The ADR Numbers Game Revisited The numbers game has not
apparently wild public
on
run
drug
adverse
its
course.
reactions (ADRs) We continue to witness
purported morbidity and already been pointed out, ADRs are an inevitable consequence of medical practice.1 The aim of good therapy, therefore, is to decrease ADRs tality
caused
statements
by
of
mor-
ADRs. As has
the irreducible minimum. Yet, many critics of the medical profession seem to imply that, given a system of closer surveillance of therapeutics, the ADR problem could be eliminated altogether. As every physician knows, this is to
nonsense.
A basic tenet of good scientific problem-solving is to identify the problem, determine its extent, and then advocate remedial measures. That a problem of preventable ADRs exists cannot be denied; the literature abounds with references to the prescription of the wrong drug or dose, to unforeseen drug interactions, or simply to the administration of a drug when none was indicated. How extensive this problem may be is quite another matter. Despite the various speculations and extrapolations from fragmen¬ tary data, the simple fact is that no one really knows. This is the message that is so well reported by Karch and Lasagna in this issue of The Journal (p 1236). After a painstaking analysis of the ADR literature, the authors conclude that the data "are incomplete, unrepresentative, uncontrolled, and lacking in operational criteria for iden¬ tifying ADRs." They further observe that
quantitative conclusions can be drawn from the reported data in regard to morbidity, mortality, or the underlying causes of ADRs, and attempts to extrapolate the available data to the general population would be invalid and perhaps mis¬ no
leading.
Having acknowledged that a problem exists but not knowing the extent of the problem, the only logical con¬ clusion one can come to is that properly designed studies must be undertaken, including investigations of the out¬ come of drug therapy, in order to provide perspective on the risk vs benefit aspects of therapeutics. This is precisely what Karch and Lasagna have proposed. Until such studies
are performed, the authors call for a moratorium on reck¬ less ADR statements and estimates. To this recommenda¬ tion, one can only conclude, "amen."
John C. Ballin, PhD, Director AMA Department of Drugs 1. Ballin
JC: The ADR numbers
game.
Address editorial communications to the
JAMA 229:1097-1098,
1974.
International Classification of Health Problems in Primary Care The content of medical care given in the ambulatory setting is for the most part unknown.1 The need for these kinds of data by health care providers, health planners, government agencies, and epidemiologists is apparent. The ability to compile data about health problems of ambulatory patients has been impeded by the lack of a suitable classification. Attempts to use the International Classification of Diseases (ICD) to classify health problems encountered by general practitioners have often been unsuccessful.2 Physicians in England, Canada, Australia, Germany, and other countries have developed ambulatory classifications, but these several classifications have often neither been compatible with each other nor with the ICD. It is, therefore, of considerable interest to primary care physicians that a new international classification of health problems, specifically designed for their use, has been developed. The International Classification of Health Problems in Primary Care (ICHPPC) was approved by the World Organization of National Colleges and Academies of General Practice-Family Medicine (WONCA) at a meeting in Mexico City in November 1973. The classification was developed by a working party of that group and field tested for one year at multiple sites in nine countries. More than 300 practices participated and data on more than 100,000 doctor-patient contacts were collected. The classification contains somewhat less than 400 separate categories divided into 18 sections. Individual categories were chosen because of frequency of occurrence, importance of the health problem, and its ability to be diagnosed in the primary -care setting. The ICHPPC is completely compatible with both the ICD Eighth Revision3 and the ICD Adapted4 and uses a similar numbering system. Arrangements have been made for ICHPPC to be translated into French, Spanish, German, and Norwegian. The classification is suitable for use in all primary care sites including physicians' offices, emergency rooms, and organized outpatient clinics. The data can be recorded and retrieved by means of manual systems, such as the diagnostic index (E book), and also with computer techniques. The ICHPPC will be published by the American Hospital Association and will be available from them soon. Jack Froom, MD Rochester, NY
Editor, 535 N Dearborn St, Chicago 60610
Downloaded From: http://jama.jamanetwork.com/ by a Yale University User on 05/18/2015
apparently wild public
on
run
drug
adverse
its
course.
reactions (ADRs) We continue to witness
purported morbidity and already been pointed out, ADRs are an inevitable consequence of medical practice.1 The aim of good therapy, therefore, is to decrease ADRs tality
caused
statements
by
of
mor-
ADRs. As has
the irreducible minimum. Yet, many critics of the medical profession seem to imply that, given a system of closer surveillance of therapeutics, the ADR problem could be eliminated altogether. As every physician knows, this is to
nonsense.
