- Email: [email protected]
Reference health centres
1
Reference health centres SIR-In your June 19 editorial (p 1563) you attempt to dismiss an idea that has developed over many years and been tried in many places. Urban reference health centres will not be appropriate for all cities. The WHO report states clearly that their role "will depend on local circumstances and on a comprehensive situation analysis that takes into account social as well as financial factors and the level of organisational development". A 1990 international workshop held in Boston, USA, concluded that these centres represent a new paradigm in health care delivery to better meet community health needs. However, the success of these centres crucially depends on several factors. The centres need an adequate number of patients for efficient use, which can be a difficulty if existing hospitals are partly empty. In the Caribbean and Egypt, many hospitals have low occupancy rates and these sites would probably not provide enough patients to warrant building these centres. However, in sections of Jakarta, Karachi, and other cities, the population expands at more than 10% annually. These areas are far from existing hospitals and health centres, and inhabitants have a pressing need for services. Unless these reference health centres can be perceived as providing high quality services, the community will not attend them and will seek care in hospitals or the private sector. In Cali, Colombia, specialists from the university regularly provide services at the reference centres. In Cali these centres are located on the primary bus line, are open late, and the cost to the patient is deliberately less than in hospitals. Other possible incentive schemes could be local insurance schemes, or requiring a referral from these centres before receiving care at hospital. These centres are an integral part of the health system. They receive logistical support and clinical back-up from hospitals as well as referrals from and to the lower level health posts. A 24-hour ambulance service in Cali and in Mexico provides rapid transport for emergencies and records are carefully transferred up and down the system. In Newark, New Jersey, the private, non-profit Cathedral Health System closed one of its hospitals because it had too many beds. However, it reopened the facility as an ambulatory care hospital and a chronic nursing facility with close links to the system’s other hospital. This integrated system provides a broad range of services, from primary to tertiary to extended nursing home care.1 The centres must remain accountable to the people they serve to ensure that the community uses the facilities. To maintain efficient management, thorough, accurate information systems, careful manpower planning, and quality monitoring are needed. When used appropriately, these reference urban health centres can provide services at a reduced cost.2 They are well poised to take advantage of the enormous advances in knowledge that have allowed more health care to be provided in an outpatient setting. In the USA, because of these advances and strong incentives to use outpatient services, age-adjusted hospital admissions have declined 15 0,’o between 1985 and 1990. The savings in hospital services can be used for more primary health care. For example, in Puerto Rico, by transferring the responsibility for AIDS care to a private health foundation with community outpatient centres, the mean cost of inpatient care dropped from$15 118 per patient to$3869. The funds saved were used to support comprehensive outpatient, prevention, education, detection, and outreach services.3 Very little will be gained if we dismiss ideas without giving them a trial. Rather, developing countries need opportunities to envisage and try out innovations since that is the only path to progress in health systems with the limited resources available. Julia A Walsh Harvard School of Public Health, Boston, Massachusetts 02115, USA
372
2
3
J, Walsh JA. The role of Saint Mary’s Ambulatory Care Hospital in serving its urban population. Health Prog (in press). Shepard DS, Walsh J, Munar W, et al. Cost-effectiveness of ambulatory surgery in Cali, Colombia. Health Policy Plan 1993; 8: Warren
136-42. Kouri Y, Shepard DS, Borras F, Sotomayor J, Geller GA. Improving the cost-effectiveness of AIDS health care in San Juan, Puerto Rico. Lancet 1991; 337: 1397-99.
SiR-In your editorial on reference health centres you seem to have got hold of the wrong end of the stick. The WHO study group on the role of health centres in the development of urban health systems,’ to which I was the secretary, heard accounts of various elaborated health centre developments from differnt parts of the world including Malaysia, Latin America, Indonesia, and Africa. The report is not seeking to invent a new concept and promote it without any experience, but rather it has tried to bring together the lessons of these initiatives. Evidence so far suggests that reference health centres may indeed help to strengthen health services, especially by raising the credibility of primary health care and making good quality first level care more accessible. These centres may also reduce the pressure on acute hospitals. Contrary to your opinion the study group received numerous accounts of the inappropriate use and overuse of hospital facilities in different countries. Your statement that in effect reference health centres are indistinguishable from small district hospitals is inaccurate. In fact it seems that these centres are most effective when there is a deliberate policy of restricting stays to a maximum of 24 hours. The issue of financial support is important and you seem to overlook the fact that in countries whose populations are still growing there is inevitably going to be further capital development. What seems to be sensible is that an appropriate proportion of such development should go to ensure high quality primary care, and reference health centres provide one important option. However, the issue of redistribution of resources from secondary to primary care may still arise, not least in developed countries, and reports and reviews in large cities both in the UK and elsewhere indicate that reference health centres could be important in the reshaping of health services to enable them to fit contemporary rather than historic health needs. John Ashton Department of Public Health, University of Liverpool, PO Box 147, Liverpool L69 3BX, UK
1
Organisaton. The Role of Health Centres in the Development of Urban Health Systems. WHO Tech Rep Ser 827,
World Health 1992.
