452
role of the hormone in the control of acid-base disturbance in these patients.7 Parathyroid-hormoneinduced bone disease as manifested by osteitis fibrosa is not, however, one of the major features of dialysis osteodystrophy and progresses only slowly.’ The major problem in dialysis osteodystrophy is the osteomaiacic component, with disabling bone pain and fractures. The mineralisation defect in dialysis patients cannot be attributed to hypocalcæmia.3 These patients do have plasma concentrations of 25-hydroxycholecalciferol,5 8 and one possible explanation is that 25-H.L.c. accumulates in plasma because the kidney cannot convert it to the dihydroxy metabolite-either owing to reduction in functional renal mass or because of interference with the 1a-hydroxylation mechanism. The aetiological importance of defective 1,25-dihydroxycholecalciferol production is, however, debatable : PIERIDES et a1.9 conclude that lack of this metabolite may not be wholly responsible for the osteomalacic component of dialysis osteodystrophy, and suggest that phosphate depletion may be an important contributory factor. In the formation of hydroxyapatite crystals and the mineralisation of bone, phosphate is potentially
high
as important as calcium. Hypophosphatsemic osteomalacia has been identified in dialysis patients taking oral phosphate binders,1O " and this treatment was regarded as the cause of the phosphate depletion. Back in 1971, BISHOP et al.12 suggested that dialysis with phosphate-free dialysates could lead to substantial total-body-phosphate depletion over long periods and contribute to the osteomalacia of dialysis osteodystrophy. Now Dr AHMEDand his colleagues record on p. 439 their observations in four haemodialysis patients with hypophosphataemic osteomalacia who were not taking oral phosphate binders and had not done so for some time. They attribute the phosphate depletion in these patients to a combination of intestinal malabsorption, loss during dialysis, and a low dietary intake, the last as part of their therapeutic regimen. These three mechanisms are potentially present in all patients on hæmodialysis treatment and we need to pay much more attention to phosphate status in such patients. The more important aspect of these studies is that they may have provided the clue to the missing link in dialysis osteodystrophy-in particular the osteomalacic component, with its painful disabling sequelae.
just
7. Mioni, G , Castellani, A., Cecchettin, M., Maiorca, R., Heynen, G., Franchimont, P. Lancet, 1975, i, 605. 8. Fairney, A. F., Bowling, K., Varghese, Z., Moorhead, J. F., Wills, M. R. in Vitamin D and Problems Related to Uremic Bone Disease; p. 319. Berlin, 1975. 9. Pierides, A. M., Simpson, W., Ward, M. K., Ellis, H. A., Dewar, J. H., Kerr, D. N. S. Lancet, 1976, i, 1092. 10 Baker, L. R. I., Ackrill, P, Cattell, W. R., Stamp, T. C. B., Watson, L. Br. med. J. 1975, iii, 150. 11. Mahony, J. F., Hayes, J. M., Ingham, J. P., Posen, S. ibid. 1976, ii, 142. 12. Bishop, M. C., Ledingham, J. G. G., Oliver, D. O. Proc. Eur. Dialysis Transplant Ass. 1971, 8, 106.
