal birth Sir—I am delighted to see the randomised controlled trial of Christine Kettle and colleagues (June 29, p 2217),1 in which they show that when trained midwives do continuous perineal repair, compared with interrupted sutures, women experience less short-term discomfort after delivery. They address important questions well, consulting appropriate practitioners (the deliverers), and raise important issues, such as can the improvement of perineal repair techniques contribute to a reduction in caesarean sections? I hope their findings will be used to address the investigators’ final statement that there is a urgent need to make appropriate perineal-repair training programmes available for midwives and doctors. I am reminded of a personal experience as a mother, of more than 1 month’s perineal discomfort, but more importantly of my training when I was a medical student. 27 years ago, a registrar in my London teaching hospital took me into a delivery room, where a woman lay with her legs in stirrups, having given birth. He said, “She may be a surgeon one day, but she’s never done one of these before”, and walked out, leaving me with the woman and a trolley of equipment, both of us sharing glances of horror and intimidation. I completed the job with interrupted external sutures, after sharing with her that I had sewn other areas of the body, so she agreed I should do it. After all, sewing perineums was the job of medical students in those days, since midwives did not undertake this task. I have no idea of the puerperal outcome. I hope things have improved from the era of “see one, do one, teach one”, and unnecessary splitting of care. Midwives suture people they have delivered. And I hope role models and communication-skills training have replaced arrogance with humanity in hospitals. There are other good reasons for becoming a general practitioner. Anna Eleri Livingstone Limehouse Practice, Gill Street Health Centre, London E14 8HQ, UK (e-mail: [email protected]) 1
Kettle C, Hills RK, Jones P, Darby L, Gray R, Johanson R. Continuous versus interrupted perineal repair with standard or rapidly absorbed sutures after spontaneous vaginal birth: a randomised controlled trial. Lancet 2002; 359: 2217–23.
1694
Bridges to Iran Sir—I read with incredulity the utterly naive Commentary by Stuart Spencer and David Sharp (June 8, p 1960),1 in which they promote improved relations with Iran. Although they seem to attribute Iran’s outcast status mainly to the “bellicosity of some Western leaders”, there are several excellent and obvious reasons why Iran is shunned. Its government, a fierce theocracy, has suppressed all attempts at real democratic reform. State-sponsored oppression of minority groups and women is an ongoing issue. Iran’s current regime enthusiastically offers financial and material support, as well as safe haven, to acknowledged terrorist groups, such as Hezbollah, that have targeted and murdered Israeli, US, and European civilians. Iran has openly threatened Israel, the Middle East’s only democracy, with nuclear annihilation, and has made efforts to destabilise the newly formed government of war-torn Afghanistan. Any improvement in relations between the USA and Europe and Iran at this time serves only to reward this dangerous behaviour. We would do so only at their society’s and the world’s peril. Allon N Friedman Human Nutrition Research Center, Tufts University, Boston, MA 02111, USA (e-mail: [email protected]) 1
Spencer S, Sharp D. Bridges to Iran. Lancet 2002; 359: 1960.
Sir—I thank Stuart Spencer and David Sharp1 for pointing out some of the good things met within and good reasons for going to Iran. I have just returned from running a 2-day seminar on developing clinical skills learning centres at Kashan University Medical School. About 40 doctors and others attended from several medical schools and half were women. The seriousness with which they worked was inspiring, and both women and men were brilliant at presenting results of group discussions. A major difficulty for them was conversational English, and for me, coping with Farsi. Throughout the week I never for a moment felt in harm’s way, except on the road—more than 15 000 known road-traffic-accident deaths were reported in 2001 for a population of 70 million. Thanks to political interests, the press on Iran is almost entirely negative but this reporting is quite unjustified. Most things are very much centrally controlled by government but some of the restrictions developed after
the revolution of 1979 are gradually being reduced, such as music being freely played and listened to, although satellite television is still not permitted. I can heartily recommend a working visit. The doctors and other people do feel isolated from other parts of the world, as indeed has been the purpose of the US embargo. I noticed exactly the same in Iraq last year. A visit will be extraordinarily appreciated (I was told I was the first ever foreign visitor to the medical school), and you will undoubtedly make friends. Historically we have much to make amends for and I hope medical organisations here will make contact with their Iranian (and Iraqi) counterparts to enhance relations in their hour of need. Chris Burns-Cox Southend Farm, Wotton-Under-Edge GL12 7PB, UK (e-mail: [email protected]) 1
Spencer S, Sharp D. Bridges to Iran. Lancet 2002; 359: 1960.