SIR-In your editorial you suggest that the creation of reference health centres is a "simplistic solution to the broader problems of management and resource allocation" of developing countries-this is far from the case. As far as we are aware, the 24-h primary care hospital was created in its modern form in Cali, Colombia. This experiment in health-care delivery evolved over a 15-year period. Today, Cali, a city of 1 ’5 million people, is served by only two tertiary hospitals, four strategically-placed 24-h hospitals (secondary level), and a broad network of primary health care centres. There is efficient referral up and down this network. This may be one of the most efficient urban health care systems in the world. Early studies have shown that selected surgical procedures were demonstrably less expensive in 24-h hospitals than the same procedures done at the tertiary level. Complications were correspondingly fewer.24-h refers to the average duration of stay, not to the hours during which service is available. Nevertheless, reference health centres, as envisaged by the WHO report, are designed to provide 24-h health care services.
It is a fact that urban populations are growing world wide. And, as noted in the 1993 World Development Report,2 global ageing trends presage illnesses that will increasingly burden hospital facilities. Reference health centres are proposed as a cost-effective measure to respond to unmet needs, to relieve strained tertiary hospitals, yet provide quality, low-cost health care. The model is by no means relevant only to poorer countries. When examined more carefully, health planners will see that this elephant does indeed have all the appropriate colours.
also noteworthy that a priori testing is not without its pitfalls, and several alternative procedures exist that will produce different results. That there is controversy among professional statisticians themselves over the correct strategy in the face of these difficulties, militates against the simple approach to statistics we were all taught at medical school. It has always puzzled me that we are prepared to devote so much energy to obsessionally collecting the data, and yet spend so little time actually understanding it.
Scott B Halstead, Robert S Lawrence
Rajendra Persaud
Health Sciences Division, Rockefeller Foundation, 1133 Avenue of the Americas, New York, NY 10036, USA
Institute of
wholly agree with all Jolley’s sentiments significance of results and their clear, simple, graphical expression, I am a little doubtful about his conversion of the data shown in figure 1 (business graphic) to those in figure 2 (scientific graphic). Never, past, and current smoking SIR—Although
1 Shepard DS, Walsh J, Munar W, et al. Cost-effectiveness of ambulatory surgery in Cali, Colombia. Health Policy Plan 1993; 8: Investing in Health. World Development Report, Oxford University Press, 1993.
I
about statistical
136-42. 2
Psychiatry, Denmark Hill, London SE5 8AF, UK
1993. New York:
represent a discontinuous state and not a continuous spectrum. Points on a line graph derived from experiment surely imply intermediate, interpolated values. Should not line plots be restricted to continuous variables? Would not a tidy, fairly simple, but mathematically more correct, graphic be a straightforward bar chart in two dimensions with 3 x3 columns and different shading (sic) for the various countries or smoking histories?
status
Statistics: the glitter of the t table SIR- The Lancet is
to
be commended in its attempts
to
highlight the role of medical statistics in clinical research and publication through its series, "Facts, figures and fallacies". The example cited by Jolley (July 3, p 27) of a paper by Hirschowitz et aP runs directly contrary to your editorial view (July 3, p 2). This paper was rejected with the following explanation, "the statistical analysis of the data is inadequate detection of high-grade dyskaryosis is confounded by the duration of follow-up which varies greatly between patients. Therefore ’survival analysis’ techniques should be used...". Not able to carry out the required analysis for themselves, the authors asked for and received my help with Kaplan-Meier and log rank tests; we needed to do this to achieve publication-not because we lacked the ability to know that 0-7% of 437 is different from 22-4%of 437. Bradford Hill exhorted common sense; Jolley likewise; but when will the statistical purists who referee for the leading medical journals accept that there is not always the necessity for absolute rigour, and although authors "could do better" (with help), it is often not necessary and, indeed, can be confusing to a non-statistical readership. ...
A O Hughes Department of Epidemiology and
Public Health Medicine,
University of Bristol,
Bristol BS8 1TH, UK
1 Hirschowitz L, Raffle AE, Mackenzie EFD, Hughes AO. Long term follow up of women with borderline cervical smear test results: effects of age and viral infection on progression to high grade dyskaryosis.
