308
Epidemiology in central
and eastern
Europe
SiR,—John Newton’s conclusion (July 18, p 170), that the quality epidemiology in the countries of central and eastern Europe (CCEE) is generally poor, is justified. However, he is not wholly correct in his analysis of the reasons for this situation. Epidemiology has existed and, at least in some countries, was not politically suppressed. The difficulty was that since the late 1940s epidemiology was based on the Soviet model, concentrating on control of communicable diseases. In this narrow field, epidemiology achieved some respectable results,l but since communicable disease control needs only limited aetiological research, epidemiological methodology was limited to descriptive methods. Furthermore, as with other scientific disciplines, public health was isolated from developments in the west, and the shift towards non-communicable disease epidemiology in the 1960s did not take place in the CCEE. More recently, those who attempted to develop it were faced with a shortage of funds. Nevertheless, there is now a growing body of high quality epidemiological research into non-communicable disease taking place in the CCEE. For example, staff of Charles University and the Institute of Hygiene and Epidemiology in Prague are working with colleagues from the London School of Hygiene and Tropical Medicine on studies of the determinants of the epidemic of cardiovascular disease, on effects of environmental pollution on infant health, and on the mortality patterns associated with the Czech mining industry. Newton is unduly pessimistic about the probability of new schools of public health emerging in the near future. Programmes funded by the World Bank to develop new schools of public health and health service management in Hungary and Romania will start early in 1993. The European Community TEMPUS programme has funded a major project to restructure public health training in medical universities in Hungary. This involves universities in Canada, Denmark, France, Norway, Spain, and the UK. With a budget of almost C500 000, the programme is providing library facilities, computers, teacher training, and study visits to western Europe. Its first year has been very successful, with a complete review of the undergraduate curriculum. The second and third years will concentrate on postgraduate training, linking with developments in the school of public health. Proposals for similar projects have been submitted in respect of the Czech Republic and Romania. Finally, a new school of public health is being developed in Krakow, Poland, with assistance from the American organisation Project HOPE. All these projects will need time to take effect but we hope that we can persuade Newton to share our optimism.
of
Health Services Research Unit, London School of Hygiene and Tropical Medicine, London WC1 E 7HT, UK
MARTIN MCKEE
Third Medical Faculty, Charles University, Prague, Czechoslavakia
MARTIN BOBAK
School of Public Health, Krakow, Poland
ADAM NAZIM
CHARLES NORMAND
1. Feachem RGA, Preker A. The Czech and Slovak Federal Republic: the health sector, issues and priorities. Washington: World Bank, 1991.
Costs of Medline and CD-ROM
searching
information is an important part of medical research and clinical practice. Much time and money is devoted to it by physicians and hospitals. In these times of diminishing resources, those facilities should function efficiently. Judicious and justifiable use of modem technology can help. The Rouen University Hospitals have two medical libraries: one is at the School of Medicine for students and junior doctors, the other is in one of the hospitals, for the 280 staff members. In the hospital, all expenses are paid by the hospital and literature searches are done by a medical librarian, more efficiently than by even experienced end-users.1 From April, 1987, to December, 1990, Medline was accessed (on the Questel Server) through a Minitel videotext terminal, and after this date, through a PS/2 microcomputer. The cost of online Medline is C20 per hour, with an additional jO.08 per reference. In April, 1991, Medline on CD-
SIR,-Access
to
(Compact Disc-Read Only Memory) was obtained (Compact Cambridge edition). At first only one CD player was available. In January, 1992, a second player was bought, and two ROM
in March, 1992. Medline remains accessible online. Since Medline has been available both online and on CD-ROMs, the cost per search has declined strikingly: No of No of CD Cost/search Monthly
more
Dates (mo/yr)
1-3/1991 3-6/1991 1-2/1992 3-6/1992
drives 0 1 2 4
*Including the subscription to
searches (f) (E) 10 1364 135 5.8 730* 127 51 178 909* 42 609* 145 the Medhne CD-ROM (f1400/year), and the cost
reduction to zero of the cost of the CD players (E560 per player) over 4 years. If one assumes a mean of 145 searches per month, the subscription to CD-ROM Medline, and the cost of the first CD player is reimbursed in a little more than three months, the second player in 5 months, and the last two in 8 months. This is much less than earlier estimates.2 However, the complete Medline collection comes on 18 CD discs. Access to all this information implies either exchanging discs (which is time-consuming and painful on the wrists), or having multiple CD players, or online access. Four players enables access to the last four years of information directly. Online access to Medline is restricted essentially to exhaustive searches over long periods, especially when very few references are found on the most recent discs, or to searches limited to records added to Medline since the last disc update. In both cases, in fact, the online search is prepared and tested first on the CD-ROMs, to keep to a minimum the time spent and the number of references accessed online. This cost-analysis should also be done in other countries, since it involves country-specific costs (essentially communication costs), and should be repeated over time, since the reducing cost of the materials (computers, CD players) will make them increasingly costeffective. Medical
Library, Regional Centre for Hospital Information, and Service of Pharmacology, CHU de Rouen, 76031 Rouen, France