Interventional cardiology in Germany Sir—In their Viewpoint on possible overuse of invasive cardiac procedures in Germany, Wolfgang Dissmann and Michael de Ridder (June 8, p 202)1 raise important issues. However, they do not discuss the effect of increased use of invasive procedures on morbidity and mortality from cardiovascular disease. This issue must surely be the main endpoint used for assessment of “value for money”, rather than a simple comparison with common practices in other countries. I would be grateful to know if comparative data are available for the countries discussed. S E Baldeweg Department of Endocrinology, The Middlesex Hospital, University College London Hospitals, London W1N 8AA, UK (e-mail: [email protected]) 1
Dissmann W, de Ridder M. The soft science of German cardiology. Lancet 2002; 359: 2027–29.
Sir—Wolfgang Dissmann and Michael criticise German de Ridder1 cardiologists’ overuse of invasive procedures for coronary heart disease. However, they fail to adequately address either the science of cardiology in Germany, or the deficiencies of the German health-care system, which itself suffers from a lack of research on use of health care. Since German insurance companies have not made available data on the use of cardiovascular procedures, Dissmann
THE LANCET • Vol 360 • November 23, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
CORRESPONDENCE
and de Ridder’s critique lacks an important source of information. The published works Dissmann and de Ridder cite do not allow for their conclusions. None of the studies mentioned provide data, which are needed to judge any health-care system. Moreover, they omit reference to important studies about invasive procedures for coronary disease that provide insight into decision making.2–4 Dissmann and de Ridder contend that the German Cardiac Society (GCS) is responsible for the alleged abuse of resources in the health-care system. The GCS is even accused of misinterpreting and withholding data from the German Health Experts’ Council. According to Dissmann and de Ridder’s simplistic thesis, the highest number of invasive procedures per capita in Europe is an indicator of overuse and misuse. They forget that use of invasive procedures in other countries may be catching up with practice in Germany. Their claim that the GCS mislead the German Health Experts’ Council by not presenting European data from the Bruckenberger Report for 2000, which, with respect to Germany, depends on data collected and published annually by the GCS. They conceal the fact that the report by the GCS was delivered at the end of August, 2000, whereas the Bruckenberger Report was available only later, in the middle of September, 2000. The fact that comparative national data for 1995 (not 1993, as they state), published by the European Society of Cardiology in 1999, were used in the GCS report at the end of August, 2000, is interpreted as fraud by Dissmann and de Ridder.5 Dissmann and de Ridder are incorrect when they claim that the GCS position on use of percutaneous transluminal coronary angioplasties (PTCA) was based on data from community hospitals. Our voluntary registries were done and audited in both community and university hospitals. They complain that these statistics represent only 25% of PTCAs done in Germany. We do not agree, since a prospective registry of this size is unique, even from an international perspective. Interestingly, Dissmann and de Ridder did not register data on their use of procedures. Dissmann and de Ridder must be unaware of legislation passed in 2000, which imposed a compulsory registry on all invasive procedures as a precondition for reimbursement by health-insurance companies. They also fail to realise that this quality programme is based on the registries
developed by the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte, all of which are members of the GCS. They may also be unaware that a working group of the GCS has been giving expert advice to governmental agencies in the procedural adjustments of these registries. Unfortunately, Dissmann and de Ridder do not help to solve any of the important issues that face cardiologists in Germany. They misinterpret the facts and misrepresent the constructive approach taken by the GCS and its members towards quality assessment. *M Gottwik, G Breithardt *Klinikum Nürnberg Süd, Med Klinik 8, D90471 Nürnberg, Germany; and German Cardiac Society, D-40237 Düsseldorf, Germany (e-mail: [email protected]) 1
2
3
4
5
Dissmann W, de Ridder M. The soft science of German cardiology. Lancet 2002; 359: 2027–29. Hilborne LH, Leape LL, Bernstein SJ, et al. The appropriateness of use of percutaneous transluminal coronary angioplasty in New York State. JAMA 1993; 6: 761–65. Brook RH, Kosecoff JB, Park RE, et al. Diagnosis and treatment of coronary disease: comparison of doctors’ attitudes in the USA and the UK. Lancet 1988; 1: 750–53. Hemingway H, Crook AM, Feder G, et al. Underuse of coronary revascularization procedures in patients considered appropriate candidates for revascularization. N Engl J Med 2001; 344: 645–54. Boersma H, Doornbos G, Bloemberg BPM, et al. Cardiovascular diseases in Europe. European registries of cardiovascular diseases and patient management. Sophia Antipolis, France: European Society of Cardiology, 1999.