LEFT AXIS DEVIATION
The precise significance of the mean frontal-plane axis of the QRS complex of the electrocardiogram (E.c.G.; has been debated since the earliest days of electrocardiography.l Deflection of the axis beyond the normal range to left or right was attributed to hypertrophy of the corresponding ventricle.23 Reappraisal of this view became more important when Grant4 confirmed that the frontalplane axis was unrelated to the anatomical long axis of the heart; and it was later suggested that significant left axis deviation reflected the presence of block in the anterior radiations of the left-bundle-branch system,S Rosenbaum et a1.6 then introduced the term left anterior hemiblock in this sense, emphasising that alterations in the initial vectors made the diagnosis more specific. When their work, which was based on the results of dissection of the dog heart, was reappraised by means of craniocaudal section of the conducting system to define the anatomical distribution of the various radicles of the left bundle branch,’the situation became less clear than had been implied. The left bundle branch was shown to break up into multiple fascicles,8 usually concentrated in three definite units9 rather than just two, in keeping with electrophysiological studies on the isolated human heart which had demonstrated three sites of left ventricular activation. 10 No close correlation exists between the E.c.G. appearances of left- anterior hemiblock and the corresponding anatomical lesions, which are usually more extensive than predicted,’ 1’ unlike the situation in so-called left posterior hemiblock. 12 Vector cardiographic criteria for the detection of lesions of the centroseptal radicles13 make sense, but they await anatomical corroboration. Clearly, much remains to be done, and perhaps some confusion has been caused because the term left anterior hemiblock has been used too widely, as, for example, when left axis deviation would suffice to define the electrocardiographic appearances in some cases of inferior-wall myocardial infarction. 14 While cardiac ischaemia is an important cause of disturbed intraventricular conduction in Western countries, this does not apply in Japan, where the incidence of ischaemic heart-disease is considerably lower. A series of 1000 consecutive necropsies in aged Japanese may thus be of more than local interest. Sugiura et al." investigated people with various electrical axes, they sought evidence of coronary sclerosis as the basis for
1. Waller, A. D. Br. med. J. 1888, ii, 751 2. Einthoven, W. Pflugers Arch. ges. Physiol. 1908, 122, 517. 3. Dieuaide, F. R. Archs intern. Med. 1921, 27, 558. 4. Grant, R. P. Circulation, 1956, 14, 233. 5. Pryor, R., Blount, S. G., Jr. Am. Heart J. 1966, 72, 391. 6. Rosenbaum, M. B., Elizari, M. V., Lazzari, J. O. The Hemiblocks. Oldsmar. 1970. 7. Demoulin, J. C., Kulbertus, H. E. Br. Heart J. 1972, 34, 807. 8 Davies, M. J. Pathology of Conducting Tissue of the Heart. London, 1971 9. Uhley, H. N. Am J. Cardiol. 1972, 30, 919. 10. Durrer, D., Van Dam, R. T., Freud, G. E., Janse, M. J., Meijler, F. L., Arzbaecher, R. C. Circulation, 1970, 41, 899. 11. Rizzon, P., Latour, H., Dibiaze, M., Baissus, C. Archs Mal. Côeur, 1976.
69, 41. Demoulin, J. C., Kulbertus, H. E. Am. J. Cardiol. 1976, 37, 131. 13. Kulbertus, H. E., De Leval-Rutten, F., Casters, P. Br. Heart J. 1976. 38, 12.
549. 14. Kourtesis, P.,
Lichstein, E., Chadda, K. D., Gupta, P. K. Circulation, 1976. 53, 784. 15. Sugiura, M., Ohkawa, S., Hiraoka, K., Kuwajima, I., Ueda, K. Jap. Heart. J. 1976, 17, 25. 16. Massing, G. K., James, T. N. Circulation, 1976, 53, 609.
ischxmic myocardial lesions, and they examined consecutive unselected individuals. In only 20% of patients could significant left axis deviation be correlated with extensive myocardial necrosis, and in most patients there was no evidence of ischsemic lesions. Unfortunately, as Sugiura et al. recognise, examination of the conduction system did not meet current criteria.7 11 11 16 Despite the technical gaps, their finding that left axis deviation was common in the elderly, in the absence of ischæmic heart-disease, supports the suggestion that left axis deviation reflects a variety of pathological changes in the left bundle branch and its radicles. This is also the message from a careful study17 of intraventricular conduction in 63 persons in whom E.c.G.s were available before and after the appearance of left axis deviation. We may not seem to have come much further than Waller’ and may need to remind ourselves of Lewis’s cautious attitude to axis deviation,18 but the growing volume of clinicopathological findings is slowly to unravel the enigma of left axis deviation.
