--l
1tLetters to the Editor
Letters are welcomed ancd will be published, iffountd suiitable, as space permiiits. The editors reserve the right to edit and abridge letters, to plublish replies, anid to solicit responses from authors and others. Letters shouild be suibmitted in duiplicate,
douible-spaced (inclluding references), and getnerally shoiulSd not exceecd 400 words.
that a label by race is presently inappropriate. C. M. G. Blittery, MD, MPH Associate Professor Departmnent ofFamily Medicine Easteruz Vir-giiia Mediical School
No:fiolk,
VA 23501
tions of anemia are necessary to facilitate decision-making in administration of various food, nutrition and health programs. Geor-ge M. Oweel, MD Pr-ofessor- & Dir-ector Hiuniia i Nu/tr ition1 Pr-ogr-amll
The Univ'ersitv of Miclhigan
REFERENCES
On Definition of Anemia
1. Owen, G. M., and Yanochik-Owen, A. Should there be a different definition of anemia in black and white children? Am. J. Public Health 67:865-866. 1977. 2. Wright, 1. S. Correct Levels of Serum Cholesterol, Average vs. Normal vs. Optimal JAMA 236:261, 1976.
I am writing to comment on the article by Owen & Owen' on the definition of anemia in the September 77 issue of the Journal. The basic fallacy in the argument Author's Response advanced in this article is the lack of understanding of the terms "normal" No attempt was made to define an and "optimal" in regard to clinical con"optimal" level of hemoglobin. For ditions. This difference is particularly preschool children in whom iron is not well discussed in an article by Wright likely to be limiting, there is an approxregarding cholesterol.' imate 0.Sgm/dI difference between The "normal" level is a statistical Blacks and Whites in hemoglobin coninterpretation of the mean. This may, centration through the normal range. in fact, be different for the two races. A This appears to present a simple disnormal range is often stated to be the placement of the distribution curves mean +/-2 standard deviations. This rather than alterations in shape of the again refers to a statistical curve, not to cuL-ves. We suggest that hemoglobin the clinical association of symptoms. levels less than 10.5 or 11 gm/dl are beI am not sure that any of the preslow "normal" for Black and White ent standar-ds spelling out maximal hechildren, respectively. moglobin levels defined as anemia are It is true that I to 3 year-old todclinically correct. At what maximum dlers with levels of hemoglobin in the 8 level of hemoglobin do a significant to 10 gm/dl range may have no obvious number of individuals, in fact, still sufsigns or symptoms of anemia. Yet, it is fer physical signs or symptoms? Many likely that these children have signifiof us have had patients come into our cant iron deficiency, functional abnoroffices with hemoglobin levels of 8Gm malities in iron-dependent enzymes inor less with no, or minimal, symptomcluding monamine oxidases' which may atology. be reflected in behavioral changes.' It is time we stopped confusing Iron deficient children may demonstatistical analyses with clinical labels. strate growth impairment.3 We should relate the laboratory values The definition of iron deficiency, to functional abnormalities (physical or with or without anemia, needs more mental). I would suggest that the matstudy as does evaluation of clinical sigter of the definition of anemia still nificance and importance. In the meanneeds more study and discussion, and time, we believe that working defini174
A n n A hbor, MI 48109
REFERENCES 1. Vorhess, M. L., Stuart, N. J., Stockman. J. A.. and Oski. F. A. Iron deficiency anemia and increased norepinephrine excretion. J. Pediat. 86:542, 1975. 2. Pollitt, E.. and Leibel. R. L. Iron deficiency and behavior. J. Pediat. 88:372, 1976. 3. Judish. J. N., Nauman, J. L., and Oski, F. A. The fallacy of the fat iron-deficient child. Pediatrics, 37:987. 1966. 4. Owen, G. M., Lubin, A. H., and Garry, P. J. Preschool children in the United States: Who has iron deficiency? J. Pediat. 79:563, 1971
Categorization of Comprehensive Community Mental Health Center Services It has occurred to us that emergency-crisis community mental health services can be usefully classified according to the levels of comprehensiveness of the services they offer. The idea for this classification or categorization is derived from the guidelines for the categorization of hospital emergency facilities' and is based upon the institution's capability to provide effective mental health care for those individuals it serves: Level 1: Answering service available five days a week (eight to five office hours); with appointments being made for client to be seen by a professional the following working day. AJPH February 1978, Vol. 68, No. 2
LETTERS TO THE EDITOR
Level II: Answering service seven days a week, twenty-four hours per day with telephone conversation with mental health worker within one hour. Level III: Answering service seven days a week, twenty-four hours per day with a mental health professional available within thirty minutes by telephone. Level IV: Answering service around the clock with mental health professional available both by phone or in emergency setting at time of call. Level V: Around the clock phone, emergency setting and home visits, mental health and medical coverage. Comprehensive community mental health centers would benefit by a set of guidelines similar to those the AMA has developed for hospital emergency rooms. Categorization by level of service would describe in a common language the exact nature of the services
available. John E. Holman Regional Consultant for Mental Health and Ernest Hamburger, MD Regional Consultant in Psychiatry DHEW, Region VIII, Federal Office Bldg. Denver, CO 80202 REFERENCE 1. American Medical Association, Recommendations of the Conference on the Guidelines for the Categorization of Hos-
pital Emergency Capabilities, Chicago, IL: American Medical Association, 1971,
p.'.
