327
results obtained by some in persuading people not to smoke are anything to go by, it might equally well be argued that funds allocated for this purpose should be used for Preinvasive cancer-cell research into other problems. as a means of of identifying a group at special cytology sputa not been fully investigated. cancer has risk from lung high No-one would minimise the difficulties of the preventive approach to bronchitis, but what of the newer diagnostic techniques ? A multiphasic M.H.E., incorporating closing volume, transfer factor, anti-trypsin, serum electrophoresis, and blood-carboxyhaemoglobin levels, was successfully tested in a general population of 650 people examined over 2 weeks in Scotland last autumn. The unwarranted conclusion that multiphasic screening procedures appear to be of little value in medical practice at present needs modification.ll At the 2nd International Symposium on Epidemiology of Hypertension in Chicago in September, 1974, Kannel commented on the importance of the screening profile in the management of the hypertensive patient. In a series of untreated patients with bloodpressures over 100 mm. Hg diastolic observed over 5 years, the risk of untoward cardiovascular events ranged from 4% to 40% according to the cumulative contribution made by smoking, E.C.G. evidence of ischaemia, left ventricular hypertrophy, raised cholesterol, and glucose intolerance. 12 In Scotland, in 1972, our multiphasic procedure produced a wider profile at a cost of E4.31 per examination.4 Despite inflation, exclusive of university overheads and computer time, this cost could probably be reduced if expensive research procedures required for validation were taken out and the operation transferred to general practice, where neither venue, census, or much in the way of extra staff would be needed to screen patients naturally in regular contact with their family doctor. At this stage there is little danger of N.H.S., or any other resources for that matter, being dissipated in case-counting contests like those conducted in Rotherham, Southwark, and Glasgow.I3 Nor is breast-cancer screening likely to be launched as precipitately as cervical screening, which may yet be justified, albeit retrospectively. In the meantime there is plenty of scope for interested general practitioners with ancillary staff and access to epidemiological, statistical, and computer support to consider setting up their own pilot schemes. I might add that in Scotland our objectives are clearly defined. We use M.H.E.S to derive rates of disease and predisposing factors illustrative of natural history, or where this appears reasonably well understood, to conduct large-scale random con-trolled field trials of interventive advice or treatment. By careful planning it is generally also possible to combine epidemiological surveys with monitoring the status of a disease like tuberculosis, and, at the same time, to attempt to evaluate the place of prescriptive screening as a complement to the curative services of the N.H.S. An example of the use of the M.H.E. to serve all three functions simultaneously is provided by our current trials in smoking, hypertension, and surveillance of tuberculosis in the census-identified populations between the ages of 45 and 64 years of 3800 and 20,000 persons resident in the Burghs of Renfrew and Paisley.14 We are fortunate in Scotland in being able to assess outcome in these large populations not only by physical examination but indirectly by both mortality and morbidity medical-record linkage through the Registrar General and the Scottish Hospitals In-patient Statistics,
respectively. By 1980 it is probable that 80 % of the Scottish population will be cared for by health centres. The prototype of a 11. Knox, E. G. Lancet, 1974, ii, 1434. 12. Proceedings of 2nd International Symposium on Epidemiology of Hypertension. Chicago Heart Foundation (in the press). 13. Horne, W. A., Clark, J., Patterson, W. J. Lancet, 1967, i, 494. 14. Hawthorne, V. M. Scot. med. J. 1969, 14, 22.
simple basic screening package is already in existence and is being studied by an integrated group of general practitioners and hospital and community physicians. The experience is both stimulating and satisfying to all concerned and the difficulties far from formidable when approached jointly in a fully integrated health service. Glasgow University Department of Community Medicine and Glasgow MMR Cardio-respiratory Screening Unit, Ruchill Hospital, Glasgow G20 9NB.
