232
Routine
diagnostic testing
SiR,—The concerns you express in your Nov 18 editorial are even cogent on this side of the Atlantic since medical costs continue rise unabated, approaching$600 billion in 1989. In the US most doctors developed their style of practice of ’occupational rituals’ in patient management", as you say, in an era when health care dollars were plentiful. But American companies can no longer be competitive in a world market with such excessive health care costs, and ways should be found to reduce the 20-60% of the laboratory "testing which may be unnecessary".1 To establish a successful educational intervention, one must clearly demonstrate that the frugal and intelligent use of diagnostic resources is consistent with high quality care, rather than detracting from care. This "principle of parsimony" has been demonstrated on a small scale in both the US and the UK,2,3 But it will probably be practised more broadly in the US beginning in 1990 when joint guidelines developed by Blue Cross/Blue Shield, the largest private health insurer, and the American College of Physicians are implemented. The guidelines advise doctors when to order fifteen commonly used diagnostic tests that account for more than$30 billion a year in health care costs 4°5 On the basis of the premise that unnecessary tests are by definition bad quality medicine, these tests, which represent 90% of all hospital tests, will not be paid for when ordered inappropriately. This initiative will undoubtedly govern the practice of medicine and occupational rituals in the US for the decade.
more
to "
Brown University Program in Family Medicine, Memorial Hospital of Rhode Island, Pawtucket, Rhode Island 02860, USA
PATRICK T. DOWLING
1. Angell M. Cost containment and the physicians. JAMA 1985; 254: 1203-07. 2. Fowkes FGR, Davies ER, Evans KT, et al. Multicentre trial of four strategies to reduce use of a radiological test. Lancet 1986; i: 367-70.
Dowling PT, Alfonsi G, Brown MI, Culpepper L. An education program to reduce unnecessary laboratory tests by residents. Acad Med 1989; 64: 410-12 4. Freudenheim M. New guidelines on medical tests issued in attempt to control costs. New York Times April 2, 1987: A1. 5. Sox HC. Probability theory in the use of diagnostic tests. Ann Intern Med 1986; 104: 3.
60-66.
Diagnostic related
groups in neonatal medicine
SiR,—Dr McKee and Ms Jenkins (Dec 9, p 1397) suggest that our doubts about the use of diagnostic related groups (DRGs) in neonatal medicine (Nov 18, p 1221) were misplaced. We grouped together the main activity related DRGs in neonatal medicine (386, 387, 389) obtained over one year for each perinatal unit in the Trent health region. We found little relation to ventilator days, the accepted measure of performance. We did this grouping for the sake of brevity. McKee and Jenkins felt this to be inappropriate and supply the most recent US weightings for VENTILATOR DAYS FOR PERINATAL UNITS AND TOTAL VALUE FOR THREE ACTIVITY RELATED DRGS AFTER WEIGHTING
to these DRGs (3.648, 1.8267, and 0.5425, respectively). We wish therefore to reinforce our previous comments by supplying the total value of the DRGs 386, 387, and 389 for each unit after multiplication by the "appropriate" weightings and comparing the values to ventilator days (table). The ability of these DRGs to determine prospective funding are clearly and would cause major discrepancies if not improved, implemented.
payment relating
We feel that insufficient attention has been paid to basic differences between the US system of health care and that in the UK. Clearly the fact that even in the USA it has been necessary to refine DRGs for neonatal care to include data such as ventilator days indicates that there too difficulties have arisen. Our intention in our previous communication was to point out that work is needed now to develop an appropriate system for the UK. Department of Child Health, Clinical Sciences Building, Leicester Royal Infirmary, Leicester LE2 7LX, UK
D. J. FIELD P. CHETCUTI
Euthanasia SIR,-It seems to me that most non-Kantian arguments against (active) euthanasia are based on the same dubious premisenamely, that legislation would inevitably have unacceptable medical and social consequences. Voluntary euthanasia of a small number of competent, terminally ill patients will, according to this view, eventually lead to involuntary euthanasia of many patients with incurable diseases or handicaps. Professor Reichel and Professor Dyck (Dec 2, p 1321) list several presumed harmful effects of legalised euthanasia. Such statements are empirical, the truth or falseness of which can and should be decided empirically. Reichel and Dyck mention that active euthanasia under certain conditions is allowed in the Netherlands. A logical question is, therefore, can the Dutch experience verify these ominous predictions? Further, has voluntary euthanasia turned involuntary? Has mercy killing become a substitute for traditional terminal care? To the best of my knowledge this is not so, which is probably why advocates of euthanasia more often speak of the practice in the Netherlands than do their opponents. What is the public opinion? Polls in various countries have shown surprisingly similar results. 50-69% are in favour of some kind of euthanasia.1 In Holland the figure is higher, at 75%.2 Most of my patients do not seem to be afraid to die, but some are afraid that it will happen in a painful and unworthy way. Unfortunately such fears are not totally groundless despite the resources of modem terminal care. Department of Thoracic Medicine, Karolinska Hospital, S-114 01 Stockholm, Sweden
CARL-ERIC BERGSTROM
1. Stehbens WE. Euthanasia. NZ Med J 1986; 99: 190-93. 2. Pence EP. Do not go slowly into that dark night: mercy killing in Holland. Am Med
J
1988; 84: 139-41.