B. THIRION
S. J. DARMONI N. MOORE
1. McKibbon KA, Haynes RB, Dilks CJ, et al. How good are clinical Medline searches?
A comparative study of clinical end-user and librarian searches.
Comput Biomed
Res
1990; 23: 583-93. 2. Fox GN. Computer literature searching: will docs byte? Fam Pract Res J 1991; 11: 9-14.
Audit and research SIR,-Professor Sherwood (July 4, p 37) implies that we must choose between audit and research. The use of audit funds to address questions more appropriately answered by research lends some support to his contention but highlights a fundamental difference between the two activities-the nature of the question being asked. In audit one is asking whether an activity, known to be capable of achieving a specific outcome, is actually achieving that outcome in the hands of those undertaking the audit. This presupposes knowledge of efficacy, measurability of outcome, and agreement on an acceptable standard against which performance can be measured. Audit is about doing the right thing and doing it better-is an efficacious intervention effective? In this context research is asking what the right thing is. Free thinking and audit are not incompatible, although the scope for the former may be restricted in the setting of the latter. The lack of knowledge about the efficacy of many medical interventions (and, I suspect, the difficulties of obtaining support for small research projects) underlies the move to conduct research in the context of audit. The constraints of the audit cycle, the questions about who it is for, and the fears expressed by Sherwood about "dullness" and "intellectual coercion" are likely to lead to poor research as well as ineffective audit despite the apparent increase in a questioning attitude that is engendered by the profession embracing audit. One solution to this paradox is to restrict formal audit activity to those topics for which it is appropriate-namely, interventions with
Epidemiology in central
and eastern
Europe
SiR,—John Newton’s conclusion (July 18, p 170), that the quality epidemiology in the countries of central and eastern Europe (CCEE) is generally poor, is justified. However, he is not wholly correct in his analysis of the reasons for this situation. Epidemiology has existed and, at least in some countries, was not politically suppressed. The difficulty was that since the late 1940s epidemiology was based on the Soviet model, concentrating on control of communicable diseases. In this narrow field, epidemiology achieved some respectable results,l but since communicable disease control needs only limited aetiological research, epidemiological methodology was limited to descriptive methods. Furthermore, as with other scientific disciplines, public health was isolated from developments in the west, and the shift towards non-communicable disease epidemiology in the 1960s did not take place in the CCEE. More recently, those who attempted to develop it were faced with a shortage of funds. Nevertheless, there is now a growing body of high quality epidemiological research into non-communicable disease taking place in the CCEE. For example, staff of Charles University and the Institute of Hygiene and Epidemiology in Prague are working with colleagues from the London School of Hygiene and Tropical Medicine on studies of the determinants of the epidemic of cardiovascular disease, on effects of environmental pollution on infant health, and on the mortality patterns associated with the Czech mining industry. Newton is unduly pessimistic about the probability of new schools of public health emerging in the near future. Programmes funded by the World Bank to develop new schools of public health and health service management in Hungary and Romania will start early in 1993. The European Community TEMPUS programme has funded a major project to restructure public health training in medical universities in Hungary. This involves universities in Canada, Denmark, France, Norway, Spain, and the UK. With a budget of almost C500 000, the programme is providing library facilities, computers, teacher training, and study visits to western Europe. Its first year has been very successful, with a complete review of the undergraduate curriculum. The second and third years will concentrate on postgraduate training, linking with developments in the school of public health. Proposals for similar projects have been submitted in respect of the Czech Republic and Romania. Finally, a new school of public health is being developed in Krakow, Poland, with assistance from the American organisation Project HOPE. All these projects will need time to take effect but we hope that we can persuade Newton to share our optimism.
of
Health Services Research Unit, London School of Hygiene and Tropical Medicine, London WC1 E 7HT, UK
MARTIN MCKEE
Third Medical Faculty, Charles University, Prague, Czechoslavakia
MARTIN BOBAK
School of Public Health, Krakow, Poland
ADAM NAZIM
CHARLES NORMAND
1. Feachem RGA, Preker A. The Czech and Slovak Federal Republic: the health sector, issues and priorities. Washington: World Bank, 1991.