Author’s reply Sir—I am unable to answer to the question raised by S E Baldeweg, because there are insufficient data to assess the effect of interventional cardiology on morbidity and mortality in patients with coronary heart disease in Germany. One striking finding is that case fatality rates of patients with myocardial infarction are increasing slightly in Germany. In view of the high rates of invasive procedures in Germany, one would have expected a decline in case fatality.1 In reply to the comments made by M Gottwik and G Breithardt, I maintain that the German Health Experts’ Council was seriously misled by the GCS; this contention is based on the Bruckenberger report2 and a report published by the GCS itself.3 In January, 2000, 8 months before delivering its report to the Council, the GCS listed 515 510 diagnostic coronary angiographies for 1998, which corresponds to 6·286 procedures per million inhabitants. This figure differs only slightly from that of
THE LANCET • Vol 360 • November 23, 2002 • www.thelancet.com
Bruckenberger (6·441 procedures per million inhabitants in 1998), but sharply from that the GCS delivered to the Council (3·900 procedures per million inhabitants). With respect to the PTCA registry, we made it clear that “86 general hospitals” (“Allgemeine Krankenhäuser”) took part in the registry. The three university hospitals out of a total of 36 in Germany that joined the registry are negligible. Curiously, M Gottwik and G Breithardt seem to expect other countries in Europe to “catch up” with Germany’s flawed practice of cardiology. Should other countries adopt the common practice in Germany of coronary angiography without an unequivocal indication? Should they follow the German example to undertake PTCA in more than 50% of all cases in patients with chronic stable angina? A new balance between the limited effects of costly interventional cardiology (which is in fact palliative treatment) and more causal treatment approaches of coronary heart disease are urgently needed in Germany. There is much evidence that arrest and reversal therapy of coronary heart disease is effective and that changes in lifestyle can stop progression of the disease. Many German cardiologists do not seem to believe that prevention is an important part of their work. However, this attitude is untenable today, as C Mensah and colleagues assert: “There is no question that among other duties and responsibilities cardiologists should serve as champions of prevention”.4 But German cardiologists prefer to drive the train in aggressive cardiac interventions; between 1998–2001 there was an increase of 15% in coronary angiographies and 33% in angioplasties.2 E Erdmann, the forthcoming president of the annual general meeting of the GCS in 2003, has criticised German cardiologists, and physicians in general, because they do not conform with established guidelines: “An autistic and undisciplined therapeutic medical attitude is to the debit of our patients”.5 I hope that Erdmann will seize the opportunity to discuss the consequences of his statement at the forthcoming meeting of the GCS. Michael de Ridder Klinikum Am Urban, 10967 Berlin, Germany (e-mail: [email protected]) 1
Tunstall-Pedoe H, Kuulasmaa K, Mähönen M, et al. Contribution of trends in survival and coronary-event rates to changes in coronary heart disease mortality: 10-year results from 37 WHO MONICA
1695
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Perineal repair after spontaneous vaginal birth Sir—I am delighted to see the randomised controlled trial of Christine Kettle and colleagues (June 29, p 2217),1 in which they show that when trained midwives do continuous perineal repair, compared with interrupted sutures, women experience less short-term discomfort after delivery. They address important questions well, consulting appropriate practitioners (the deliverers), and raise important issues, such as can the improvement of perineal repair techniques contribute to a reduction in caesarean sections? I hope their findings will be used to address the investigators’ final statement that there is a urgent need to make appropriate perineal-repair training programmes available for midwives and doctors. I am reminded of a personal experience as a mother, of more than 1 month’s perineal discomfort, but more importantly of my training when I was a medical student. 