- Email: [email protected]
NECESSARY TESTS OR RITUAL DANCES?
990 NECESSARY TESTS OR RITUAL DANCES?
SIR,-Dr Middleton’s experience (Oct. 16, p. 877) of the HLAB27 tests that no-one really wanted represents the tip of a huge and very expensive iceberg, and we can offer three further examples. (1.) During a survey of the ritual performance of intravenous urography in patients presenting with acute retention,we found no instance in which the result of the test had influenced the patient’s management. When we scrutinised the reports of the radiographic findings it was clear that most of them had not impinged on the clinicians in charge of the patients, as judged by the case notes or the pattern of treatment. Indeed, in some of the rare instances in which serious renal abnormalities had been detected (hypernephroma, polycystic disease) the X-ray reports were still in their folders and no reference to these abnormalities could be found in the case notes. (2.) At the General Hospital, Nottingham, we routinely reported all the ECGs requested by non-medical wards. Suspecting that most surgical patients had been operated on before the ECG tracing and reports would have reached the wards, we wrote our reports on file cards for a trial period and sent the mounted but unreported ECGs back. On no occasion during this period was the ECG department asked why the report had been omitted and what it said. (3.) During his root-and-branch search of the early literature on sphygmomanometry and the emergence of hypertension as a disease, the late Sir George Pickering took out of the Radcliffe Science Library, Oxford, the only known copy of a book which had been widely cited by previous authors. He found that its pages were still uncut, and therefore unread. What we fear is that "process" is deemed more important than "outcome". If the house physician or surgeon can beat the ward round and can protect himself by answering "yes" to the question-"Have you done an IVU/ECG?" then everyone is happy and no-one seems to ask "What did it show?". Similarly, authors can demonstrate great scholarship by citing references which they have never read. If everyone ordered only those tests which actually affect patient management and cited those references which illuminate the area under discussion then patients, readers, and the national purse would be better off. Department of Medicine, University Hospital, Nottingham NG7 2UH
J. R. A. MITCHELL R. G. WILCOX
J. R. HAMPTON
DIALYSIS, CUTS, AND DISTRICT POLICY SIR,-There has lately been much discussion about the state of the National Health Service, concern about the level of service provided, and talk of runaway expenditure. The level of treatment for renal failure is one area of the N.H.S. much in the public eye, though it is no more important than other activities. An editorial in Nephron2 was highly critical of the level of treatment for renal failure provided by the N.H.S., echoing previous criticisms. 3,5 The. U.K., though in the forefront of the development of dialysis and transplantation, has provided a much lower level of treatment for patients with renal failure than most developed countries, and within the U.K. the West Midlands has treated fewer patients than have other regionsThe development of continuous ambulatory peritoneal dialysis (CAPD) has allowed us, and the hard-pressed nephrologists, to increase the number of patients being treated since the technique requires fewer physical facilities and fewer staff, long the favoured administrative constraints to expansion. We have taken the view that patients with renal failure who were judged to be medically suitable for treatment and who would die
r
without should be treated and that to withhold a successful treatment for a lethal condition for purely financial reasons was unethical. This policy has resulted in a written instruction from the Central Birmingham Health Authority forbidding the acceptance of RG, Mitchell JRA. Intravenous urography in the management of acute retention. Lancet 1977; i: 1247-49. Editorial. Over 50 and uraemic ° death. Nephron 1982; 3: 189. Editorial. Audit in renal failure: the wrong target? Br Med J 1981; 283: 261. Laing W. End-stage renal failure: OHE briefing. London: Office of Health Economics, 1980. Held PJ, Pauly MV, Smits HL. Treatment of end-stage renal disease. N Engl J Med 1981; 304: 355.
1 Wilcox
2. 3. 4. 5.