Maternal Mortality Committees Reassessed In their recent article on the impact of Maternity Mortality Committees, Grimes and Cates' list a number of sources of potential bias that might have contributed to their observation of a lack of association between the existence of maternity mortality committees and a decline in maternal mortality ratios. Although they acknowledge the possibility of reporting differences between states with and without committees they reject this for the reason that "Birth and death data from all states were subjected to uniform definitions and classifications durAJPH February 1978, Vol. 68, No. 2
ing the years under consideration." I believe, however, that this does not rule out reporting differences that are related to the increased intensity of search for deaths in states with maternal mortality committees. Counts of maternal deaths in states without mortality committees are based on the cause of death information submitted on death certificates. Although searching techniques may vary, states with maternal mortality committees usually select for further investigation all death certificates that contain key words referring to pregnancy. Schaffner2 and his colleagues described the methods used in Michigan for the identification of maternal deaths. Gregory3 recently reported that a new method of surveillance of maternal deaths in New Jersey (a state with a maternal mortality committee) identified " 13 more 1974 maternal deaths than the 16 enumerated by the traditional reporting method." My assessment is that there are reporting differences between states with and without maternal mortality committees. In addition, over a period of time committees probably change the intensity of search. There is evidence from another type of mortality study committee to support the observation that case identification is related to search effort. For the period 1953-58, Vital Statistics of the U.S. show that in the entire country 416 deaths were ascribed to the cause "Therapeutic Misadventure in Anesthesia" (E954). During those years there were a few anesthesia mortality study committees functioning. One was the Baltimore Anesthesia Study Committee. During the period 1953-58 this committee reviewed, from a screening of death certificates and follow-up investigation of hospital and autopsy reports, 1,024 postoperative deaths and judged 196 to be associated with anesthesia. Of these in 64 cases anesthesia was voted to be the principal cause of death.4 This is far in excess of the number of deaths due to anesthesia that could be expected from the State of Maryland or from metropolitan Baltimore even taking into account its regional importance as a medical center. Instead of high-risk anesthesia, a more likely explanation seemed to be that in Baltimore anesthesiologists carried out
a more intensive search and peer review than was done in other areas. There is one other problem that could have impaired the type of analysis used by Grimes and Cates. The results of mortality committee studies may fail to be reflected accurately in national vital statistics. There are several reasons for this. In some cases a committee's vote based on an assessment of the information from hospital records and autopsy reports may not be available until after the end of the vital event reporting year cut-off date. Second, committee votes on principal and contributing causes of deaths may not translate readily into standard cause of death rubrics. Finally, in some areas committees are not directly related to the vital statistics systems. It is possible that the analysis presented by Grimes and Cates masks real differences between states with and without maternal mortality committees. It would be unfortunate if this led to a decrease in interest in methods that could be used for more intensive surveillance of a broader range of medical care evaluation studies. Todd M. Frazier Assistant Director Centerfor Community Health and Medical Care Harvard School of Public Health Boston, MA 02115
REFERENCES 1. Grimes, D. A., Cates, W. The impact of state maternal mortality committees on maternal death in the United States. Am. J. Public Health 67:830-835, 1977. 2. Schaffner, W., et. al. Maternal mortality in Michigan: An epidemiologic analysis, 1950-71. Am. J. Public Health 67:821829, 1977. 3. Gregory, M., et. al. Surveillance of Maternal Deaths-New Jersey. CDC: MMWR 26.8, February 27, 1977. 4. Phillips, 0. C., et. al. The Baltimore Anesthesia Study Committee: A Review of 1,024 Postoperative Deaths, JAMA 174:16, December 1960, pp. 2015-2019.