helping
AUDIT OF AUDIT IN the United Kingdom the medical profession, with its traditions of clinical freedom and its distrust of formal structures for the conduct of day-to-day life, has moved only slowly and reluctantly towards any form of quality control. In laboratory work, where the process can be seen as related more to machinery than to men, the principles are well-established and moderately widely applied;19 but most clinicians see little medical virtue in the review of their work by others. This is not to say that individuals have been idle in finding ways of examining performance both in general practice and in hospital; in addition, many ideas on shortening hospital stay, reducing admissions, and economising on resources have originated in the U.K. The American hospital tradition has been different and much more structured. Since 1918 the profession has been standardising practice and devising yardsticks for accreditation based on review of what has actually taken place within an institution. Lately, and in the wake of increased federal repayments under the Medicare and Medicaid schemes, Government has insisted on stronger and more uniform quality assurance. This has taken two forms: utilisation review, which assesses the efficiency of the hospital; and medical audit, which tries to judge professional performance, Both have been introduced (and promoted also in the U.K.20) on an axiomatic basis-that they are right and proper and that they will work. Neither has been subjected to any prospective critical analysis. A paper by McSherry,21recounting experience with utilisation review and medical audit in the department of surgery at Cornell, comes therefore as something of a surprise, because it highlights more serious difficulties and problems than most enthusiasts would have cared to admit. First, cost in money and resources: though trivial 17 Das. G ibid p. 917. 18 Lewis, T. The Mechanism and Graphic Registration of the
Heart Beat. Lon-
percentage of total expenditure, McSherry points out that the most conservative extrapolations from his data give a nationwide figure which probably exceeds the research budget of the National Institutes of Health and a workload for doctors equivalent to the full-time employment of six times the yearly number of graduates from his own medical school. Second, complexity: externally imposed rules (in this case from the New York State Department of Health) have increased the size of the guideline documents from 3 to 26 pages over some three years and led to a non-medical staff requirement of twenty at Cornell. The shortage of money in New York City and New York State is evidently provoking second-thoughts in the central administrators about continuing to implement a utilisation-review plan of this magnitude, even though it was initially thrust on the hospital by legislation. Third, effectiveness: as judged by control of length of stay, an average of 9500 hospital records have been reviewed yearly to identify 6 patients who were in hospital too long. The cost of identification per patient was reckoned at$34 212. There was no evidence that the introduction of utilisation review had had any effect on length of stay, which had remained roughly the same throughout the whole period. Medical audit, which at Cornell is the review of professional behaviour in relation to selected clinical conditions such as status asthmaticus and inguinal hernia, is exposed as having similar deficiencies. McSherry reports that a programme of 15 audits over a period of two years at a cost of$71 821 was received by the medical staff with almost total indifference. 21 It did little or nothing to alter behaviour. What, as might be expected, it did reveal was widespread lack of basic information on what constitutes sound medical care, the existence of a generation gap characterised by more intuitive (but not necessarily more effective) action in older clinicians, and a possible increase in laboratory tests consequent on the defensive medicine necessary in American practice because of the possibility of litigation. These are sobering and disappointing results. McSherry’s general conclusions are that the utilisationreview and medical-audit programmes in his hospital have not worked,that their complex and costly administrative apparatus should be dismantled, and that much more reliance should be invested in the continuing inbuilt concern of doctors for high-quality care. This manifests itself in, and can be derived from, clinical studies made for research purposes and published in the journals, rather than in weighty statistical compilations that gather dust in administrative pigeon-holes. as a
Nevertheless, there
must remain an uneasy feeling that entirely rely on ad-hoc interest to control cost, even if quality seems to be assured.22 The problem remains of devising machinery from within the medical profession which can provide a method of assuring a good match between delivery of the clinical goods and
we cannot
reasoned attention to the costs involved. Until such a matching of objectives is achieved it would, in the light of McSherry’s work, be folly in the U.K. to consider complex, centralised administration of utilisation review or the untested imposition, say by the Royal Colleges, of standards for medical audit.
don, 1925 19 Stokes E.
J, and others. Proc. R. Soc Med. 1975, 68, 611. 20 Dudley, H. A F. Br. med. J. 1974, i, 275. 21 McSherry, C K. Surgery, 1976, 80, 122.
24.
Dudley, H.
