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Under supervision
Tubercle (1973), 54,247
LEADING
ARTCLE
‘UNDER SUPERVISION’ In England in 1971 more than 200,000 people were reported to be ‘under supervision’ at chest clinics for tuberculosis. During the same year about 11,000 new cases were notified. Thus for every new case there were approximately 20 others attending the clinics for various reasons* In addition to those being treated, the number includes, no doubt, many not notified as ‘tuberculous’, such as tuberculin-positive children and those with so-called ‘fibrotic lesions’ without bacteriological evidence of tuberculosis, as well as patients treated before chemotherapy was available. But there were probably many continuing to attend 6-monthly or yearly for many years after completing apparently effective chemotherapy. Is this necessary? There is good evidence that it is not. There have been several studies of relapse rates after prolonged chemotherapy. In Edinburgh’ and Birmingham2 the relapse rate was about 2 ‘A during five years. Springett3, with a longer observation period, estimated the annual rate to be only 1 in 1000 after the fifth anniversary. In Ontario4 the rate during the first 5 years was as low as 0.1%. Strict comparisons are, of course, unwarranted because, among other factors, of the different definitions of relapse. But it can be accepted that the rate after regular, prolonged chemotherapy of good quality is very low indeed. Further indirect evidence has recently been reported. In New Orleans5 between 1965 and 1972, 1585 cases of ‘active’ tuberculosis were registered : only 63 (4 %) were previously treated patients ; and only 7 (0.4%) of these had probably had 2 years chemotherapy acceptable as efficient by modern standards. Nine had been treated before isoniazid was available and 43 had stopped treatment prematurely. Among the 63, the relapse was detected by routine examination in only 40 per cent: in the remainder symptoms led to the patients seeking medical help. In New York City6 during 1970, 476 patients were reported to have ‘reactivated’ tuberculosis. From data obtained during a similar survey in 1967’ it was estimated that less than half of these were, in fact, ‘confirmed reactivations’. Only about 35 per cent were detected through symptoms (about 40 per cent), or routine examination on admission to hospital for other diseases or at necropsy. During the year about 13,000 patients were ‘under supervision’; so the yield of relapses was only O-6 per cent. Among the patients in whom the relapse was discovered by routine ‘supervision’ half had had inadequate chemotherapy. In only 6 per cent were there no factors, such as insufficient treatment, poor co-operation and alcoholism that might have increased the risk of relapse and justified continued observation. The yield from routine follow-up of patients without such factors was therefore considerably less than 0.6 per cent. The authors suggest that such a small proportion does not justify the work involved and that patients ‘should be discharged from supervision when a course of adequate treatment has been completed’. This seems sensible: but such a radical departure from tradition may not be acceptable to many. The old concept of ‘supervision’ in tuberculosis implied much more than looking for radiographic. changes. Advice was given about hours of work and rest, marriage, child-bearing, accommodation and almost every major facet of life. It was accepted that tuberculosis could never be considered ‘cured’ ; the patient must be taught to adjust his life to the restrictions imposed by his lung disease. And he must be frequently reminded of this. Hence the frequent visits to the clinic over many years. With effective chemotherapy such ‘supervision’ is no longer necessary. The patients should have been leading normal lives throughout most or all of their treatment. They should continue to do so. Their activities do not need to be ‘supervised’. Thus the only reason for continuing to examine patients after treatment has finished is to detect relapse before symptoms appear, and hence before they become infectious. This is not ‘supervision’ but ‘observation’. Whether it is profitable depends
248
LEADING
ARTICLt
solely on the yield of relapses. Relapse is rare. Moreover, at least a third of those that do occur will not be detected by ‘observation’ but by symptoms developing during the interval between examinations. If there were no shortage of medical, nursing, technical and clerical staff for all the requirements of a health service, routine ‘observation’ could be done without detriment to other tasks. But there seldom is. The more time spent on ‘routine observation’ the less can be given to the much more important work of treating patients. Better ‘supervision’ of treatment would lead to less need for ‘observation’ later. However, even if long-continued ‘observation’ were administratively acceptable, it could still be psychologically harmful for the patients. Many, after 13 to 2 years of attending clinics, would be delighted to be told that they were no longer ‘patients’ and need not attend again; that they were healthy people who need not be ‘observed’ or their lives ‘supervised’. In a recently published memorandum from the Department of Health and Social SecurityX it is recommended that ‘patients should normally be followed up for 18-24 months after completion of drug therapy’. It is doubtful whether this is necessary or desirable. It is more