any further patients onto our CAPD programme because the budget allocated by the West Midlands Regional Health Authority was overspent. Since our haemodialysis facilities are physically and financially constrained this is an effective ban on the acceptance of new patients with- renal failure. The success of treatment programmes for renal failure is well documented; a 50% 10-yearsurvival rate compares very favourably with that for treatment for other lethal conditions. We recognise the impossible position of our local health authority faced with a statutory obligation to balance its budget, yet responsible for several major regional specialties that are not always properly funded. The needs of the other district activities have also to be considered. The unprecedented step taken by our district authority is serious, not only for the patients potentially denied lifesaving treatment but also for the N.H.S., and should not be accepted lightly. We will fully support our local health authority in its attempt to gain proper funding for these patients from the region and D.H.S.S. As doctors our main responsibility must lie in providing treatment for our patients; this we have now been forbidden to do. These patients would receive treatment in most other regions in the U.K. and in most other developed countries. A Health Service that denies life-saving treatment of proven success falls far short of the compassionate organisation we thought we had joined. If this is an example of "improved efficiency" in the N.H.S. we fear for the future ofaservice in which we firmly believe. Queen Elizabeth Hospital, Birmingham B15 2TH
JONATHAN MICHAEL D. ADU
COST EFFECTIVENESS OF CIMETIDINE
SIR,-Cimetidine may be cost-effective in reducing hospital admissions for peptic ulcer, as Mr Bulthuis and Mr Laing (Oct. 9, p. 828) observe. However, this does not resolve all the questions that arise from the penetration of this or other new techniques into the National Health Service. The heterogeneity of the case-mix in N.H.S. hospitals means that a given single diagnostic group often uses only small quantities of each of the many different types of staff and other resources of the hospital. A new treatment may change the demands made on the resources, freeing small quantities of some, while putting others under greater pressure. In the case of cimetidine, pressure shifts from staff, beds, and theatre time to hospital or family practitioner committee pharmaceutical budgets. But it may not be possible to shift resources accordingly. Medical and other staff cannot have a few hours a week cut from their work, and much of the cost of wards and theatres will be unaffected by small amounts of disuse. More plausibly, surgical resources released by cimetidine will be redeployed to treat other cases. The benefit of the drug is this extension of treatment, together with its benefits to ulcer patients. But the cost of achieving it will typically require an increase in total spending. If this increase cannot be found, then either the drug budget or the hospital budget must be constrained, potentially in ways unconnected with ulcer treatment. None of this is to deny the possible benefits of cimetidine to patients. Rather, my concern is to emphasise that appraisals of alternative treatment regimens may need to adopt a wider focus if they are to take adequate account of the current reality of the N.H.S. In some extreme cases-e.g., where the drug costs of keeping a patient out of the hospital are less than the marginal cost in drugs, meals, or linen of his admission-this will be unnecessary. However, in many others, the focus for an appraisal may need to be an entire ward or an entire firm’s activities. Each of these represents a discrete unit of the hospital’s resources which could (in principle) be transferred to another use in time. But typically such units deal with heterogeneous cases and so cannot be properly evaluated by research studies focused onto a single condition and age-group. In consequence, changes in techniques, instead of being met by a redeployment of resources, merely generate additional pressure on one or another part of the system. The difficulties outlined may be less likely to arise in the particular case of cimetidine, for instance, if any costs can be met by family practitioner committees without financial crisis. However,
SIR,-Dr Middleton’s experience (Oct. 16, p. 877) of the HLAB27 tests that no-one really wanted represents the tip of a huge and very expensive iceberg, and we can offer three further examples. (1.) During a survey of the ritual performance of intravenous urography in patients presenting with acute retention,we found no instance in which the result of the test had influenced the patient’s management. When we scrutinised the reports of the radiographic findings it was clear that most of them had not impinged on the clinicians in charge of the patients, as judged by the case notes or the pattern of treatment. Indeed, in some of the rare instances in which serious renal abnormalities had been detected (hypernephroma, polycystic disease) the X-ray reports were still in their folders and no reference to these abnormalities could be found in the case notes. (2.) At the General Hospital, Nottingham, we routinely reported all the ECGs requested by non-medical wards. Suspecting that most surgical patients had been operated on before the ECG tracing and reports would have reached the wards, we wrote our reports on file cards for a trial period and sent the mounted but unreported ECGs back. On no occasion during this period was the ECG department asked why the report had been omitted and what it said. (3.) During his root-and-branch search of the early literature on sphygmomanometry and the emergence of hypertension as a disease, the late Sir George Pickering took out of the Radcliffe Science Library, Oxford, the only known copy of a book which had been widely cited by previous authors. He found that its pages were still uncut, and therefore unread. What we fear is that "process" is deemed more important than "outcome". If the house physician or surgeon can beat the ward round and can protect himself by answering "yes" to the question-"Have you done an IVU/ECG?" then everyone is happy and no-one seems to ask "What did it show?". Similarly, authors can demonstrate great scholarship by citing references which they have never read. If everyone ordered only those tests which actually affect patient management and cited those references which illuminate the area under discussion then patients, readers, and the national purse would be better off. Department of Medicine, University Hospital, Nottingham NG7 2UH
J. R. A. MITCHELL R. G. WILCOX
J. R. HAMPTON
DIALYSIS, CUTS, AND DISTRICT POLICY SIR,-There has lately been much discussion about the state of the National Health Service, concern about the level of service provided, and talk of runaway expenditure. The level of treatment for renal failure is one area of the N.H.S. much in the public eye, though it is no more important than other activities. An editorial in Nephron2 was highly critical of the level of treatment for renal failure provided by the N.H.S., echoing previous criticisms. 3,5 The. U.K., though in the forefront of the development of dialysis and transplantation, has provided a much lower level of treatment for patients with renal failure than most developed countries, and within the U.K. the West Midlands has treated fewer patients than have other regionsThe development of continuous ambulatory peritoneal dialysis (CAPD) has allowed us, and the hard-pressed nephrologists, to increase the number of patients being treated since the technique requires fewer physical facilities and fewer staff, long the favoured administrative constraints to expansion. We have taken the view that patients with renal failure who were judged to be medically suitable for treatment and who would die
r
without should be treated and that to withhold a successful treatment for a lethal condition for purely financial reasons was unethical. This policy has resulted in a written instruction from the Central Birmingham Health Authority forbidding the acceptance of RG, Mitchell JRA. Intravenous urography in the management of acute retention. Lancet 1977; i: 1247-49. Editorial. Over 50 and uraemic ° death. Nephron 1982; 3: 189. Editorial. Audit in renal failure: the wrong target? Br Med J 1981; 283: 261. Laing W. End-stage renal failure: OHE briefing. London: Office of Health Economics, 1980. Held PJ, Pauly MV, Smits HL. Treatment of end-stage renal disease. N Engl J Med 1981; 304: 355.