Authors' Response We appreciate Dr. Frazier's correspondence inquiring whether ascertainment bias could have led to our observed lack of association between maternal mortality study committees and 175
1tLetters to the Editor
Letters are welcomed ancd will be published, iffountd suiitable, as space permiiits. The editors reserve the right to edit and abridge letters, to plublish replies, anid to solicit responses from authors and others. Letters shouild be suibmitted in duiplicate,
douible-spaced (inclluding references), and getnerally shoiulSd not exceecd 400 words.
that a label by race is presently inappropriate. C. M. G. Blittery, MD, MPH Associate Professor Departmnent ofFamily Medicine Easteruz Vir-giiia Mediical School
No:fiolk,
VA 23501
tions of anemia are necessary to facilitate decision-making in administration of various food, nutrition and health programs. Geor-ge M. Oweel, MD Pr-ofessor- & Dir-ector Hiuniia i Nu/tr ition1 Pr-ogr-amll
The Univ'ersitv of Miclhigan
REFERENCES
On Definition of Anemia
1. Owen, G. M., and Yanochik-Owen, A. Should there be a different definition of anemia in black and white children? Am. J. Public Health 67:865-866. 1977. 2. Wright, 1. S. Correct Levels of Serum Cholesterol, Average vs. Normal vs. Optimal JAMA 236:261, 1976.
I am writing to comment on the article by Owen & Owen' on the definition of anemia in the September 77 issue of the Journal. The basic fallacy in the argument Author's Response advanced in this article is the lack of understanding of the terms "normal" No attempt was made to define an and "optimal" in regard to clinical con"optimal" level of hemoglobin. For ditions. This difference is particularly preschool children in whom iron is not well discussed in an article by Wright likely to be limiting, there is an approxregarding cholesterol.' imate 0.Sgm/dI difference between The "normal" level is a statistical Blacks and Whites in hemoglobin coninterpretation of the mean. This may, centration through the normal range. in fact, be different for the two races. A This appears to present a simple disnormal range is often stated to be the placement of the distribution curves mean +/-2 standard deviations. This rather than alterations in shape of the again refers to a statistical curve, not to cuL-ves. We suggest that hemoglobin the clinical association of symptoms. levels less than 10.5 or 11 gm/dl are beI am not sure that any of the preslow "normal" for Black and White ent standar-ds spelling out maximal hechildren, respectively. moglobin levels defined as anemia are It is true that I to 3 year-old todclinically correct. At what maximum dlers with levels of hemoglobin in the 8 level of hemoglobin do a significant to 10 gm/dl range may have no obvious number of individuals, in fact, still sufsigns or symptoms of anemia. Yet, it is fer physical signs or symptoms? Many likely that these children have signifiof us have had patients come into our cant iron deficiency, functional abnoroffices with hemoglobin levels of 8Gm malities in iron-dependent enzymes inor less with no, or minimal, symptomcluding monamine oxidases' which may atology. be reflected in behavioral changes.' It is time we stopped confusing Iron deficient children may demonstatistical analyses with clinical labels. strate growth impairment.3 We should relate the laboratory values The definition of iron deficiency, to functional abnormalities (physical or with or without anemia, needs more mental). I would suggest that the matstudy as does evaluation of clinical sigter of the definition of anemia still nificance and importance. In the meanneeds more study and discussion, and time, we believe that working defini174
A n n A hbor, MI 48109
REFERENCES 1. Vorhess, M. L., Stuart, N. J., Stockman. J. A.. and Oski. F. A. Iron deficiency anemia and increased norepinephrine excretion. J. Pediat. 86:542, 1975. 2. Pollitt, E.. and Leibel. R. L. Iron deficiency and behavior. J. Pediat. 88:372, 1976. 3. Judish. J. N., Nauman, J. L., and Oski, F. A. The fallacy of the fat iron-deficient child. Pediatrics, 37:987. 1966. 4. Owen, G. M., Lubin, A. H., and Garry, P. J. Preschool children in the United States: Who has iron deficiency? J. Pediat. 79:563, 1971
Categorization of Comprehensive Community Mental Health Center Services It has occurred to us that emergency-crisis community mental health services can be usefully classified according to the levels of comprehensiveness of the services they offer. The idea for this classification or categorization is derived from the guidelines for the categorization of hospital emergency facilities' and is based upon the institution's capability to provide effective mental health care for those individuals it serves: Level 1: Answering service available five days a week (eight to five office hours); with appointments being made for client to be seen by a professional the following working day. AJPH February 1978, Vol. 68, No. 2
LETTERS TO THE EDITOR
Level II: Answering service seven days a week, twenty-four hours per day with telephone conversation with mental health worker within one hour. Level III: Answering service seven days a week, twenty-four hours per day with a mental health professional available within thirty minutes by telephone. Level IV: Answering service around the clock with mental health professional available both by phone or in emergency setting at time of call. Level V: Around the clock phone, emergency setting and home visits, mental health and medical coverage. Comprehensive community mental health centers would benefit by a set of guidelines similar to those the AMA has developed for hospital emergency rooms. Categorization by level of service would describe in a common language the exact nature of the services
available. John E. Holman Regional Consultant for Mental Health and Ernest Hamburger, MD Regional Consultant in Psychiatry DHEW, Region VIII, Federal Office Bldg. Denver, CO 80202 REFERENCE 1. American Medical Association, Recommendations of the Conference on the Guidelines for the Categorization of Hos-
pital Emergency Capabilities, Chicago, IL: American Medical Association, 1971,
p.'.