rational, in view of all the evidence, that such follow-up should be ‘abnormal’ rather than ‘normal’. In other words that ‘observation’ to detect relapse should be restricted to those most likely to relapse - such as patients who have had less than 18 months chemotherapy, or are known or suspected to have taken drugs irregularly. For the ‘normal’ patient who appears to have co-operated and taken the drugs as regularly as one can expect any ‘normal’ person to have done for the prescribed period, even 14 to 2 years ‘observation’ seems unrewarding. The physician should assess each patient individually and record the reason why, at the end of treatment, he thinks it necessary to impose on the patient the burden of being ‘observed’. To stop ‘routine observation’ of adequately treated patients will reduce the number of people attending out-patient clinics. It might reduce the number of clinics required and hence the number of staff employed for this particular purpose. Unless there are other worthwhile activities for physicians to turn their attention to, there is little incentive for them to break with tradition and stop ‘observing’ healthy people by yearly chest x-rays. It is not only in tuberculosis that the practice of ‘routine observation’ should be critically examined. There is probably considerable waste of effort and patient’s time in many other diseases as well. There is sometimes less mental effort and responsibility required to ‘continue under observation’ than to ‘discharge’. REFERENCES ‘HORNE, N. W. (1966). Chronic pulmonary tuberculosis: present problems. Bulletin of the International Union against Tuberculosis, 37,172. 2T~o~.~, H. E. (1965). Five-year assessment of sputum positive pulmonary tuberculosis notified in Birmingham in 1957-58. Tubercle, 46,352. %PRINGETT,V. H. (1971). Ten-year results during the introduction of chemotherapy for tuberculosis. Tubercfe, 52,73 4G~~~~~~~~, S., MCKINNON,V., TUTERS, L., PINKUS, G., & Phillips, R. (1966). Reactivation in inactive pulmonary tuberculosis. American Review of Respiratory Disease, 93,352. 6B~~~~~, W. C., THOMPSON,D. H., JACOBS, S., ZISKIND, M. & GREENBERG,H. B. (1973). Evaluating the need for periodic recall and re-examination of patients with inactive pulmonary tuberculosis. American Review of Respiratory Disease, 107,854. pE~~~~~, J. & COLLINS, G. (1973). Routine follow-up of inactive tuberculosis, a practice to be abandoned. American Review of Respiratory Disease, 107,851. ‘EDSALL, J., COLLINS,J. &GRAY, J. A. C. (1970). The reactivation of tuberculosis in New York City in 1967. American Review of Respiratory Disease, 102.725. *DEPARTMENTOF HEALTH AND SOCIAL SECURITY (1973). Standing Medical Advisory Committee. Tuberculosis: epidemiology and control.
PRINTED
BY HOLMES
MCDOUGALL
LIMITED.
PERTH,
SCOTLAND
LEADING
ARTCLE
‘UNDER SUPERVISION’ In England in 1971 more than 200,000 people were reported to be ‘under supervision’ at chest clinics for tuberculosis. During the same year about 11,000 new cases were notified. Thus for every new case there were approximately 20 others attending the clinics for various reasons* In addition to those being treated, the number includes, no doubt, many not notified as ‘tuberculous’, such as tuberculin-positive children and those with so-called ‘fibrotic lesions’ without bacteriological evidence of tuberculosis, as well as patients treated before chemotherapy was available. But there were probably many continuing to attend 6-monthly or yearly for many years after completing apparently effective chemotherapy. Is this necessary? There is good evidence that it is not. There have been several studies of relapse rates after prolonged chemotherapy. In Edinburgh’ and Birmingham2 the relapse rate was about 2 ‘A during five years. Springett3, with a longer observation period, estimated the annual rate to be only 1 in 1000 after the fifth anniversary. In Ontario4 the rate during the first 5 years was as low as 0.1%. Strict comparisons are, of course, unwarranted because, among other factors, of the different definitions of relapse. But it can be accepted that the rate after regular, prolonged chemotherapy of good quality is very low indeed. Further indirect evidence has recently been reported. In New Orleans5 between 1965 and 1972, 1585 cases of ‘active’ tuberculosis were registered : only 63 (4 %) were previously treated patients ; and only 7 (0.4%) of these had probably had 2 years chemotherapy acceptable as efficient by modern standards. Nine had been treated before isoniazid was available and 43 had stopped treatment prematurely. Among the 63, the relapse was detected by routine examination in only 40 per cent: in the remainder symptoms led to the patients seeking medical help. In New York City6 during 1970, 476 patients were reported to have ‘reactivated’ tuberculosis. From data obtained during a similar survey in 1967’ it was estimated that less than half of these were, in fact, ‘confirmed reactivations’. Only about 35 per cent were detected through symptoms (about 40 per cent), or routine examination on admission to hospital for other diseases or at necropsy. During the year about 13,000 patients were ‘under supervision’; so the yield of relapses was only O-6 per cent. Among the patients in whom the relapse was discovered by routine ‘supervision’ half had had inadequate chemotherapy. In only 6 per cent were there no factors, such as insufficient treatment, poor co-operation and alcoholism that might have increased the risk of relapse and