1 Wilcox
2. 3. 4. 5.
any further patients onto our CAPD programme because the budget allocated by the West Midlands Regional Health Authority was overspent. Since our haemodialysis facilities are physically and financially constrained this is an effective ban on the acceptance of new patients with- renal failure. The success of treatment programmes for renal failure is well documented; a 50% 10-yearsurvival rate compares very favourably with that for treatment for other lethal conditions. We recognise the impossible position of our local health authority faced with a statutory obligation to balance its budget, yet responsible for several major regional specialties that are not always properly funded. The needs of the other district activities have also to be considered. The unprecedented step taken by our district authority is serious, not only for the patients potentially denied lifesaving treatment but also for the N.H.S., and should not be accepted lightly. We will fully support our local health authority in its attempt to gain proper funding for these patients from the region and D.H.S.S. As doctors our main responsibility must lie in providing treatment for our patients; this we have now been forbidden to do. These patients would receive treatment in most other regions in the U.K. and in most other developed countries. A Health Service that denies life-saving treatment of proven success falls far short of the compassionate organisation we thought we had joined. If this is an example of "improved efficiency" in the N.H.S. we fear for the future ofaservice in which we firmly believe. Queen Elizabeth Hospital, Birmingham B15 2TH
JONATHAN MICHAEL D. ADU
COST EFFECTIVENESS OF CIMETIDINE
SIR,-Cimetidine may be cost-effective in reducing hospital admissions for peptic ulcer, as Mr Bulthuis and Mr Laing (Oct. 9, p. 828) observe. However, this does not resolve all the questions that arise from the penetration of this or other new techniques into the National Health Service. The heterogeneity of the case-mix in N.H.S. hospitals means that a given single diagnostic group often uses only small quantities of each of the many different types of staff and other resources of the hospital. A new treatment may change the demands made on the resources, freeing small quantities of some, while putting others under greater pressure. In the case of cimetidine, pressure shifts from staff, beds, and theatre time to hospital or family practitioner committee pharmaceutical budgets. But it may not be possible to shift resources accordingly. Medical and other staff cannot have a few hours a week cut from their work, and much of the cost of wards and theatres will be unaffected by small amounts of disuse. More plausibly, surgical resources released by cimetidine will be redeployed to treat other cases. The benefit of the drug is this extension of treatment, together with its benefits to ulcer patients. But the cost of achieving it will typically require an increase in total spending. If this increase cannot be found, then either the drug budget or the hospital budget must be constrained, potentially in ways unconnected with ulcer treatment. None of this is to deny the possible benefits of cimetidine to patients. Rather, my concern is to emphasise that appraisals of alternative treatment regimens may need to adopt a wider focus if they are to take adequate account of the current reality of the N.H.S. In some extreme cases-e.g., where the drug costs of keeping a patient out of the hospital are less than the marginal cost in drugs, meals, or linen of his admission-this will be unnecessary. However, in many others, the focus for an appraisal may need to be an entire ward or an entire firm’s activities. Each of these represents a discrete unit of the hospital’s resources which could (in principle) be transferred to another use in time. But typically such units deal with heterogeneous cases and so cannot be properly evaluated by research studies focused onto a single condition and age-group. In consequence, changes in techniques, instead of being met by a redeployment of resources, merely generate additional pressure on one or another part of the system. The difficulties outlined may be less likely to arise in the particular case of cimetidine, for instance, if any costs can be met by family practitioner committees without financial crisis. However,