27 years ago, a registrar in my London teaching hospital took me into a delivery room, where a woman lay with her legs in stirrups, having given birth. He said, “She may be a surgeon one day, but she’s never done one of these before”, and walked out, leaving me with the woman and a trolley of equipment, both of us sharing glances of horror and intimidation. I completed the job with interrupted external sutures, after sharing with her that I had sewn other areas of the body, so she agreed I should do it. After all, sewing perineums was the job of medical students in those days, since midwives did not undertake this task. I have no idea of the puerperal outcome. I hope things have improved from the era of “see one, do one, teach one”, and unnecessary splitting of care. Midwives suture people they have delivered. And I hope role models and communication-skills training have replaced arrogance with humanity in hospitals. There are other good reasons for becoming a general practitioner. Anna Eleri Livingstone Limehouse Practice, Gill Street Health Centre, London E14 8HQ, UK (e-mail: [email protected]) 1
Kettle C, Hills RK, Jones P, Darby L, Gray R, Johanson R. Continuous versus interrupted perineal repair with standard or rapidly absorbed sutures after spontaneous vaginal birth: a randomised controlled trial. Lancet 2002; 359: 2217–23.
1694
Bridges to Iran Sir—I read with incredulity the utterly naive Commentary by Stuart Spencer and David Sharp (June 8, p 1960),1 in which they promote improved relations with Iran. Although they seem to attribute Iran’s outcast status mainly to the “bellicosity of some Western leaders”, there are several excellent and obvious reasons why Iran is shunned. Its government, a fierce theocracy, has suppressed all attempts at real democratic reform. State-sponsored oppression of minority groups and women is an ongoing issue. Iran’s current regime enthusiastically offers financial and material support, as well as safe haven, to acknowledged terrorist groups, such as Hezbollah, that have targeted and murdered Israeli, US, and European civilians. Iran has openly threatened Israel, the Middle East’s only democracy, with nuclear annihilation, and has made efforts to destabilise the newly formed government of war-torn Afghanistan. Any improvement in relations between the USA and Europe and Iran at this time serves only to reward this dangerous behaviour. We would do so only at their society’s and the world’s peril. Allon N Friedman Human Nutrition Research Center, Tufts University, Boston, MA 02111, USA (e-mail: [email protected]) 1
Spencer S, Sharp D. Bridges to Iran. Lancet 2002; 359: 1960.
Sir—I thank Stuart Spencer and David Sharp1 for pointing out some of the good things met within and good reasons for going to Iran. I have just returned from running a 2-day seminar on developing clinical skills learning centres at Kashan University Medical School. About 40 doctors and others attended from several medical schools and half were women. The seriousness with which they worked was inspiring, and both women and men were brilliant at presenting results of group discussions. A major difficulty for them was conversational English, and for me, coping with Farsi. Throughout the week I never for a moment felt in harm’s way, except on the road—more than 15 000 known road-traffic-accident deaths were reported in 2001 for a population of 70 million. Thanks to political interests, the press on Iran is almost entirely negative but this reporting is quite unjustified. Most things are very much centrally controlled by government but some of the restrictions developed after
the revolution of 1979 are gradually being reduced, such as music being freely played and listened to, although satellite television is still not permitted. I can heartily recommend a working visit. The doctors and other people do feel isolated from other parts of the world, as indeed has been the purpose of the US embargo. I noticed exactly the same in Iraq last year. A visit will be extraordinarily appreciated (I was told I was the first ever foreign visitor to the medical school), and you will undoubtedly make friends. Historically we have much to make amends for and I hope medical organisations here will make contact with their Iranian (and Iraqi) counterparts to enhance relations in their hour of need. Chris Burns-Cox Southend Farm, Wotton-Under-Edge GL12 7PB, UK (e-mail: [email protected]) 1
Spencer S, Sharp D. Bridges to Iran. Lancet 2002; 359: 1960.