justified continued observation. The yield from routine follow-up of patients without such factors was therefore considerably less than 0.6 per cent. The authors suggest that such a small proportion does not justify the work involved and that patients ‘should be discharged from supervision when a course of adequate treatment has been completed’. This seems sensible: but such a radical departure from tradition may not be acceptable to many. The old concept of ‘supervision’ in tuberculosis implied much more than looking for radiographic. changes. Advice was given about hours of work and rest, marriage, child-bearing, accommodation and almost every major facet of life. It was accepted that tuberculosis could never be considered ‘cured’ ; the patient must be taught to adjust his life to the restrictions imposed by his lung disease. And he must be frequently reminded of this. Hence the frequent visits to the clinic over many years. With effective chemotherapy such ‘supervision’ is no longer necessary. The patients should have been leading normal lives throughout most or all of their treatment. They should continue to do so. Their activities do not need to be ‘supervised’. Thus the only reason for continuing to examine patients after treatment has finished is to detect relapse before symptoms appear, and hence before they become infectious. This is not ‘supervision’ but ‘observation’. Whether it is profitable depends
248
LEADING
ARTICLt
solely on the yield of relapses. Relapse is rare. Moreover, at least a third of those that do occur will not be detected by ‘observation’ but by symptoms developing during the interval between examinations. If there were no shortage of medical, nursing, technical and clerical staff for all the requirements of a health service, routine ‘observation’ could be done without detriment to other tasks. But there seldom is. The more time spent on ‘routine observation’ the less can be given to the much more important work of treating patients. Better ‘supervision’ of treatment would lead to less need for ‘observation’ later. However, even if long-continued ‘observation’ were administratively acceptable, it could still be psychologically harmful for the patients. Many, after 13 to 2 years of attending clinics, would be delighted to be told that they were no longer ‘patients’ and need not attend again; that they were healthy people who need not be ‘observed’ or their lives ‘supervised’. In a recently published memorandum from the Department of Health and Social SecurityX it is recommended that ‘patients should normally be followed up for 18-24 months after completion of drug therapy’. It is doubtful whether this is necessary or desirable. It is more rational, in view of all the evidence, that such follow-up should be ‘abnormal’ rather than ‘normal’. In other words that ‘observation’ to detect relapse should be restricted to those most likely to relapse - such as patients who have had less than 18 months chemotherapy, or are known or suspected to have taken drugs irregularly. For the ‘normal’ patient who appears to have co-operated and taken the drugs as regularly as one can expect any ‘normal’ person to have done for the prescribed period, even 14 to 2 years ‘observation’ seems unrewarding. The physician should assess each patient individually and record the reason why, at the end of treatment, he thinks it necessary to impose on the patient the burden of being ‘observed’. To stop ‘routine observation’ of adequately treated patients will reduce the number of people attending out-patient clinics. It might reduce the number of clinics required and hence the number of staff employed for this particular purpose. Unless there are other worthwhile activities for physicians to turn their attention to, there is little incentive for them to break with tradition and stop ‘observing’ healthy people by yearly chest x-rays. It is not only in tuberculosis that the practice of ‘routine observation’ should be critically examined. There is probably considerable waste of effort and patient’s time in many other diseases as well. There is sometimes less mental effort and responsibility required to ‘continue under observation’ than to ‘discharge’. REFERENCES ‘HORNE, N. W. (1966). Chronic pulmonary tuberculosis: present problems. Bulletin of the International Union against Tuberculosis, 37,172. 2T~o~.~, H. E. (1965). Five-year assessment of sputum positive pulmonary tuberculosis notified in Birmingham in 1957-58. Tubercle, 46,352. %PRINGETT,V. H. (1971). Ten-year results during the introduction of chemotherapy for tuberculosis. Tubercfe, 52,73 4G~~~~~~~~, S., MCKINNON,V., TUTERS, L., PINKUS, G., & Phillips, R. (1966). Reactivation in inactive pulmonary tuberculosis. American Review of Respiratory Disease, 93,352. 6B~~~~~, W. C., THOMPSON,D. H., JACOBS, S., ZISKIND, M. & GREENBERG,H. B. (1973). Evaluating the need for periodic recall and re-examination of patients with inactive pulmonary tuberculosis. American Review of Respiratory Disease, 107,854. pE~~~~~, J. & COLLINS, G. (1973). Routine follow-up of inactive tuberculosis, a practice to be abandoned. American Review of Respiratory Disease, 107,851. ‘EDSALL, J., COLLINS,J. &GRAY, J. A. C. (1970). The reactivation of tuberculosis in New York City in 1967. American Review of Respiratory Disease, 102.725. *DEPARTMENTOF HEALTH AND SOCIAL SECURITY (1973). Standing Medical Advisory Committee. Tuberculosis: epidemiology and control.
PRINTED
BY HOLMES
MCDOUGALL
LIMITED.
PERTH,
SCOTLAND