- Email: [email protected]
Uninsured in the USA
their homes and families. Their transfer will be a sign of solidarity between health care systems, health care workers, and people. The commitment of the other governments to the medical evacuation of children has already saved many lives, and has gained the respect and gratitude of Bosnia’s government, its health community, and its public. Project Irma was an important medical initiative. A similar initiative, involving a small number of cases, deserves to be continued until the health care system of Bosnia and Herzegovina has been restored. The people of Bosnia and Herzegovina have already been exposed to too much pain. Additional suffering as a result of otherwise treatable medical conditions can and should be to
The challenge now is to expand the scope of evidencebased medicine while recognising that there are important areas of clinical practice where the light of hard research evidence is not likely to shine very brightly for the foreseeable future. *John
1 2 3
avoided.
Newton, Elizabeth West
Unit of Health-Care
4
*David Southall, Manuel Carballo
Epidemiology, University
of Oxford, Oxford OX3 7LF, UK
Schuchman M. Evidence-based medicine debated. Lancet 1996; 347: 1396. Black N. Why we need observational studies to evaluate the effectiveness of health care. BMJ 1996; 312: 1215-18. Wade DT, Connolly A, Davis SM, et al. Services for people with stroke. Quality in Health Care 1993; 2: 263-66. Fulford W, Ersser S, Hope T. Essential practice in patient-centred care. Oxford: Blackwell Science, 1996.
*Child Advocacy International, Academic Department of Paediatrics, North Staffordshire Hospital, Stoke-on-Trent ST4 6QG, UK; and International Centre for Migration and Health, Geneva, Switzerland
1
Southall DP, Ellis J, McMaster P, et al. Medical evacuation from Mostar. Lancet 1996; 347: 244-45.
Evidence-based medicine and
compassion
SiR-Shuchman’s report from the Sydenham Society (May 18, p 1396)’ illustrates the anxiety that can be generated by the concept of evidence-based medicine. Any suggestion that practice can only be good if it is based on large-scale intervention studies is worrying because it shows a misunderstanding of the nature of clinical practice, and of the inherent limitations of clinical research.2 The role of evidence-based medicine is to support good clinical skills where possible, and not to replace them. The potential to base practice on so-called hard evidence depends on the clinical setting for largely predictable reasons. Consider, for example, the likely availability of evidence on rehabilitation after stroked No two patients present precisely the same problem. The outcomes of interest are difficult to measure and different outcomes are important to different patients. A range of interventions are available that can be used in different ways and in various combinations. By contrast, take the use of thrombolysis in myocardial infarction. Clinical groups are large and homogeneous. The endpoint of interest is death, which is measurable and has a constant utility, and the intervention is standardised. In general, reliable research studies from which to extrapolate to clinical practice are easier to design and conduct when certain criteria are met. The clinical problem should be common enough for trials to be feasible. The outcomes that matter to the patient should be measurable with accuracy and validity. The relevant interventions should be well defined and tolerably homogeneous. It also helps if patient groups do not vary a great deal in their baseline characteristics or in the utility they attach to different outcomes. The availability of evidence will therefore vary enormously from specialty to specialty. Clinical practice seeks to produce outcomes desired by the patient, and to use resources efficiently. Effective clinicians combine knowledge and skills derived from sound scientific evidence (rather than dogma or anecdote) but remain prepared to tailor therapy to the particular needs of individual patients. Thus, evidence-based medicine is a subset of, and not a substitute for, effective compassionate clinical practice. In fact, the doctor-patient relationship has its own research-base, grounded in the social sciences and the humanities. This research should also be promoted in health services.
Uninsured in the USA SiR-Although I am not qualified to argue with Friedman (May 11, p 1335)’ on the largely unreferenced and dubious comparisons that he makes between the general health care available to the poor of the USA and UK (Editorial, March 16)/ I must take issue with him on the results obtained in his country in patients with end-stage renal disease (ESRD). He inform your readers that this was the sole form of that was covered by Medicare for all USA residents. Furthermore, he failed to inform you that the survival data obtained with this form of therapy in the USA was the worst in the western world. In addition, even though reimbursement for dialysis itself is probably the cheapest in a developed country, Wall Street considers that the providers of this therapy are a highly profitable investment. This year alone, one initial stock offer raised just under 100 million dollars, with the shares doubling overnight and the doctors associated with the offer becoming paper millionaires. A major factor involved in the profitability was the discounting to the provider of erythropoietin.3 Finally, in a detailed exposee of the state of ESRD therapy in USA in the New York Times, Friedman was quoted as saying in relation to the declining state of the practice of reuse of dialysers "The average re-use procedure is done by people who have not much more training than a McDonald’s hamburger flipper".4 In view of the lamentable state of the ESRD programme in USA, perhaps Friedman should concentrate on putting his own house in order, before attacking others. omitted
to
treatment
Stanley Shaldon 86 Rue de Grézac,
1
2 3 4
Montpellier 34080,
France
Editorial. Uninsured in the USA, and still waiting. Lancet 1996; 347: 703. Friedman EA. Uninsured in the USA. Lancet 1996; 347: 1335. Prospectus of IPO of Renal Care Group, Inc. 1996, Feb 6: p 8. Eichenwald K. Death and deficiency in kidney treatment. New York Times 1995, Dec 4.