Interventional cardiology in Germany Sir—In their Viewpoint on possible overuse of invasive cardiac procedures in Germany, Wolfgang Dissmann and Michael de Ridder (June 8, p 202)1 raise important issues. However, they do not discuss the effect of increased use of invasive procedures on morbidity and mortality from cardiovascular disease. This issue must surely be the main endpoint used for assessment of “value for money”, rather than a simple comparison with common practices in other countries. I would be grateful to know if comparative data are available for the countries discussed. S E Baldeweg Department of Endocrinology, The Middlesex Hospital, University College London Hospitals, London W1N 8AA, UK (e-mail: [email protected]) 1
Dissmann W, de Ridder M. The soft science of German cardiology. Lancet 2002; 359: 2027–29.
Sir—Wolfgang Dissmann and Michael criticise German de Ridder1 cardiologists’ overuse of invasive procedures for coronary heart disease. However, they fail to adequately address either the science of cardiology in Germany, or the deficiencies of the German health-care system, which itself suffers from a lack of research on use of health care. Since German insurance companies have not made available data on the use of cardiovascular procedures, Dissmann
THE LANCET • Vol 360 • November 23, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
CORRESPONDENCE
and de Ridder’s critique lacks an important source of information. The published works Dissmann and de Ridder cite do not allow for their conclusions. None of the studies mentioned provide data, which are needed to judge any health-care system. Moreover, they omit reference to important studies about invasive procedures for coronary disease that provide insight into decision making.2–4 Dissmann and de Ridder contend that the German Cardiac Society (GCS) is responsible for the alleged abuse of resources in the health-care system. The GCS is even accused of misinterpreting and withholding data from the German Health Experts’ Council. According to Dissmann and de Ridder’s simplistic thesis, the highest number of invasive procedures per capita in Europe is an indicator of overuse and misuse. They forget that use of invasive procedures in other countries may be catching up with practice in Germany. Their claim that the GCS mislead the German Health Experts’ Council by not presenting European data from the Bruckenberger Report for 2000, which, with respect to Germany, depends on data collected and published annually by the GCS. They conceal the fact that the report by the GCS was delivered at the end of August, 2000, whereas the Bruckenberger Report was available only later, in the middle of September, 2000. The fact that comparative national data for 1995 (not 1993, as they state), published by the European Society of Cardiology in 1999, were used in the GCS report at the end of August, 2000, is interpreted as fraud by Dissmann and de Ridder.5 Dissmann and de Ridder are incorrect when they claim that the GCS position on use of percutaneous transluminal coronary angioplasties (PTCA) was based on data from community hospitals. Our voluntary registries were done and audited in both community and university hospitals. They complain that these statistics represent only 25% of PTCAs done in Germany. We do not agree, since a prospective registry of this size is unique, even from an international perspective. Interestingly, Dissmann and de Ridder did not register data on their use of procedures. Dissmann and de Ridder must be unaware of legislation passed in 2000, which imposed a compulsory registry on all invasive procedures as a precondition for reimbursement by health-insurance companies. They also fail to realise that this quality programme is based on the registries
developed by the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte, all of which are members of the GCS. They may also be unaware that a working group of the GCS has been giving expert advice to governmental agencies in the procedural adjustments of these registries. Unfortunately, Dissmann and de Ridder do not help to solve any of the important issues that face cardiologists in Germany. They misinterpret the facts and misrepresent the constructive approach taken by the GCS and its members towards quality assessment. *M Gottwik, G Breithardt *Klinikum Nürnberg Süd, Med Klinik 8, D90471 Nürnberg, Germany; and German Cardiac Society, D-40237 Düsseldorf, Germany (e-mail: [email protected]) 1
2
3
4
5
Dissmann W, de Ridder M. The soft science of German cardiology. Lancet 2002; 359: 2027–29. Hilborne LH, Leape LL, Bernstein SJ, et al. The appropriateness of use of percutaneous transluminal coronary angioplasty in New York State. JAMA 1993; 6: 761–65. Brook RH, Kosecoff JB, Park RE, et al. Diagnosis and treatment of coronary disease: comparison of doctors’ attitudes in the USA and the UK. Lancet 1988; 1: 750–53. Hemingway H, Crook AM, Feder G, et al. Underuse of coronary revascularization procedures in patients considered appropriate candidates for revascularization. N Engl J Med 2001; 344: 645–54. Boersma H, Doornbos G, Bloemberg BPM, et al. Cardiovascular diseases in Europe. European registries of cardiovascular diseases and patient management. Sophia Antipolis, France: European Society of Cardiology, 1999.