V. M. HAWTHORNE.
SCREENING FOR HYPERTENSION
SIR,-Professor Sackett (Nov. 16, p. 1189) has accurately portrayed the status of hypertension control as it usually exists in the community. Screening programmes do attract those whose blood-pressure has recently been recorded and many who are already aware of their hypertension. But Professor Sackett’s major criticism of community screening appears to be based on the fact that identified hypertensives usually fail to enter or remain in treatment. Although the present situation appears disheartening, discontinuation of screening may not be the only appropriate conclusion that can be drawn. Perhaps the real lesson to be gained from this experience is that screening programmes carried out in situations where subsequent hypotensive therapy is delivered in the conventional fashion are not effective. By contrast, quite different results have been obtained when screening in defined populations is followed by fully integrated, specifically designed care programmes. 1,22 A hypertension screening and treatment programme we have developed for the 14,000 members of the United Storeworkers Union in New York City is a case in point. By providing all diagnostic and therapeutic services at the work site, it has been possible to examine 84% of all employees and bring two-thirds of those needing care into an occupationally based treatment programme (the remaining one-third sought alternate sources of care). Nurses and paraprofessionals, guided by a rigid protocol, and supervised by a physician, have succeeded in maintaining 96% of patients under care through the first year. More than 80% of these patients have achieved satisfactory bloodpressure reduction without a significant complication of therapy. This programme seems to work by improving access to therapy and providing all care within the framework of the Union-an existing cohesive institution. Preliminary results suggest that financial savings realised by reduction of disability have more than offset the cost of treatment.
This
hypertension control programme is safe, acceptable, economical, and effective. The blood-pressure reduction among storeworkers is similar to that attained by the Veterans Administration patients,3,4 and leads one to hope that a similar decline in morbidity and mortality will attend widespread replication of this model for detection and treatment.
Screening for hypertension can be successful, but only when it becomes part of a more complete health-care system which is designed to promote the long-term patient compliance so necessary for successful treatment. New York Hospital— Cornell Medical Center, 1300 York Avenue, New York, N.Y. 10021, U.S.A.
MICHAEL H. ALDERMAN.
1. Finnerty, F. A., Jr., et al. Circulation, 1973, 47, 76. 2. Wilber, J. A. in The Epidemiology of Hypertension (edited J. Stamler and T. N. Pullman); p. 439. New York, 1967. 3. J. A. Med. Ass. 1967, 202, 1028. 4. ibid. 1970, 213, 1143.
by
results obtained by some in persuading people not to smoke are anything to go by, it might equally well be argued that funds allocated for this purpose should be used for Preinvasive cancer-cell research into other problems. as a means of of identifying a group at special cytology sputa not been fully investigated. cancer has risk from lung high No-one would minimise the difficulties of the preventive approach to bronchitis, but what of the newer diagnostic techniques ? A multiphasic M.H.E., incorporating closing volume, transfer factor, anti-trypsin, serum electrophoresis, and blood-carboxyhaemoglobin levels, was successfully tested in a general population of 650 people examined over 2 weeks in Scotland last autumn. The unwarranted conclusion that multiphasic screening procedures appear to be of little value in medical practice at present needs modification.ll At the 2nd International Symposium on Epidemiology of Hypertension in Chicago in September, 1974, Kannel commented on the importance of the screening profile in the management of the hypertensive patient. In a series of untreated patients with bloodpressures over 100 mm. Hg diastolic observed over 5 years, the risk of untoward cardiovascular events ranged from 4% to 40% according to the cumulative contribution made by smoking, E.C.G. evidence of ischaemia, left ventricular hypertrophy, raised cholesterol, and glucose intolerance. 12 In Scotland, in 1972, our multiphasic procedure produced a wider profile at a cost of E4.31 per examination.4 Despite inflation, exclusive of university overheads and computer time, this cost could probably be reduced if expensive research procedures required for validation were taken out and the operation transferred to general practice, where neither venue, census, or much in the way of extra staff would be needed to screen patients naturally in regular contact with their family doctor. At this stage there is little danger of N.H.S., or any other resources for that matter, being dissipated in case-counting contests like those conducted in Rotherham, Southwark, and Glasgow.I3 Nor is breast-cancer screening likely to be launched as precipitately as cervical screening, which may yet be justified, albeit retrospectively. In the meantime there is plenty of scope