A. F. Br
med. J. 1975, iv, 274.
role of the hormone in the control of acid-base disturbance in these patients.7 Parathyroid-hormoneinduced bone disease as manifested by osteitis fibrosa is not, however, one of the major features of dialysis osteodystrophy and progresses only slowly.’ The major problem in dialysis osteodystrophy is the osteomaiacic component, with disabling bone pain and fractures. The mineralisation defect in dialysis patients cannot be attributed to hypocalcæmia.3 These patients do have plasma concentrations of 25-hydroxycholecalciferol,5 8 and one possible explanation is that 25-H.L.c. accumulates in plasma because the kidney cannot convert it to the dihydroxy metabolite-either owing to reduction in functional renal mass or because of interference with the 1a-hydroxylation mechanism. The aetiological importance of defective 1,25-dihydroxycholecalciferol production is, however, debatable : PIERIDES et a1.9 conclude that lack of this metabolite may not be wholly responsible for the osteomalacic component of dialysis osteodystrophy, and suggest that phosphate depletion may be an important contributory factor. In the formation of hydroxyapatite crystals and the mineralisation of bone, phosphate is potentially
high
as important as calcium. Hypophosphatsemic osteomalacia has been identified in dialysis patients taking oral phosphate binders,1O " and this treatment was regarded as the cause of the phosphate depletion. Back in 1971, BISHOP et al.12 suggested that dialysis with phosphate-free dialysates could lead to substantial total-body-phosphate depletion over long periods and contribute to the osteomalacia of dialysis osteodystrophy. Now Dr AHMEDand his colleagues record on p. 439 their observations in four haemodialysis patients with hypophosphataemic osteomalacia who were not taking oral phosphate binders and had not done so for some time. They attribute the phosphate depletion in these patients to a combination of intestinal malabsorption, loss during dialysis, and a low dietary intake, the last as part of their therapeutic regimen. These three mechanisms are potentially present in all patients on hæmodialysis treatment and we need to pay much more attention to phosphate status in such patients. The more important aspect of these studies is that they may have provided the clue to the missing link in dialysis osteodystrophy-in particular the osteomalacic component, with its painful disabling sequelae.
just
7. Mioni, G , Castellani, A., Cecchettin, M., Maiorca, R., Heynen, G., Franchimont, P. Lancet, 1975, i, 605. 8. Fairney, A. F., Bowling, K., Varghese, Z., Moorhead, J. F., Wills, M. R. in Vitamin D and Problems Related to Uremic Bone Disease; p. 319. Berlin, 1975. 9. Pierides, A. M., Simpson, W., Ward, M. K., Ellis, H. A., Dewar, J. H., Kerr, D. N. S. Lancet, 1976, i, 1092. 10 Baker, L. R. I., Ackrill, P, Cattell, W. R., Stamp, T. C. B., Watson, L. Br. med. J. 1975, iii, 150. 11. Mahony, J. F., Hayes, J. M., Ingham, J. P., Posen, S. ibid. 1976, ii, 142. 12. Bishop, M. C., Ledingham, J. G. G., Oliver, D. O. Proc. Eur. Dialysis Transplant Ass. 1971, 8, 106.