BMJ 1992; 304:
1209-12.
Malcolm Griffiths Department of Obstetrics and Gynaecology, Royal
Berkshire
Hospital, Reading,
Berkshire RG1 5AN, UK
Benzodiazepine use in Sweden SiR-As in most other western countries, psychotropic drugs in general and benzodiazepines in particular have become a subject of concern in Sweden.1 Benzodiazepine use increases with age (two-thirds of the use is in those aged 60 +) and is among women. Hypnotic benzodiazepines account for two-thirds of the total use. The use of anxiolytic and hypnotic benzodiazepines has decreased in all age groups since 1986 (fewer prescriptions and smaller amounts, especially for the anxiolytics).’ The sale of benzodiazepines in Sweden is now the lowest among the Nordic countries2 and probably among all western countries,3 which is intriguing because Sweden has the highest proportion of elderly (18% aged 65+) among the Nordic countries. The Swedish pattern of use contrasts with most reports on benzodiazepine dependence and withdrawal events because these complaints come from the young and middle-aged.’ We analysed all 46 claims for compensation submitted to the Swedish Pharmaceutical Insurance. We compared anonymous data on age/sex and drugs and diagnosis
commoner
SiR-Although Jolly raises a timely warning of how dangerous powerful software packages become in the hands of researchers in the quest for significance, I think that his criticisms of post hoc statistical tests are unreasonably severe. He argues that dredging data for significant p values "fits targets to holes" and it is inescapably true that a priori, post-hoc, and multiple comparison procedures will have a striking effect on type I error rates. However, statistical means
new
do exist that take into
account
the effect
on
likelihood of null
hypothesis rejection. Used appropriately, therefore, they legitimately allow post-hoc and multiple comparisons, ensuring an equivalent type I error as if an a priori approach had been taken. These methods include Fisher’s least significant difference test, Tukey’s honestly significant difference test, as well
as
Newman-Keuls’, Scheffe’, and Dunnett’s
tests.
It is
’Decreased libido, personality disorder, sleep disorder, neuropathy, muscle weakness, vertigo, xerostomia, taste alteration, mcreased caries:1 of each
Table: Patients’ characteristics
373
Reference health centres SIR-In your June 19 editorial (p 1563) you attempt to dismiss an idea that has developed over many years and been tried in many places. Urban reference health centres will not be appropriate for all cities. The WHO report states clearly that their role "will depend on local circumstances and on a comprehensive situation analysis that takes into account social as well as financial factors and the level of organisational development". A 1990 international workshop held in Boston, USA, concluded that these centres represent a new paradigm in health care delivery to better meet community health needs. However, the success of these centres crucially depends on several factors. The centres need an adequate number of patients for efficient use, which can be a difficulty if existing hospitals are partly empty. In the Caribbean and Egypt, many hospitals have low occupancy rates and these sites would probably not provide enough patients to warrant building these centres. However, in sections of Jakarta, Karachi, and other cities, the population expands at more than 10% annually. These areas are far from existing hospitals and health centres, and inhabitants have a pressing need for services. Unless these reference health centres can be perceived as providing high quality services, the community will not attend them and will seek care in hospitals or the private sector. In Cali, Colombia, specialists from the university regularly provide services at the reference centres. In Cali these centres are located on the primary bus line, are open late, and the cost to the patient is deliberately less than in hospitals. Other possible incentive schemes could be local insurance schemes, or requiring a referral from these centres before receiving care at hospital. These centres are an integral part of the health system. They receive logistical support and clinical back-up from hospitals as well as referrals from and to the lower level health posts. A 24-hour ambulance service in Cali and in Mexico provides rapid transport for emergencies and records are carefully transferred up and down the system. In Newark, New Jersey, the private, non-profit Cathedral Health System closed one of its hospitals because it had too many beds. However, it reopened the facility as an ambulatory care hospital and a chronic nursing facility with close links to the system’s other hospital. This integrated system provides a broad range of services, from primary to tertiary to extended nursing home care.1 The centres must remain accountable to the people they serve to ensure that the community uses the facilities. To maintain efficient management, thorough, accurate information systems, careful manpower planning, and quality monitoring are needed. When used appropriately, these reference urban health centres can provide services at a reduced cost.2 They are well poised to take advantage of the enormous advances in knowledge that have allowed more health care to be provided in an outpatient setting. In the USA, because of these advances and strong incentives to use outpatient services, age-adjusted hospital admissions have declined 15 0,’o between 1985 and 1990. The savings in hospital services can be used for more primary health care. For example, in Puerto Rico, by transferring the responsibility for AIDS care to a private health foundation with community outpatient centres, the mean cost of inpatient care dropped from$15 118 per patient to$3869. The funds saved were used to support comprehensive outpatient, prevention, education, detection, and outreach services.3 Very little will be gained if we dismiss ideas without giving them a trial. Rather, developing countries need opportunities to envisage and try out innovations since that is the only path to progress in health systems with the limited resources available. Julia A Walsh Harvard School of Public Health, Boston, Massachusetts 02115, USA
372
2
3
J, Walsh JA. The role of Saint Mary’s Ambulatory Care Hospital in serving its urban population. Health Prog (in press). Shepard DS, Walsh J, Munar W, et al. Cost-effectiveness of ambulatory surgery in Cali, Colombia. Health Policy Plan 1993; 8: Warren
136-42. Kouri Y, Shepard DS, Borras F, Sotomayor J, Geller GA. Improving the cost-effectiveness of AIDS health care in San Juan, Puerto Rico. Lancet 1991; 337: 1397-99.