Maternal Mortality Committees Reassessed In their recent article on the impact of Maternity Mortality Committees, Grimes and Cates' list a number of sources of potential bias that might have contributed to their observation of a lack of association between the existence of maternity mortality committees and a decline in maternal mortality ratios. Although they acknowledge the possibility of reporting differences between states with and without committees they reject this for the reason that "Birth and death data from all states were subjected to uniform definitions and classifications durAJPH February 1978, Vol. 68, No. 2
ing the years under consideration." I believe, however, that this does not rule out reporting differences that are related to the increased intensity of search for deaths in states with maternal mortality committees. Counts of maternal deaths in states without mortality committees are based on the cause of death information submitted on death certificates. Although searching techniques may vary, states with maternal mortality committees usually select for further investigation all death certificates that contain key words referring to pregnancy. Schaffner2 and his colleagues described the methods used in Michigan for the identification of maternal deaths. Gregory3 recently reported that a new method of surveillance of maternal deaths in New Jersey (a state with a maternal mortality committee) identified " 13 more 1974 maternal deaths than the 16 enumerated by the traditional reporting method." My assessment is that there are reporting differences between states with and without maternal mortality committees. In addition, over a period of time committees probably change the intensity of search. There is evidence from another type of mortality study committee to support the observation that case identification is related to search effort. For the period 1953-58, Vital Statistics of the U.S. show that in the entire country 416 deaths were ascribed to the cause "Therapeutic Misadventure in Anesthesia" (E954). During those years there were a few anesthesia mortality study committees functioning. One was the Baltimore Anesthesia Study Committee. During the period 1953-58 this committee reviewed, from a screening of death certificates and follow-up investigation of hospital and autopsy reports, 1,024 postoperative deaths and judged 196 to be associated with anesthesia. Of these in 64 cases anesthesia was voted to be the principal cause of death.4 This is far in excess of the number of deaths due to anesthesia that could be expected from the State of Maryland or from metropolitan Baltimore even taking into account its regional importance as a medical center. Instead of high-risk anesthesia, a more likely explanation seemed to be that in Baltimore anesthesiologists carried out
a more intensive search and peer review than was done in other areas. There is one other problem that could have impaired the type of analysis used by Grimes and Cates. The results of mortality committee studies may fail to be reflected accurately in national vital statistics. There are several reasons for this. In some cases a committee's vote based on an assessment of the information from hospital records and autopsy reports may not be available until after the end of the vital event reporting year cut-off date. Second, committee votes on principal and contributing causes of deaths may not translate readily into standard cause of death rubrics. Finally, in some areas committees are not directly related to the vital statistics systems. It is possible that the analysis presented by Grimes and Cates masks real differences between states with and without maternal mortality committees. It would be unfortunate if this led to a decrease in interest in methods that could be used for more intensive surveillance of a broader range of medical care evaluation studies. Todd M. Frazier Assistant Director Centerfor Community Health and Medical Care Harvard School of Public Health Boston, MA 02115
REFERENCES 1. Grimes, D. A., Cates, W. The impact of state maternal mortality committees on maternal death in the United States. Am. J. Public Health 67:830-835, 1977. 2. Schaffner, W., et. al. Maternal mortality in Michigan: An epidemiologic analysis, 1950-71. Am. J. Public Health 67:821829, 1977. 3. Gregory, M., et. al. Surveillance of Maternal Deaths-New Jersey. CDC: MMWR 26.8, February 27, 1977. 4. Phillips, 0. C., et. al. The Baltimore Anesthesia Study Committee: A Review of 1,024 Postoperative Deaths, JAMA 174:16, December 1960, pp. 2015-2019.
Authors' Response We appreciate Dr. Frazier's correspondence inquiring whether ascertainment bias could have led to our observed lack of association between maternal mortality study committees and 175