LEFT AXIS DEVIATION
The precise significance of the mean frontal-plane axis of the QRS complex of the electrocardiogram (E.c.G.; has been debated since the earliest days of electrocardiography.l Deflection of the axis beyond the normal range to left or right was attributed to hypertrophy of the corresponding ventricle.23 Reappraisal of this view became more important when Grant4 confirmed that the frontalplane axis was unrelated to the anatomical long axis of the heart; and it was later suggested that significant left axis deviation reflected the presence of block in the anterior radiations of the left-bundle-branch system,S Rosenbaum et a1.6 then introduced the term left anterior hemiblock in this sense, emphasising that alterations in the initial vectors made the diagnosis more specific. When their work, which was based on the results of dissection of the dog heart, was reappraised by means of craniocaudal section of the conducting system to define the anatomical distribution of the various radicles of the left bundle branch,’the situation became less clear than had been implied. The left bundle branch was shown to break up into multiple fascicles,8 usually concentrated in three definite units9 rather than just two, in keeping with electrophysiological studies on the isolated human heart which had demonstrated three sites of left ventricular activation. 10 No close correlation exists between the E.c.G. appearances of left- anterior hemiblock and the corresponding anatomical lesions, which are usually more extensive than predicted,’ 1’ unlike the situation in so-called left posterior hemiblock. 12 Vector cardiographic criteria for the detection of lesions of the centroseptal radicles13 make sense, but they await anatomical corroboration. Clearly, much remains to be done, and perhaps some confusion has been caused because the term left anterior hemiblock has been used too widely, as, for example, when left axis deviation would suffice to define the electrocardiographic appearances in some cases of inferior-wall myocardial infarction. 14 While cardiac ischaemia is an important cause of disturbed intraventricular conduction in Western countries, this does not apply in Japan, where the incidence of ischaemic heart-disease is considerably lower. A series of 1000 consecutive necropsies in aged Japanese may thus be of more than local interest. Sugiura et al." investigated people with various electrical axes, they sought evidence of coronary sclerosis as the basis for
1. Waller, A. D. Br. med. J. 1888, ii, 751 2. Einthoven, W. Pflugers Arch. ges. Physiol. 1908, 122, 517. 3. Dieuaide, F. R. Archs intern. Med. 1921, 27, 558. 4. Grant, R. P. Circulation, 1956, 14, 233. 5. Pryor, R., Blount, S. G., Jr. Am. Heart J. 1966, 72, 391. 6. Rosenbaum, M. B., Elizari, M. V., Lazzari, J. O. The Hemiblocks. Oldsmar. 1970. 7. Demoulin, J. C., Kulbertus, H. E. Br. Heart J. 1972, 34, 807. 8 Davies, M. J. Pathology of Conducting Tissue of the Heart. London, 1971 9. Uhley, H. N. Am J. Cardiol. 1972, 30, 919. 10. Durrer, D., Van Dam, R. T., Freud, G. E., Janse, M. J., Meijler, F. L., Arzbaecher, R. C. Circulation, 1970, 41, 899. 11. Rizzon, P., Latour, H., Dibiaze, M., Baissus, C. Archs Mal. Côeur, 1976.
69, 41. Demoulin, J. C., Kulbertus, H. E. Am. J. Cardiol. 1976, 37, 131. 13. Kulbertus, H. E., De Leval-Rutten, F., Casters, P. Br. Heart J. 1976. 38, 12.
549. 14. Kourtesis, P.,
Lichstein, E., Chadda, K. D., Gupta, P. K. Circulation, 1976. 53, 784. 15. Sugiura, M., Ohkawa, S., Hiraoka, K., Kuwajima, I., Ueda, K. Jap. Heart. J. 1976, 17, 25. 16. Massing, G. K., James, T. N. Circulation, 1976, 53, 609.
ischxmic myocardial lesions, and they examined consecutive unselected individuals. In only 20% of patients could significant left axis deviation be correlated with extensive myocardial necrosis, and in most patients there was no evidence of ischsemic lesions. Unfortunately, as Sugiura et al. recognise, examination of the conduction system did not meet current criteria.7 11 11 16 Despite the technical gaps, their finding that left axis deviation was common in the elderly, in the absence of ischæmic heart-disease, supports the suggestion that left axis deviation reflects a variety of pathological changes in the left bundle branch and its radicles. This is also the message from a careful study17 of intraventricular conduction in 63 persons in whom E.c.G.s were available before and after the appearance of left axis deviation. We may not seem to have come much further than Waller’ and may need to remind ourselves of Lewis’s cautious attitude to axis deviation,18 but the growing volume of clinicopathological findings is slowly to unravel the enigma of left axis deviation.