Costs of Medline and CD-ROM
searching
information is an important part of medical research and clinical practice. Much time and money is devoted to it by physicians and hospitals. In these times of diminishing resources, those facilities should function efficiently. Judicious and justifiable use of modem technology can help. The Rouen University Hospitals have two medical libraries: one is at the School of Medicine for students and junior doctors, the other is in one of the hospitals, for the 280 staff members. In the hospital, all expenses are paid by the hospital and literature searches are done by a medical librarian, more efficiently than by even experienced end-users.1 From April, 1987, to December, 1990, Medline was accessed (on the Questel Server) through a Minitel videotext terminal, and after this date, through a PS/2 microcomputer. The cost of online Medline is C20 per hour, with an additional jO.08 per reference. In April, 1991, Medline on CD-
SIR,-Access
to
(Compact Disc-Read Only Memory) was obtained (Compact Cambridge edition). At first only one CD player was available. In January, 1992, a second player was bought, and two ROM
in March, 1992. Medline remains accessible online. Since Medline has been available both online and on CD-ROMs, the cost per search has declined strikingly: No of No of CD Cost/search Monthly
more
Dates (mo/yr)
1-3/1991 3-6/1991 1-2/1992 3-6/1992
drives 0 1 2 4
*Including the subscription to
searches (f) (E) 10 1364 135 5.8 730* 127 51 178 909* 42 609* 145 the Medhne CD-ROM (f1400/year), and the cost
reduction to zero of the cost of the CD players (E560 per player) over 4 years. If one assumes a mean of 145 searches per month, the subscription to CD-ROM Medline, and the cost of the first CD player is reimbursed in a little more than three months, the second player in 5 months, and the last two in 8 months. This is much less than earlier estimates.2 However, the complete Medline collection comes on 18 CD discs. Access to all this information implies either exchanging discs (which is time-consuming and painful on the wrists), or having multiple CD players, or online access. Four players enables access to the last four years of information directly. Online access to Medline is restricted essentially to exhaustive searches over long periods, especially when very few references are found on the most recent discs, or to searches limited to records added to Medline since the last disc update. In both cases, in fact, the online search is prepared and tested first on the CD-ROMs, to keep to a minimum the time spent and the number of references accessed online. This cost-analysis should also be done in other countries, since it involves country-specific costs (essentially communication costs), and should be repeated over time, since the reducing cost of the materials (computers, CD players) will make them increasingly costeffective. Medical
Library, Regional Centre for Hospital Information, and Service of Pharmacology, CHU de Rouen, 76031 Rouen, France
B. THIRION
S. J. DARMONI N. MOORE
1. McKibbon KA, Haynes RB, Dilks CJ, et al. How good are clinical Medline searches?
A comparative study of clinical end-user and librarian searches.
Comput Biomed
Res
1990; 23: 583-93. 2. Fox GN. Computer literature searching: will docs byte? Fam Pract Res J 1991; 11: 9-14.
Audit and research SIR,-Professor Sherwood (July 4, p 37) implies that we must choose between audit and research. The use of audit funds to address questions more appropriately answered by research lends some support to his contention but highlights a fundamental difference between the two activities-the nature of the question being asked. In audit one is asking whether an activity, known to be capable of achieving a specific outcome, is actually achieving that outcome in the hands of those undertaking the audit. This presupposes knowledge of efficacy, measurability of outcome, and agreement on an acceptable standard against which performance can be measured. Audit is about doing the right thing and doing it better-is an efficacious intervention effective? In this context research is asking what the right thing is. Free thinking and audit are not incompatible, although the scope for the former may be restricted in the setting of the latter. The lack of knowledge about the efficacy of many medical interventions (and, I suspect, the difficulties of obtaining support for small research projects) underlies the move to conduct research in the context of audit. The constraints of the audit cycle, the questions about who it is for, and the fears expressed by Sherwood about "dullness" and "intellectual coercion" are likely to lead to poor research as well as ineffective audit despite the apparent increase in a questioning attitude that is engendered by the profession embracing audit. One solution to this paradox is to restrict formal audit activity to those topics for which it is appropriate-namely, interventions with
