978
infant mortality; and employing more obstetricians may not help? Experience at SFKW supports the view that in a developed country a caesarean rate kept down to 1 % can be accompanied by combined intrauterine/infant mortality rates of only 10 per 1000. Yet the obstetric scene is coloured by inducements to higher caesarean rates. Obstetricians can make more money this way and there are few constraints on miscreants-hence comments on policies such as
("unacceptable "unbelievable").
ours
...
in any
developed country", "aggressive",
Department of Obstetrics and Gynaecology, University of Vienna, and Ignaz Semmelweis Frauenklinik,
ALFRED ROCKENSCHAUB
A-1180 Vienna, Austria
Pillai VK. Patterns of determinants of infant mortality in developed nations, 1950-1975. Demography 1986; 23: 525-42. 2. Kock Ch, Kytir J, Munz R. Risiko "Sauglingstod". 1988; Schnften der Österr Akad d 1.
Pampel FC,
Wissensch. Deuucke Wien.
Hospital admission in twin .
Projected
pregnancy
SiR,—We were interested to read that a prospective randomised trial (Feb 3, p 267) has again1 failed to show any reduction in premature delivery from routine admission of twin pregnancies. We studied the outcome of twin pregnancies to European women delivering in Bradford under the care of two consultants over the five years 1980-85. Consultant A admitted patients with twins at 30 weeks for 10-14 days’ rest. Consultant B only admitted women with twin pregnancies at the patient’s request or for other obstetric indications. The groups were analysed by consultant rather than whether they were admitted for rest (ie, by intention to treat). The results are:
On its own this small study is hardly conclusive, but taken with the Zimbabwe triaP and Dr MacLennan and colleagues’ study evidence is accumulating that rest may even increase premature labour. There is other evidence that labour is most likely to start when the mother is relaxed or asleep2-4 and it has been postulated that fetal adrenal activity (long known to be involved in the onset of labour) may be at a peak when maternal activity is least.4 It is therefore at least plausible that rest could precipitate labour. Department of Obstetrics and St James’ Hospital, Leeds LS9 7TF, UK
Gynaecology,
J. G. THORNTON D. J. ROUT
2. 3 4.
Hormone
replacement therapy for osteoporosis
220) refers to a report from the organisation funded by the pharmaceutical industry, claiming that widespread use of long-term hormone replacement therapy (HRT) could halve the incidence of fractured neck of femur in postmenopausal women and save £ 33 million a year now and £ 70 million by the year 2011. We are SjR,—A Lancet note (Jan 27, p Office of Health Economics,’
an
concerned that health service managers may be under pressure
to
of fractured neck of femur.
introduce screening or treatment programmes on the basis of a report that pays scant regard to health economics, epidemiology, or the practicalities. The claim of 50% efficacy for HRT in reducing fracture neck of femur is based on a retrospective study2 of women who have previously taken HRT. That study did not take account of selection, uptake rates, or compliance, and is not a proper investigation of the efficacy of a preventive measure in a population. A more realistic forecast for the efficacy of a screening programme to prevent osteoporosis would include an uptake rate of 70% (as found for breast cancer screening), which might be further reduced by women who refuse treatment or have contraindications; a sensitivity of 65% (the ability of screening test to identify true positives), as suggested from a study on bone density and risk of fracture;3 and 30% compliance with daily therapy for 10 years in well-motivated women. Such a programme would be unlikely to reduce hip incidence in 20 years time by more than 5-10%. The figure compares the impact of an HRT programme with Office of Health Economics assumptions and with more realistic ones for postmenopausal women in the Trent region. Most hip fractures present after the age of 75. HRT has the greatest effect on bone mineral loss if taken for 6 years or more in the immediate postmenopausal period,’ when it delays the onset of osteoporosis. A significant reduction in fractures is unlikely for at least 20 years (figure). Cost savings 20 years into the future are worth less than if they were to be seen now, and in cost-benefit analyses future cost savings are currently discounted by 6% per annum. This was not done in the Office of Health Education report. We have analysed the figures for Trent region and have not derived a net
MC, Dick JS, Brown IMcL, McPherson K, Chalmers I. The effects of hospital admission for bed rest on the duration oftwin pregnancy a randomised trial. Lancet 1985; ii 793-95 Charles E. The hour of birth. Br J Prev Soc Med 1953: 7: 43-59. Shettles LB. Hourly variation in onset of labour and rupture of membranes Am J Obstet Gynecol 1960: 79: 177 Turnbull AC, Anderson ABM. Uterine function in human pregnancy and labour. In: MacDonald RR, ed. Scientific basis of obstetrics and gynaecology. Edinburgh; Churchill Livingstone, 1978.