Hypothermia in elderly people SIR,-At an appropriate time of year to consider the thermal conditions of elderly people, Dr Woodhouse and colleagues (Nov 18, p 1201) describe 14 patients with hypothermia admitted to hospital during five months in winter and show that most cases are attributable to the functional effects of acute illness, such as falls and immobility among the old. Body-worn alarms, which are becoming increasingly popular among elderly people, might be a suitable preventative measure. Unfortunately there may be waiting lists for obtaining such a device from the local authority and patients might find the cost of a private device prohibitive. I would suggest an opportunistic measure to prevent hypothermia that avoids the need for an overall measure or for case-fmding.1 This idea arose from a survey of elderly patients’ home temperatures done with colleagues in this
department.
233
The study population consisted of 122 consecutive patients for whom a domiciliary consultation was requested during the severe winter weather of January-March, 1987, the coldest part of Woodhouse and colleagues’ study. The temperature of the homes of 103 patients were measured with a standard room thermometer. Of the 19 excluded patients, 15 were living in residential homes, 1 had died, 2 did not answer, and 1 had a missing measurement. All visits took place in the morning. The median temperature of rooms in which the patient was seen (82 sitting rooms, 21 bedrooms) was 20°C (range 12-28). Overall just under half the patients seen were in cold conditions: 13 patients were in very cold conditions (16°C or less) and a further 38 patients were at or below 18°C, the World Health Organisation’s minimum recommended temperature for
elderly people.2 This series, selected
on
the basis of ill health, indicates
some
potential for intervening to improve the thermal safety of elderly people who are unwell. All those who have professional contact with elderly people could carry thermometers. Alternatively a simple maximum/minimum thermometer to assist third-party monitoring of home temperature might make a good present for an elderly relative. Department of Geriatric Medicine, Barnet General Hospital, Barnet, Hertfordshire EN5 3DJ, UK
1.
Oty CJ, Roland
MO.
Hypothermia in the elderly:
EDWARD DICKINSON
scope for prevention. Br
Med J
1987; 297: 419-20. 2 World Health Organisation. The effects of the indoor housing climate on the health of the elderly Graz: WHO, 1982.
Complement activation by polystarch and gelatine volume expanders SIR,-Intravenous colloid infusions are used for volume replacement and for more specific functions such as thromboprophylaxis (dextran) and the treatment of microcirculation disorders. Although several substances are theoretically useful for volume substitution, in practice the choice is limited to plasma protein solutions and to "artificial" products (dextran, gelatines, and hetastarch [hydroxyethyl starch]). All these products carry the risk of anaphylactoid reaction, and there is the additional risk of transmission of infectious disease associated with plasma protein infusions. These factors, coupled with considerations of cost, have led to the predominant use in the UK of modified gelatines. Data on clinically severe life-threatening anaphylactoid reactions to plasma substitutes are limited, though a frequency of 1 in 10 000 or so for all these substances is widely accepted.1 The much higher frequency reported for certain polygelatines proved to be due to excessive diisocyanate as an impurity of the manufacturing process. That problem now seems to have been solved and the cheapness of this product has become a major attraction. The polystarches, which offer better manufacturing control of colloid size and thus of osmotic control, have taken second place, largely because of cost. The polystarches have been regarded with the suspicion that, by accumulating in the reticuloendothelial system, they might compromise phagocytic activity, perhaps increasing the risk of fatal septicaemia after major surgery. There is little evidence that this is a major problem clinically but we were interested in reports2 that polystarch activates complement in vivo, since activation might be seen as beneficial or hazardous, depending upon pathway. The availability of nafamostat (’Futhan’; Amersham International) as a plasma stabiliser which, when used with EDTA, preserves the in-vivo complement activation profile,3 has allowed us to measure, with Amersham radioimmunoassay kits, anaphylatoxin fragments C3a and C4a and to detect as little as 1 % or 2 % activation of native complement. Twelve patients undergoing major surgery and taking part in a clinical trial of ’ELOHES’, a polystarch with low molecular weight of 200 000 (Oxford Nutrition), or polygelatine (’Haemacce1’; Hoechst), for postoperative volume replacement were randomly selected for detailed complement assay.