SiR-In your editorial on reference health centres you seem to have got hold of the wrong end of the stick. The WHO study group on the role of health centres in the development of urban health systems,’ to which I was the secretary, heard accounts of various elaborated health centre developments from differnt parts of the world including Malaysia, Latin America, Indonesia, and Africa. The report is not seeking to invent a new concept and promote it without any experience, but rather it has tried to bring together the lessons of these initiatives. Evidence so far suggests that reference health centres may indeed help to strengthen health services, especially by raising the credibility of primary health care and making good quality first level care more accessible. These centres may also reduce the pressure on acute hospitals. Contrary to your opinion the study group received numerous accounts of the inappropriate use and overuse of hospital facilities in different countries. Your statement that in effect reference health centres are indistinguishable from small district hospitals is inaccurate. In fact it seems that these centres are most effective when there is a deliberate policy of restricting stays to a maximum of 24 hours. The issue of financial support is important and you seem to overlook the fact that in countries whose populations are still growing there is inevitably going to be further capital development. What seems to be sensible is that an appropriate proportion of such development should go to ensure high quality primary care, and reference health centres provide one important option. However, the issue of redistribution of resources from secondary to primary care may still arise, not least in developed countries, and reports and reviews in large cities both in the UK and elsewhere indicate that reference health centres could be important in the reshaping of health services to enable them to fit contemporary rather than historic health needs. John Ashton Department of Public Health, University of Liverpool, PO Box 147, Liverpool L69 3BX, UK
1
Organisaton. The Role of Health Centres in the Development of Urban Health Systems. WHO Tech Rep Ser 827,
World Health 1992.
SIR-In your editorial you suggest that the creation of reference health centres is a "simplistic solution to the broader problems of management and resource allocation" of developing countries-this is far from the case. As far as we are aware, the 24-h primary care hospital was created in its modern form in Cali, Colombia. This experiment in health-care delivery evolved over a 15-year period. Today, Cali, a city of 1 ’5 million people, is served by only two tertiary hospitals, four strategically-placed 24-h hospitals (secondary level), and a broad network of primary health care centres. There is efficient referral up and down this network. This may be one of the most efficient urban health care systems in the world. Early studies have shown that selected surgical procedures were demonstrably less expensive in 24-h hospitals than the same procedures done at the tertiary level. Complications were correspondingly fewer.24-h refers to the average duration of stay, not to the hours during which service is available. Nevertheless, reference health centres, as envisaged by the WHO report, are designed to provide 24-h health care services.
It is a fact that urban populations are growing world wide. And, as noted in the 1993 World Development Report,2 global ageing trends presage illnesses that will increasingly burden hospital facilities. Reference health centres are proposed as a cost-effective measure to respond to unmet needs, to relieve strained tertiary hospitals, yet provide quality, low-cost health care. The model is by no means relevant only to poorer countries. When examined more carefully, health planners will see that this elephant does indeed have all the appropriate colours.
also noteworthy that a priori testing is not without its pitfalls, and several alternative procedures exist that will produce different results. That there is controversy among professional statisticians themselves over the correct strategy in the face of these difficulties, militates against the simple approach to statistics we were all taught at medical school. It has always puzzled me that we are prepared to devote so much energy to obsessionally collecting the data, and yet spend so little time actually understanding it.