1. Saunders
cases
Women aged 45, Trent region. = No expected without prevention. =No expected with screening programme and HRT —B—B—= No with Office of Health Economics’ assumptions
saving.
The full health effects of HRT have not yet been formally evaluated. The addition of progestagen in combined preparations is fairly recent and its long-term effects are still unknown. A prospective trial in Oxford is expected to report within four years. We need those results plus a rigorous cost-benefit analysis before large numbers of women are put on long-term HRT. Trent Regional Health Authority, Sheffield S10 3TH, UK
FRANCES A. PITT
Medical Care Research Unit, Department of Public Health Medicine, Sheffield University
JOHN BRAZIER
1. Griffin J
Osteoporosis and the risk of fracture. London: Office of Health Economics,
1990. 2. Weiss NS, Ure 3. 4
CL, et al Decreased risk of fractures of the hip and lower forearm with postmenopausal use of estrogen. N Engl J Med 1980: 303: 1195-98. Wasnich RD, Ross PD, et al. Prediction of postmenopausal fracture risk with use of bone mineral measurements. Am J Obstet Gynecol 1985 (Dec): 745-51. Lindsay R, Hart DM, MacLean A, Clark AC, Kraszewski A, Garwood J, et al Bone response to termination of oestrogen treatment. Lancet 1978 i: 1325-27
infant mortality; and employing more obstetricians may not help? Experience at SFKW supports the view that in a developed country a caesarean rate kept down to 1 % can be accompanied by combined intrauterine/infant mortality rates of only 10 per 1000. Yet the obstetric scene is coloured by inducements to higher caesarean rates. Obstetricians can make more money this way and there are few constraints on miscreants-hence comments on policies such as
("unacceptable "unbelievable").
ours
...
in any
developed country", "aggressive",
Department of Obstetrics and Gynaecology, University of Vienna, and Ignaz Semmelweis Frauenklinik,
ALFRED ROCKENSCHAUB
A-1180 Vienna, Austria
Pillai VK. Patterns of determinants of infant mortality in developed nations, 1950-1975. Demography 1986; 23: 525-42. 2. Kock Ch, Kytir J, Munz R. Risiko "Sauglingstod". 1988; Schnften der Österr Akad d 1.
Pampel FC,
Wissensch. Deuucke Wien.
Hospital admission in twin .
Projected
pregnancy
SiR,—We were interested to read that a prospective randomised trial (Feb 3, p 267) has again1 failed to show any reduction in premature delivery from routine admission of twin pregnancies. We studied the outcome of twin pregnancies to European women delivering in Bradford under the care of two consultants over the five years 1980-85. Consultant A admitted patients with twins at 30 weeks for 10-14 days’ rest. Consultant B only admitted women with twin pregnancies at the patient’s request or for other obstetric indications. The groups were analysed by consultant rather than whether they were admitted for rest (ie, by intention to treat). The results are:
On its own this small study is hardly conclusive, but taken with the Zimbabwe triaP and Dr MacLennan and colleagues’ study evidence is accumulating that rest may even increase premature labour. There is other evidence that labour is most likely to start when the mother is relaxed or asleep2-4 and it has been postulated that fetal adrenal activity (long known to be involved in the onset of labour) may be at a peak when maternal activity is least.4 It is therefore at least plausible that rest could precipitate labour. Department of Obstetrics and St James’ Hospital, Leeds LS9 7TF, UK
Gynaecology,
J. G. THORNTON D. J. ROUT
2. 3 4.