C3a ANAPHYLATOXIN RELEASE BY PLASMA VOLUME EXPANDERS
*p
Routine
diagnostic testing
SiR,—The concerns you express in your Nov 18 editorial are even cogent on this side of the Atlantic since medical costs continue rise unabated, approaching$600 billion in 1989. In the US most doctors developed their style of practice of ’occupational rituals’ in patient management", as you say, in an era when health care dollars were plentiful. But American companies can no longer be competitive in a world market with such excessive health care costs, and ways should be found to reduce the 20-60% of the laboratory "testing which may be unnecessary".1 To establish a successful educational intervention, one must clearly demonstrate that the frugal and intelligent use of diagnostic resources is consistent with high quality care, rather than detracting from care. This "principle of parsimony" has been demonstrated on a small scale in both the US and the UK,2,3 But it will probably be practised more broadly in the US beginning in 1990 when joint guidelines developed by Blue Cross/Blue Shield, the largest private health insurer, and the American College of Physicians are implemented. The guidelines advise doctors when to order fifteen commonly used diagnostic tests that account for more than$30 billion a year in health care costs 4°5 On the basis of the premise that unnecessary tests are by definition bad quality medicine, these tests, which represent 90% of all hospital tests, will not be paid for when ordered inappropriately. This initiative will undoubtedly govern the practice of medicine and occupational rituals in the US for the decade.
more
to "
Brown University Program in Family Medicine, Memorial Hospital of Rhode Island, Pawtucket, Rhode Island 02860, USA
PATRICK T. DOWLING
1. Angell M. Cost containment and the physicians. JAMA 1985; 254: 1203-07. 2. Fowkes FGR, Davies ER, Evans KT, et al. Multicentre trial of four strategies to reduce use of a radiological test. Lancet 1986; i: 367-70.
Dowling PT, Alfonsi G, Brown MI, Culpepper L. An education program to reduce unnecessary laboratory tests by residents. Acad Med 1989; 64: 410-12 4. Freudenheim M. New guidelines on medical tests issued in attempt to control costs. New York Times April 2, 1987: A1. 5. Sox HC. Probability theory in the use of diagnostic tests. Ann Intern Med 1986; 104: 3.
60-66.
Diagnostic related
groups in neonatal medicine
SiR,—Dr McKee and Ms Jenkins (Dec 9, p 1397) suggest that our doubts about the use of diagnostic related groups (DRGs) in neonatal medicine (Nov 18, p 1221) were misplaced. We grouped together the main activity related DRGs in neonatal medicine (386, 387, 389) obtained over one year for each perinatal unit in the Trent health region. We found little relation to ventilator days, the accepted measure of performance. We did this grouping for the sake of brevity. McKee and Jenkins felt this to be inappropriate and supply the most recent US weightings for VENTILATOR DAYS FOR PERINATAL UNITS AND TOTAL VALUE FOR THREE ACTIVITY RELATED DRGS AFTER WEIGHTING
to these DRGs (3.648, 1.8267, and 0.5425, respectively). We wish therefore to reinforce our previous comments by supplying the total value of the DRGs 386, 387, and 389 for each unit after multiplication by the "appropriate" weightings and comparing the values to ventilator days (table). The ability of these DRGs to determine prospective funding are clearly and would cause major discrepancies if not improved, implemented.
payment relating
We feel that insufficient attention has been paid to basic differences between the US system of health care and that in the UK. Clearly the fact that even in the USA it has been necessary to refine DRGs for neonatal care to include data such as ventilator days indicates that there too difficulties have arisen. Our intention in our previous communication was to point out that work is needed now to develop an appropriate system for the UK. Department of Child Health, Clinical Sciences Building, Leicester Royal Infirmary, Leicester LE2 7LX, UK
D. J. FIELD P. CHETCUTI
Euthanasia SIR,-It seems to me that most non-Kantian arguments against (active) euthanasia are based on the same dubious premisenamely, that legislation would inevitably have unacceptable medical and social consequences. Voluntary euthanasia of a small number of competent, terminally ill patients will, according to this view, eventually lead to involuntary euthanasia of many patients with incurable diseases or handicaps. Professor Reichel and Professor Dyck (Dec 2, p 1321) list several presumed harmful effects of legalised euthanasia. Such statements are empirical, the truth or falseness of which can and should be decided empirically. Reichel and Dyck mention that active euthanasia under certain conditions is allowed in the Netherlands. A logical question is, therefore, can the Dutch experience verify these ominous predictions? Further, has voluntary euthanasia turned involuntary? Has mercy killing become a substitute for traditional terminal care? To the best of my knowledge this is not so, which is probably why advocates of euthanasia more often speak of the practice in the Netherlands than do their opponents. What is the public opinion? Polls in various countries have shown surprisingly similar results. 50-69% are in favour of some kind of euthanasia.1 In Holland the figure is higher, at 75%.2 Most of my patients do not seem to be afraid to die, but some are afraid that it will happen in a painful and unworthy way. Unfortunately such fears are not totally groundless despite the resources of modem terminal care. Department of Thoracic Medicine, Karolinska Hospital, S-114 01 Stockholm, Sweden
CARL-ERIC BERGSTROM
1. Stehbens WE. Euthanasia. NZ Med J 1986; 99: 190-93. 2. Pence EP. Do not go slowly into that dark night: mercy killing in Holland. Am Med
J
1988; 84: 139-41.