Author’s reply Sir—I am unable to answer to the question raised by S E Baldeweg, because there are insufficient data to assess the effect of interventional cardiology on morbidity and mortality in patients with coronary heart disease in Germany. One striking finding is that case fatality rates of patients with myocardial infarction are increasing slightly in Germany. In view of the high rates of invasive procedures in Germany, one would have expected a decline in case fatality.1 In reply to the comments made by M Gottwik and G Breithardt, I maintain that the German Health Experts’ Council was seriously misled by the GCS; this contention is based on the Bruckenberger report2 and a report published by the GCS itself.3 In January, 2000, 8 months before delivering its report to the Council, the GCS listed 515 510 diagnostic coronary angiographies for 1998, which corresponds to 6·286 procedures per million inhabitants. This figure differs only slightly from that of
THE LANCET • Vol 360 • November 23, 2002 • www.thelancet.com
Bruckenberger (6·441 procedures per million inhabitants in 1998), but sharply from that the GCS delivered to the Council (3·900 procedures per million inhabitants). With respect to the PTCA registry, we made it clear that “86 general hospitals” (“Allgemeine Krankenhäuser”) took part in the registry. The three university hospitals out of a total of 36 in Germany that joined the registry are negligible. Curiously, M Gottwik and G Breithardt seem to expect other countries in Europe to “catch up” with Germany’s flawed practice of cardiology. Should other countries adopt the common practice in Germany of coronary angiography without an unequivocal indication? Should they follow the German example to undertake PTCA in more than 50% of all cases in patients with chronic stable angina? A new balance between the limited effects of costly interventional cardiology (which is in fact palliative treatment) and more causal treatment approaches of coronary heart disease are urgently needed in Germany. There is much evidence that arrest and reversal therapy of coronary heart disease is effective and that changes in lifestyle can stop progression of the disease. Many German cardiologists do not seem to believe that prevention is an important part of their work. However, this attitude is untenable today, as C Mensah and colleagues assert: “There is no question that among other duties and responsibilities cardiologists should serve as champions of prevention”.4 But German cardiologists prefer to drive the train in aggressive cardiac interventions; between 1998–2001 there was an increase of 15% in coronary angiographies and 33% in angioplasties.2 E Erdmann, the forthcoming president of the annual general meeting of the GCS in 2003, has criticised German cardiologists, and physicians in general, because they do not conform with established guidelines: “An autistic and undisciplined therapeutic medical attitude is to the debit of our patients”.5 I hope that Erdmann will seize the opportunity to discuss the consequences of his statement at the forthcoming meeting of the GCS. Michael de Ridder Klinikum Am Urban, 10967 Berlin, Germany (e-mail: [email protected]) 1
Tunstall-Pedoe H, Kuulasmaa K, Mähönen M, et al. Contribution of trends in survival and coronary-event rates to changes in coronary heart disease mortality: 10-year results from 37 WHO MONICA
1695
For personal use. Only reproduce with permission from The Lancet Publishing Group.