Hormone
replacement therapy for osteoporosis
220) refers to a report from the organisation funded by the pharmaceutical industry, claiming that widespread use of long-term hormone replacement therapy (HRT) could halve the incidence of fractured neck of femur in postmenopausal women and save £ 33 million a year now and £ 70 million by the year 2011. We are SjR,—A Lancet note (Jan 27, p Office of Health Economics,’
an
concerned that health service managers may be under pressure
to
of fractured neck of femur.
introduce screening or treatment programmes on the basis of a report that pays scant regard to health economics, epidemiology, or the practicalities. The claim of 50% efficacy for HRT in reducing fracture neck of femur is based on a retrospective study2 of women who have previously taken HRT. That study did not take account of selection, uptake rates, or compliance, and is not a proper investigation of the efficacy of a preventive measure in a population. A more realistic forecast for the efficacy of a screening programme to prevent osteoporosis would include an uptake rate of 70% (as found for breast cancer screening), which might be further reduced by women who refuse treatment or have contraindications; a sensitivity of 65% (the ability of screening test to identify true positives), as suggested from a study on bone density and risk of fracture;3 and 30% compliance with daily therapy for 10 years in well-motivated women. Such a programme would be unlikely to reduce hip incidence in 20 years time by more than 5-10%. The figure compares the impact of an HRT programme with Office of Health Economics assumptions and with more realistic ones for postmenopausal women in the Trent region. Most hip fractures present after the age of 75. HRT has the greatest effect on bone mineral loss if taken for 6 years or more in the immediate postmenopausal period,’ when it delays the onset of osteoporosis. A significant reduction in fractures is unlikely for at least 20 years (figure). Cost savings 20 years into the future are worth less than if they were to be seen now, and in cost-benefit analyses future cost savings are currently discounted by 6% per annum. This was not done in the Office of Health Education report. We have analysed the figures for Trent region and have not derived a net
MC, Dick JS, Brown IMcL, McPherson K, Chalmers I. The effects of hospital admission for bed rest on the duration oftwin pregnancy a randomised trial. Lancet 1985; ii 793-95 Charles E. The hour of birth. Br J Prev Soc Med 1953: 7: 43-59. Shettles LB. Hourly variation in onset of labour and rupture of membranes Am J Obstet Gynecol 1960: 79: 177 Turnbull AC, Anderson ABM. Uterine function in human pregnancy and labour. In: MacDonald RR, ed. Scientific basis of obstetrics and gynaecology. Edinburgh; Churchill Livingstone, 1978.
1. Saunders
cases
Women aged 45, Trent region. = No expected without prevention. =No expected with screening programme and HRT —B—B—= No with Office of Health Economics’ assumptions
saving.
The full health effects of HRT have not yet been formally evaluated. The addition of progestagen in combined preparations is fairly recent and its long-term effects are still unknown. A prospective trial in Oxford is expected to report within four years. We need those results plus a rigorous cost-benefit analysis before large numbers of women are put on long-term HRT. Trent Regional Health Authority, Sheffield S10 3TH, UK
FRANCES A. PITT
Medical Care Research Unit, Department of Public Health Medicine, Sheffield University
JOHN BRAZIER
1. Griffin J
Osteoporosis and the risk of fracture. London: Office of Health Economics,
1990. 2. Weiss NS, Ure 3. 4
CL, et al Decreased risk of fractures of the hip and lower forearm with postmenopausal use of estrogen. N Engl J Med 1980: 303: 1195-98. Wasnich RD, Ross PD, et al. Prediction of postmenopausal fracture risk with use of bone mineral measurements. Am J Obstet Gynecol 1985 (Dec): 745-51. Lindsay R, Hart DM, MacLean A, Clark AC, Kraszewski A, Garwood J, et al Bone response to termination of oestrogen treatment. Lancet 1978 i: 1325-27