Hypothermia in elderly people SIR,-At an appropriate time of year to consider the thermal conditions of elderly people, Dr Woodhouse and colleagues (Nov 18, p 1201) describe 14 patients with hypothermia admitted to hospital during five months in winter and show that most cases are attributable to the functional effects of acute illness, such as falls and immobility among the old. Body-worn alarms, which are becoming increasingly popular among elderly people, might be a suitable preventative measure. Unfortunately there may be waiting lists for obtaining such a device from the local authority and patients might find the cost of a private device prohibitive. I would suggest an opportunistic measure to prevent hypothermia that avoids the need for an overall measure or for case-fmding.1 This idea arose from a survey of elderly patients’ home temperatures done with colleagues in this
department.
233
The study population consisted of 122 consecutive patients for whom a domiciliary consultation was requested during the severe winter weather of January-March, 1987, the coldest part of Woodhouse and colleagues’ study. The temperature of the homes of 103 patients were measured with a standard room thermometer. Of the 19 excluded patients, 15 were living in residential homes, 1 had died, 2 did not answer, and 1 had a missing measurement. All visits took place in the morning. The median temperature of rooms in which the patient was seen (82 sitting rooms, 21 bedrooms) was 20°C (range 12-28). Overall just under half the patients seen were in cold conditions: 13 patients were in very cold conditions (16°C or less) and a further 38 patients were at or below 18°C, the World Health Organisation’s minimum recommended temperature for
elderly people.2 This series, selected
on
the basis of ill health, indicates
some
potential for intervening to improve the thermal safety of elderly people who are unwell. All those who have professional contact with elderly people could carry thermometers. Alternatively a simple maximum/minimum thermometer to assist third-party monitoring of home temperature might make a good present for an elderly relative. Department of Geriatric Medicine, Barnet General Hospital, Barnet, Hertfordshire EN5 3DJ, UK
1.
Oty CJ, Roland
MO.
Hypothermia in the elderly:
EDWARD DICKINSON
scope for prevention. Br
Med J
1987; 297: 419-20. 2 World Health Organisation. The effects of the indoor housing climate on the health of the elderly Graz: WHO, 1982.
Complement activation by polystarch and gelatine volume expanders SIR,-Intravenous colloid infusions are used for volume replacement and for more specific functions such as thromboprophylaxis (dextran) and the treatment of microcirculation disorders. Although several substances are theoretically useful for volume substitution, in practice the choice is limited to plasma protein solutions and to "artificial" products (dextran, gelatines, and hetastarch [hydroxyethyl starch]). All these products carry the risk of anaphylactoid reaction, and there is the additional risk of transmission of infectious disease associated with plasma protein infusions. These factors, coupled with considerations of cost, have led to the predominant use in the UK of modified gelatines. Data on clinically severe life-threatening anaphylactoid reactions to plasma substitutes are limited, though a frequency of 1 in 10 000 or so for all these substances is widely accepted.1 The much higher frequency reported for certain polygelatines proved to be due to excessive diisocyanate as an impurity of the manufacturing process. That problem now seems to have been solved and the cheapness of this product has become a major attraction. The polystarches, which offer better manufacturing control of colloid size and thus of osmotic control, have taken second place, largely because of cost. The polystarches have been regarded with the suspicion that, by accumulating in the reticuloendothelial system, they might compromise phagocytic activity, perhaps increasing the risk of fatal septicaemia after major surgery. There is little evidence that this is a major problem clinically but we were interested in reports2 that polystarch activates complement in vivo, since activation might be seen as beneficial or hazardous, depending upon pathway. The availability of nafamostat (’Futhan’; Amersham International) as a plasma stabiliser which, when used with EDTA, preserves the in-vivo complement activation profile,3 has allowed us to measure, with Amersham radioimmunoassay kits, anaphylatoxin fragments C3a and C4a and to detect as little as 1 % or 2 % activation of native complement. Twelve patients undergoing major surgery and taking part in a clinical trial of ’ELOHES’, a polystarch with low molecular weight of 200 000 (Oxford Nutrition), or polygelatine (’Haemacce1’; Hoechst), for postoperative volume replacement were randomly selected for detailed complement assay.
C3a ANAPHYLATOXIN RELEASE BY PLASMA VOLUME EXPANDERS
*p