A basic tenet of good scientific problem-solving is to identify the problem, determine its extent, and then advocate remedial measures. That a problem of preventable ADRs exists cannot be denied; the literature abounds with references to the prescription of the wrong drug or dose, to unforeseen drug interactions, or simply to the administration of a drug when none was indicated. How extensive this problem may be is quite another matter. Despite the various speculations and extrapolations from fragmen¬ tary data, the simple fact is that no one really knows. This is the message that is so well reported by Karch and Lasagna in this issue of The Journal (p 1236). After a painstaking analysis of the ADR literature, the authors conclude that the data "are incomplete, unrepresentative, uncontrolled, and lacking in operational criteria for iden¬ tifying ADRs." They further observe that
quantitative conclusions can be drawn from the reported data in regard to morbidity, mortality, or the underlying causes of ADRs, and attempts to extrapolate the available data to the general population would be invalid and perhaps mis¬ no
leading.
Having acknowledged that a problem exists but not knowing the extent of the problem, the only logical con¬ clusion one can come to is that properly designed studies must be undertaken, including investigations of the out¬ come of drug therapy, in order to provide perspective on the risk vs benefit aspects of therapeutics. This is precisely what Karch and Lasagna have proposed. Until such studies
are performed, the authors call for a moratorium on reck¬ less ADR statements and estimates. To this recommenda¬ tion, one can only conclude, "amen."
John C. Ballin, PhD, Director AMA Department of Drugs 1. Ballin
JC: The ADR numbers
game.
Address editorial communications to the
JAMA 229:1097-1098,
1974.
International Classification of Health Problems in Primary Care The content of medical care given in the ambulatory setting is for the most part unknown.1 The need for these kinds of data by health care providers, health planners, government agencies, and epidemiologists is apparent. The ability to compile data about health problems of ambulatory patients has been impeded by the lack of a suitable classification. Attempts to use the International Classification of Diseases (ICD) to classify health problems encountered by general practitioners have often been unsuccessful.2 Physicians in England, Canada, Australia, Germany, and other countries have developed ambulatory classifications, but these several classifications have often neither been compatible with each other nor with the ICD. It is, therefore, of considerable interest to primary care physicians that a new international classification of health problems, specifically designed for their use, has been developed. The International Classification of Health Problems in Primary Care (ICHPPC) was approved by the World Organization of National Colleges and Academies of General Practice-Family Medicine (WONCA) at a meeting in Mexico City in November 1973. The classification was developed by a working party of that group and field tested for one year at multiple sites in nine countries. More than 300 practices participated and data on more than 100,000 doctor-patient contacts were collected. The classification contains somewhat less than 400 separate categories divided into 18 sections. Individual categories were chosen because of frequency of occurrence, importance of the health problem, and its ability to be diagnosed in the primary -care setting. The ICHPPC is completely compatible with both the ICD Eighth Revision3 and the ICD Adapted4 and uses a similar numbering system. Arrangements have been made for ICHPPC to be translated into French, Spanish, German, and Norwegian. The classification is suitable for use in all primary care sites including physicians' offices, emergency rooms, and organized outpatient clinics. The data can be recorded and retrieved by means of manual systems, such as the diagnostic index (E book), and also with computer techniques. The ICHPPC will be published by the American Hospital Association and will be available from them soon. Jack Froom, MD Rochester, NY
Editor, 535 N Dearborn St, Chicago 60610
Downloaded From: http://jama.jamanetwork.com/ by a Yale University User on 05/18/2015