Diphtheria immunity in health staff SIR-John and colleagues (April 6, p 969)’ report that the results of ELISA serology for antibody to diphtheria indicated that only 26% of their staff were fully protected. We have done ELISA studies of immunity in health care staff and applying the same internationally accepted definitions cited,’ our findings were somewhat different. 1839
The challenge now is to expand the scope of evidencebased medicine while recognising that there are important areas of clinical practice where the light of hard research evidence is not likely to shine very brightly for the foreseeable future. *John
1 2 3
avoided.
Newton, Elizabeth West
Unit of Health-Care
4
*David Southall, Manuel Carballo
Epidemiology, University
of Oxford, Oxford OX3 7LF, UK
Schuchman M. Evidence-based medicine debated. Lancet 1996; 347: 1396. Black N. Why we need observational studies to evaluate the effectiveness of health care. BMJ 1996; 312: 1215-18. Wade DT, Connolly A, Davis SM, et al. Services for people with stroke. Quality in Health Care 1993; 2: 263-66. Fulford W, Ersser S, Hope T. Essential practice in patient-centred care. Oxford: Blackwell Science, 1996.
*Child Advocacy International, Academic Department of Paediatrics, North Staffordshire Hospital, Stoke-on-Trent ST4 6QG, UK; and International Centre for Migration and Health, Geneva, Switzerland
1
Southall DP, Ellis J, McMaster P, et al. Medical evacuation from Mostar. Lancet 1996; 347: 244-45.
Evidence-based medicine and
compassion
SiR-Shuchman’s report from the Sydenham Society (May 18, p 1396)’ illustrates the anxiety that can be generated by the concept of evidence-based medicine. Any suggestion that practice can only be good if it is based on large-scale intervention studies is worrying because it shows a misunderstanding of the nature of clinical practice, and of the inherent limitations of clinical research.2 The role of evidence-based medicine is to support good clinical skills where possible, and not to replace them. The potential to base practice on so-called hard evidence depends on the clinical setting for largely predictable reasons. Consider, for example, the likely availability of evidence on rehabilitation after stroked No two patients present precisely the same problem. The outcomes of interest are difficult to measure and different outcomes are important to different patients. A range of interventions are available that can be used in different ways and in various combinations. By contrast, take the use of thrombolysis in myocardial infarction. Clinical groups are large and homogeneous. The endpoint of interest is death, which is measurable and has a constant utility, and the intervention is standardised. In general, reliable research studies from which to extrapolate to clinical practice are easier to design and conduct when certain criteria are met. The clinical problem should be common enough for trials to be feasible. The outcomes that matter to the patient should be measurable with accuracy and validity. The relevant interventions should be well defined and tolerably homogeneous. It also helps if patient groups do not vary a great deal in their baseline characteristics or in the utility they attach to different outcomes. The availability of evidence will therefore vary enormously from specialty to specialty. Clinical practice seeks to produce outcomes desired by the patient, and to use resources efficiently. Effective clinicians combine knowledge and skills derived from sound scientific evidence (rather than dogma or anecdote) but remain prepared to tailor therapy to the particular needs of individual patients. Thus, evidence-based medicine is a subset of, and not a substitute for, effective compassionate clinical practice. In fact, the doctor-patient relationship has its own research-base, grounded in the social sciences and the humanities. This research should also be promoted in health services.
Uninsured in the USA SiR-Although I am not qualified to argue with Friedman (May 11, p 1335)’ on the largely unreferenced and dubious comparisons that he makes between the general health care available to the poor of the USA and UK (Editorial, March 16)/ I must take issue with him on the results obtained in his country in patients with end-stage renal disease (ESRD). He inform your readers that this was the sole form of that was covered by Medicare for all USA residents. Furthermore, he failed to inform you that the survival data obtained with this form of therapy in the USA was the worst in the western world. In addition, even though reimbursement for dialysis itself is probably the cheapest in a developed country, Wall Street considers that the providers of this therapy are a highly profitable investment. This year alone, one initial stock offer raised just under 100 million dollars, with the shares doubling overnight and the doctors associated with the offer becoming paper millionaires. A major factor involved in the profitability was the discounting to the provider of erythropoietin.3 Finally, in a detailed exposee of the state of ESRD therapy in USA in the New York Times, Friedman was quoted as saying in relation to the declining state of the practice of reuse of dialysers "The average re-use procedure is done by people who have not much more training than a McDonald’s hamburger flipper".4 In view of the lamentable state of the ESRD programme in USA, perhaps Friedman should concentrate on putting his own house in order, before attacking others. omitted
to
treatment
Stanley Shaldon 86 Rue de Grézac,
1
2 3 4
Montpellier 34080,
France
Editorial. Uninsured in the USA, and still waiting. Lancet 1996; 347: 703. Friedman EA. Uninsured in the USA. Lancet 1996; 347: 1335. Prospectus of IPO of Renal Care Group, Inc. 1996, Feb 6: p 8. Eichenwald K. Death and deficiency in kidney treatment. New York Times 1995, Dec 4.
Diphtheria immunity in health staff SIR-John and colleagues (April 6, p 969)’ report that the results of ELISA serology for antibody to diphtheria indicated that only 26% of their staff were fully protected. We have done ELISA studies of immunity in health care staff and applying the same internationally accepted definitions cited,’ our findings were somewhat different. 1839