- Email: [email protected]
PACEMAKERS: THE LONG-TERM COST
88 standards of general education, disproportionate amounts of medical manpower are located. It has been shown that persons with a little training can care for a wide range of diseases. For example, diabetics can monitor their insulin requirements, parents can administer antihaemophilic factor to their afflicted children, and hypertensives can take their blood-pressure and regulate their medication
satisfactorily. Various methods suggest themselves to further facilitate self
help: (1) Safe drugs with clear instructions could become widely available via slot-machines (e.g., contraceptive pills). (2) Adult education and secondary-school courses in self-care could be established. Such courses could be an extension of the common first-aid course with additional attention to the prevention, recognition, and treatment of common illnesses. On passing the course the
graduate should have access to simple pathology tests (e.g. Papanicolaou smear) and drugs such as penicillin or oral contraceptives. It might be hoped that the general practitioner would be at the centre of any teaching programme and that both he and the health authorities would see this as a stimulating new way to provide primary and personal care. Department of Community Medicine, University of Papua New Guinea, Kainantu, E.H.P.,
PACEMAKERS: THE LONG-TERM COST
SiR,—There has been considerable discussion of the
cost
of
implanted pacemakers, and of whether the Health Service can sustain the cost of units incorporating the improved lithium/
battery.!
It is difficult
SIR,--Griffith Edwards’ article’ is a most significant and important communication. Nevertheless, the situation throughout the country is not quite as hopeless as it may seem from his communication. In the area in which I work, Buckinghamshire, the "four wise men" have functioned for many years. Problems which have arisen have been dealt with in a most sympathetic fashion, based on the premises that the doctor himself needs help and that the patient needs protection, and that such help and protection should emanate from medical sources rather than administrative or legal ones. I feel sure that there are other "wise men" who function in a similar capacity in other areas, though I know of one instance of an alcoholic problem where hospital doctors did not function in the interests of both the profession and the patients, and were said to have stuck together and "protected" a very disabled colleague for many years. St
John’s Hospital, Stone,
Aylesbury, Bucks HP17 8PP.
to see
how the
proposed
recent
expenditure by the Government2 on isotopic (238PU) pacemakers can be justified, at a time when the need for this radioactive energy source is being reduced by the increasing production of long-life lithium-powered pacemakers, which pose no environmental pollution problems. Any realistic assessment of the cost to the Health Service of these improved units must take into consideration the cost of surgical implantation and the further cost of reimplantation at intervals as widely different as three years and ten years. The cost to the Health Service of one patient pacing for unit time is the figure of importance, and a comparison of this figure, calculated for the four main short and long term energy sources now available, confirms that the lithium-powered unit is the most economic. The estimated implantation cost of ,E400 is modest by other standards.3 COST PER PACING PATIENT WEEK OF PACEMAKERS POWERED BY SEVERAL
IRVING SHRIBMAN
ISOCALORIC DIETS AND SLEEP
B. HOCKING
P.N.G.
iodine
THE ALCOHOLIC DOCTOR
SiR,—Iwas interested to read the paper by Miss Phillips and others (Oct. 18, p. 723) reporting the effect that changes in the composition of isocaloric diets had on sleep patterns. A relation between nutrition and sleep is emerging as more research is undertaken. However, the claimed correlation between carbohydrate content of the diet and the amount of slow-wave-sleep (s.w.s.) and rapid-eye-movement (R.E.M.) sleep are reduced in credibility by the unbalanced design. Statistical tests cannot overcome adaptation effects. Hence the comparisons made between the normal diet and either of the experimental diets are of diminished value. In the experiment subjects attended the sleep laboratory on four consecutive nights, the first serving for adaptation and the second as the night recorded after the "normal" diet. It is usual for subjects to sleep relatively badly on their first night at the sleep laboratory, and the following night is often also atypical. Thus, only the comparisons made between the two experimental diets have any validity, but here the statistical significance of these findings is also in doubt. This doubt arises from table n where the value of N = 16 was quoted when only eight subjects were recorded. It would be helpful if the St. George’s workers would tell us the results of recalculations based on N=8.
ENERGY SOURCES
Sleep Laborator , University Department of Psychiatry, Edinburgh EH10 5HF
*
*
____________’I
I
I
I
I
The accompanying table shows that the mercury/zinc powered unit is the most expensive, and, at a time when the utmost economies are being urged upon us, there would seem to be little justification for its continued use. The fact that it remains the unit which the Health Service prefers to have implanted confirms a view I have earlier expressed4-that the concept of high initial purchase price which is offset by low annual servicing costs is not one which fits easily into the D.H.S.S. fiscal system. Department of Clinical Measurement, National Heart Hospital, London W1M 8BA. 1. 2.
Oxford Times, Nov. 14, 1975.
Times, Nov. 11, 1975. 3. Flood, M. New Scientist, Nov. 20, 1975. 4. Norman, J. Bio-engineeringin Britain, August, 1975.
JOHN NORMAN
KIRSTINE ADAM
* Miss Adam’s letter has been shown to the St workers, whose reply follows.-ED. L.
George’s
SIR,-We are aware of the problems of an unbalanced design. However, in our study we were mainly concerned with
comparing the two experimental diets (i.e.,
the
high-carbohyd-
rate/low-fat and the low-carbohydrate/high-fat isocaloric diets). Since temporal effects (i.e., periods, days, and their interactions) were not significant it seemed reasonable to compare the normal balanced diet with the two experimental diets Nevertheless, as stated in our paper, we would not deny the shortcomings in these comparisons. We have since done experiments which are better controlled in this respect, and these will be described elsewhere. N=16 in our table u refers to 16 observation nights on eight subjects. Since temporal effects were not significant we felt it was unnecessary to jam the table with figures for the two experimental nights, and we apologise for 1.