Scott B Halstead, Robert S Lawrence
Rajendra Persaud
Health Sciences Division, Rockefeller Foundation, 1133 Avenue of the Americas, New York, NY 10036, USA
Institute of
wholly agree with all Jolley’s sentiments significance of results and their clear, simple, graphical expression, I am a little doubtful about his conversion of the data shown in figure 1 (business graphic) to those in figure 2 (scientific graphic). Never, past, and current smoking SIR—Although
1 Shepard DS, Walsh J, Munar W, et al. Cost-effectiveness of ambulatory surgery in Cali, Colombia. Health Policy Plan 1993; 8: Investing in Health. World Development Report, Oxford University Press, 1993.
I
about statistical
136-42. 2
Psychiatry, Denmark Hill, London SE5 8AF, UK
1993. New York:
represent a discontinuous state and not a continuous spectrum. Points on a line graph derived from experiment surely imply intermediate, interpolated values. Should not line plots be restricted to continuous variables? Would not a tidy, fairly simple, but mathematically more correct, graphic be a straightforward bar chart in two dimensions with 3 x3 columns and different shading (sic) for the various countries or smoking histories?
status
Statistics: the glitter of the t table SIR- The Lancet is
to
be commended in its attempts
to
highlight the role of medical statistics in clinical research and publication through its series, "Facts, figures and fallacies". The example cited by Jolley (July 3, p 27) of a paper by Hirschowitz et aP runs directly contrary to your editorial view (July 3, p 2). This paper was rejected with the following explanation, "the statistical analysis of the data is inadequate detection of high-grade dyskaryosis is confounded by the duration of follow-up which varies greatly between patients. Therefore ’survival analysis’ techniques should be used...". Not able to carry out the required analysis for themselves, the authors asked for and received my help with Kaplan-Meier and log rank tests; we needed to do this to achieve publication-not because we lacked the ability to know that 0-7% of 437 is different from 22-4%of 437. Bradford Hill exhorted common sense; Jolley likewise; but when will the statistical purists who referee for the leading medical journals accept that there is not always the necessity for absolute rigour, and although authors "could do better" (with help), it is often not necessary and, indeed, can be confusing to a non-statistical readership. ...
A O Hughes Department of Epidemiology and
Public Health Medicine,
University of Bristol,
Bristol BS8 1TH, UK
1 Hirschowitz L, Raffle AE, Mackenzie EFD, Hughes AO. Long term follow up of women with borderline cervical smear test results: effects of age and viral infection on progression to high grade dyskaryosis.
BMJ 1992; 304:
1209-12.
Malcolm Griffiths Department of Obstetrics and Gynaecology, Royal
Berkshire
Hospital, Reading,
Berkshire RG1 5AN, UK
Benzodiazepine use in Sweden SiR-As in most other western countries, psychotropic drugs in general and benzodiazepines in particular have become a subject of concern in Sweden.1 Benzodiazepine use increases with age (two-thirds of the use is in those aged 60 +) and is among women. Hypnotic benzodiazepines account for two-thirds of the total use. The use of anxiolytic and hypnotic benzodiazepines has decreased in all age groups since 1986 (fewer prescriptions and smaller amounts, especially for the anxiolytics).’ The sale of benzodiazepines in Sweden is now the lowest among the Nordic countries2 and probably among all western countries,3 which is intriguing because Sweden has the highest proportion of elderly (18% aged 65+) among the Nordic countries. The Swedish pattern of use contrasts with most reports on benzodiazepine dependence and withdrawal events because these complaints come from the young and middle-aged.’ We analysed all 46 claims for compensation submitted to the Swedish Pharmaceutical Insurance. We compared anonymous data on age/sex and drugs and diagnosis
commoner
SiR-Although Jolly raises a timely warning of how dangerous powerful software packages become in the hands of researchers in the quest for significance, I think that his criticisms of post hoc statistical tests are unreasonably severe. He argues that dredging data for significant p values "fits targets to holes" and it is inescapably true that a priori, post-hoc, and multiple comparison procedures will have a striking effect on type I error rates. However, statistical means
new
do exist that take into
account
the effect
on
likelihood of null
hypothesis rejection. Used appropriately, therefore, they legitimately allow post-hoc and multiple comparisons, ensuring an equivalent type I error as if an a priori approach had been taken. These methods include Fisher’s least significant difference test, Tukey’s honestly significant difference test, as well
as
Newman-Keuls’, Scheffe’, and Dunnett’s
tests.
It is
’Decreased libido, personality disorder, sleep disorder, neuropathy, muscle weakness, vertigo, xerostomia, taste alteration, mcreased caries:1 of each
Table: Patients’ characteristics
373