for interested general practitioners with ancillary staff and access to epidemiological, statistical, and computer support to consider setting up their own pilot schemes. I might add that in Scotland our objectives are clearly defined. We use M.H.E.S to derive rates of disease and predisposing factors illustrative of natural history, or where this appears reasonably well understood, to conduct large-scale random con-trolled field trials of interventive advice or treatment. By careful planning it is generally also possible to combine epidemiological surveys with monitoring the status of a disease like tuberculosis, and, at the same time, to attempt to evaluate the place of prescriptive screening as a complement to the curative services of the N.H.S. An example of the use of the M.H.E. to serve all three functions simultaneously is provided by our current trials in smoking, hypertension, and surveillance of tuberculosis in the census-identified populations between the ages of 45 and 64 years of 3800 and 20,000 persons resident in the Burghs of Renfrew and Paisley.14 We are fortunate in Scotland in being able to assess outcome in these large populations not only by physical examination but indirectly by both mortality and morbidity medical-record linkage through the Registrar General and the Scottish Hospitals In-patient Statistics,
respectively. By 1980 it is probable that 80 % of the Scottish population will be cared for by health centres. The prototype of a 11. Knox, E. G. Lancet, 1974, ii, 1434. 12. Proceedings of 2nd International Symposium on Epidemiology of Hypertension. Chicago Heart Foundation (in the press). 13. Horne, W. A., Clark, J., Patterson, W. J. Lancet, 1967, i, 494. 14. Hawthorne, V. M. Scot. med. J. 1969, 14, 22.
simple basic screening package is already in existence and is being studied by an integrated group of general practitioners and hospital and community physicians. The experience is both stimulating and satisfying to all concerned and the difficulties far from formidable when approached jointly in a fully integrated health service. Glasgow University Department of Community Medicine and Glasgow MMR Cardio-respiratory Screening Unit, Ruchill Hospital, Glasgow G20 9NB.
V. M. HAWTHORNE.
SCREENING FOR HYPERTENSION
SIR,-Professor Sackett (Nov. 16, p. 1189) has accurately portrayed the status of hypertension control as it usually exists in the community. Screening programmes do attract those whose blood-pressure has recently been recorded and many who are already aware of their hypertension. But Professor Sackett’s major criticism of community screening appears to be based on the fact that identified hypertensives usually fail to enter or remain in treatment. Although the present situation appears disheartening, discontinuation of screening may not be the only appropriate conclusion that can be drawn. Perhaps the real lesson to be gained from this experience is that screening programmes carried out in situations where subsequent hypotensive therapy is delivered in the conventional fashion are not effective. By contrast, quite different results have been obtained when screening in defined populations is followed by fully integrated, specifically designed care programmes. 1,22 A hypertension screening and treatment programme we have developed for the 14,000 members of the United Storeworkers Union in New York City is a case in point. By providing all diagnostic and therapeutic services at the work site, it has been possible to examine 84% of all employees and bring two-thirds of those needing care into an occupationally based treatment programme (the remaining one-third sought alternate sources of care). Nurses and paraprofessionals, guided by a rigid protocol, and supervised by a physician, have succeeded in maintaining 96% of patients under care through the first year. More than 80% of these patients have achieved satisfactory bloodpressure reduction without a significant complication of therapy. This programme seems to work by improving access to therapy and providing all care within the framework of the Union-an existing cohesive institution. Preliminary results suggest that financial savings realised by reduction of disability have more than offset the cost of treatment.
This
hypertension control programme is safe, acceptable, economical, and effective. The blood-pressure reduction among storeworkers is similar to that attained by the Veterans Administration patients,3,4 and leads one to hope that a similar decline in morbidity and mortality will attend widespread replication of this model for detection and treatment.
Screening for hypertension can be successful, but only when it becomes part of a more complete health-care system which is designed to promote the long-term patient compliance so necessary for successful treatment. New York Hospital— Cornell Medical Center, 1300 York Avenue, New York, N.Y. 10021, U.S.A.
MICHAEL H. ALDERMAN.
1. Finnerty, F. A., Jr., et al. Circulation, 1973, 47, 76. 2. Wilber, J. A. in The Epidemiology of Hypertension (edited J. Stamler and T. N. Pullman); p. 439. New York, 1967. 3. J. A. Med. Ass. 1967, 202, 1028. 4. ibid. 1970, 213, 1143.
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