Edwards, G. Lancet, 1975, ii, 1297.
satisfactorily. Various methods suggest themselves to further facilitate self
help: (1) Safe drugs with clear instructions could become widely available via slot-machines (e.g., contraceptive pills). (2) Adult education and secondary-school courses in self-care could be established. Such courses could be an extension of the common first-aid course with additional attention to the prevention, recognition, and treatment of common illnesses. On passing the course the
graduate should have access to simple pathology tests (e.g. Papanicolaou smear) and drugs such as penicillin or oral contraceptives. It might be hoped that the general practitioner would be at the centre of any teaching programme and that both he and the health authorities would see this as a stimulating new way to provide primary and personal care. Department of Community Medicine, University of Papua New Guinea, Kainantu, E.H.P.,
PACEMAKERS: THE LONG-TERM COST
SiR,—There has been considerable discussion of the
cost
of
implanted pacemakers, and of whether the Health Service can sustain the cost of units incorporating the improved lithium/
battery.!
It is difficult
SIR,--Griffith Edwards’ article’ is a most significant and important communication. Nevertheless, the situation throughout the country is not quite as hopeless as it may seem from his communication. In the area in which I work, Buckinghamshire, the "four wise men" have functioned for many years. Problems which have arisen have been dealt with in a most sympathetic fashion, based on the premises that the doctor himself needs help and that the patient needs protection, and that such help and protection should emanate from medical sources rather than administrative or legal ones. I feel sure that there are other "wise men" who function in a similar capacity in other areas, though I know of one instance of an alcoholic problem where hospital doctors did not function in the interests of both the profession and the patients, and were said to have stuck together and "protected" a very disabled colleague for many years. St
John’s Hospital, Stone,
Aylesbury, Bucks HP17 8PP.
to see
how the
proposed
recent
expenditure by the Government2 on isotopic (238PU) pacemakers can be justified, at a time when the need for this radioactive energy source is being reduced by the increasing production of long-life lithium-powered pacemakers, which pose no environmental pollution problems. Any realistic assessment of the cost to the Health Service of these improved units must take into consideration the cost of surgical implantation and the further cost of reimplantation at intervals as widely different as three years and ten years. The cost to the Health Service of one patient pacing for unit time is the figure of importance, and a comparison of this figure, calculated for the four main short and long term energy sources now available, confirms that the lithium-powered unit is the most economic. The estimated implantation cost of ,E400 is modest by other standards.3 COST PER PACING PATIENT WEEK OF PACEMAKERS POWERED BY SEVERAL
IRVING SHRIBMAN
ISOCALORIC DIETS AND SLEEP
B. HOCKING
P.N.G.
iodine
THE ALCOHOLIC DOCTOR
SiR,—Iwas interested to read the paper by Miss Phillips and others (Oct. 18, p. 723) reporting the effect that changes in the composition of isocaloric diets had on sleep patterns. A relation between nutrition and sleep is emerging as more research is undertaken. However, the claimed correlation between carbohydrate content of the diet and the amount of slow-wave-sleep (s.w.s.) and rapid-eye-movement (R.E.M.) sleep are reduced in credibility by the unbalanced design. Statistical tests cannot overcome adaptation effects. Hence the comparisons made between the normal diet and either of the experimental diets are of diminished value. In the experiment subjects attended the sleep laboratory on four consecutive nights, the first serving for adaptation and the second as the night recorded after the "normal" diet. It is usual for subjects to sleep relatively badly on their first night at the sleep laboratory, and the following night is often also atypical. Thus, only the comparisons made between the two experimental diets have any validity, but here the statistical significance of these findings is also in doubt. This doubt arises from table n where the value of N = 16 was quoted when only eight subjects were recorded. It would be helpful if the St. George’s workers would tell us the results of recalculations based on N=8.
ENERGY SOURCES
Sleep Laborator , University Department of Psychiatry, Edinburgh EH10 5HF
*
*
____________’I
I
I
I
I
The accompanying table shows that the mercury/zinc powered unit is the most expensive, and, at a time when the utmost economies are being urged upon us, there would seem to be little justification for its continued use. The fact that it remains the unit which the Health Service prefers to have implanted confirms a view I have earlier expressed4-that the concept of high initial purchase price which is offset by low annual servicing costs is not one which fits easily into the D.H.S.S. fiscal system. Department of Clinical Measurement, National Heart Hospital, London W1M 8BA. 1. 2.
Oxford Times, Nov. 14, 1975.
Times, Nov. 11, 1975. 3. Flood, M. New Scientist, Nov. 20, 1975. 4. Norman, J. Bio-engineeringin Britain, August, 1975.
JOHN NORMAN
KIRSTINE ADAM
* Miss Adam’s letter has been shown to the St workers, whose reply follows.-ED. L.
George’s
SIR,-We are aware of the problems of an unbalanced design. However, in our study we were mainly concerned with
comparing the two experimental diets (i.e.,
the
high-carbohyd-
rate/low-fat and the low-carbohydrate/high-fat isocaloric diets). Since temporal effects (i.e., periods, days, and their interactions) were not significant it seemed reasonable to compare the normal balanced diet with the two experimental diets Nevertheless, as stated in our paper, we would not deny the shortcomings in these comparisons. We have since done experiments which are better controlled in this respect, and these will be described elsewhere. N=16 in our table u refers to 16 observation nights on eight subjects. Since temporal effects were not significant we felt it was unnecessary to jam the table with figures for the two experimental nights, and we apologise for 1.
Edwards, G. Lancet, 1975, ii, 1297.