helping
AUDIT OF AUDIT IN the United Kingdom the medical profession, with its traditions of clinical freedom and its distrust of formal structures for the conduct of day-to-day life, has moved only slowly and reluctantly towards any form of quality control. In laboratory work, where the process can be seen as related more to machinery than to men, the principles are well-established and moderately widely applied;19 but most clinicians see little medical virtue in the review of their work by others. This is not to say that individuals have been idle in finding ways of examining performance both in general practice and in hospital; in addition, many ideas on shortening hospital stay, reducing admissions, and economising on resources have originated in the U.K. The American hospital tradition has been different and much more structured. Since 1918 the profession has been standardising practice and devising yardsticks for accreditation based on review of what has actually taken place within an institution. Lately, and in the wake of increased federal repayments under the Medicare and Medicaid schemes, Government has insisted on stronger and more uniform quality assurance. This has taken two forms: utilisation review, which assesses the efficiency of the hospital; and medical audit, which tries to judge professional performance, Both have been introduced (and promoted also in the U.K.20) on an axiomatic basis-that they are right and proper and that they will work. Neither has been subjected to any prospective critical analysis. A paper by McSherry,21recounting experience with utilisation review and medical audit in the department of surgery at Cornell, comes therefore as something of a surprise, because it highlights more serious difficulties and problems than most enthusiasts would have cared to admit. First, cost in money and resources: though trivial 17 Das. G ibid p. 917. 18 Lewis, T. The Mechanism and Graphic Registration of the
Heart Beat. Lon-
percentage of total expenditure, McSherry points out that the most conservative extrapolations from his data give a nationwide figure which probably exceeds the research budget of the National Institutes of Health and a workload for doctors equivalent to the full-time employment of six times the yearly number of graduates from his own medical school. Second, complexity: externally imposed rules (in this case from the New York State Department of Health) have increased the size of the guideline documents from 3 to 26 pages over some three years and led to a non-medical staff requirement of twenty at Cornell. The shortage of money in New York City and New York State is evidently provoking second-thoughts in the central administrators about continuing to implement a utilisation-review plan of this magnitude, even though it was initially thrust on the hospital by legislation. Third, effectiveness: as judged by control of length of stay, an average of 9500 hospital records have been reviewed yearly to identify 6 patients who were in hospital too long. The cost of identification per patient was reckoned at$34 212. There was no evidence that the introduction of utilisation review had had any effect on length of stay, which had remained roughly the same throughout the whole period. Medical audit, which at Cornell is the review of professional behaviour in relation to selected clinical conditions such as status asthmaticus and inguinal hernia, is exposed as having similar deficiencies. McSherry reports that a programme of 15 audits over a period of two years at a cost of$71 821 was received by the medical staff with almost total indifference. 21 It did little or nothing to alter behaviour. What, as might be expected, it did reveal was widespread lack of basic information on what constitutes sound medical care, the existence of a generation gap characterised by more intuitive (but not necessarily more effective) action in older clinicians, and a possible increase in laboratory tests consequent on the defensive medicine necessary in American practice because of the possibility of litigation. These are sobering and disappointing results. McSherry’s general conclusions are that the utilisationreview and medical-audit programmes in his hospital have not worked,that their complex and costly administrative apparatus should be dismantled, and that much more reliance should be invested in the continuing inbuilt concern of doctors for high-quality care. This manifests itself in, and can be derived from, clinical studies made for research purposes and published in the journals, rather than in weighty statistical compilations that gather dust in administrative pigeon-holes. as a
Nevertheless, there
must remain an uneasy feeling that entirely rely on ad-hoc interest to control cost, even if quality seems to be assured.22 The problem remains of devising machinery from within the medical profession which can provide a method of assuring a good match between delivery of the clinical goods and
we cannot
reasoned attention to the costs involved. Until such a matching of objectives is achieved it would, in the light of McSherry’s work, be folly in the U.K. to consider complex, centralised administration of utilisation review or the untested imposition, say by the Royal Colleges, of standards for medical audit.
don, 1925 19 Stokes E.
J, and others. Proc. R. Soc Med. 1975, 68, 611. 20 Dudley, H. A F. Br. med. J. 1974, i, 275. 21 McSherry, C K. Surgery, 1976, 80, 122.
24.
Dudley, H.
A. F. Br
med. J. 1975, iv, 274.
