blueprints for individual clinics because clinic arrangements must reflect the nature of the work carried out at that clinic. But we found signs in some clinics that practices had not been realistically planned: clinics did not start on time; patients were seen in order of arrival rather than in appointment order, thus encouraging patients to arrive early and increasing their waiting time; appointments were not evenly spread throughout the clinic period; the number of patients attending a clinic varied significantly from one week to the next owing to patients not attending for their appointment and the clinic being overbooked to compensate; overbooking of clinics meant that additional patients would not have had individual appointment times. It was clear from our survey that some factors which contributed to long waiting times (such as doctors being called away from the clinic) may have 'reflected emergencies elsewhere in the hospital or staffing problems and may have been unavoidable. The points listed above were avoidable, however, and action to deal with them would help to reduce patients' waiting time in clinic. We were encouraged to find that some of the hospitals visited were beginning to do this. JILL GOLDSMITH National Audit Office, London SWI'W;9SP I Smith J. Improv-ing outpatient services. BAR7 1991;302:435. (23 i'chruarv.' 2 Jettnittgs A. Audit of a new appointments system in a hospital ouitpatient clinic. BMU 1991;302:148-9. 19 January.

bill for erythropoietin has been halved. Assay of erythropoietin before treatment can indicate patients' requirements and can largely predict dosage and subsequent response. Optimum therapeutic schedules and avoidance of overdosage are readily ascertained, and patient non-compliance can be highlighted. Modern immunoassays for serum erythropoietin cost a fraction of the weekly cost of the drug to a single patient, and the establishment of the assay service will repay the outlay within a month. This assay is, however, not generally available in NHS laboratories, in spite of the clear need for this service. We hope that erythropoietin assays will soon be available on a regional or supraregional basis, to the benefit of all concerned -not least the Exchequer. ANDREW HILLIS JOANNE MARSDEN Dulwich South Hospital, London

TIMOTHY j PETERS ROY SHERWOOD King's College Hospital, London SE5 9RS I Correspondence. Picking up the tab for ervthropoietin. BMJ 1991;302:407-8,592. (16 February, 9 March.) 2 Gabriel R. Picking up the tab for ervthropoietin. BMJ 1991;302:

248-9. (2 February.) 3 Taylor JE, Henderson IS, Mactier RA, Stewart WK. Effects of withdrawing erythropoietin. BMJ 1991;302:272-3. 2 February.)

secondary prevention of myocardial infarction has been shown only for U adrenergic blockers. Our results suggest that the results of recent clinical trials may have had some influence in increasing the prescription rate of [i adrenergic blockers in these patients. They also suggest that this influence may have been limited, at least in part, by the strong promotion of calcium channel agonists for the secondary prevention of myocardial infarction, an indication for which their efficacy has not been proved.' J M ARNAU A AGUSTi X VIDAL J R LAPORTE

Servei de Farmacologia Clinica, C S Vall D'Hiebron, Unitat de Farmacologia, Universitat Autonoma de Barcelona, 08035-Barcelona, Spain 1 Eccles M, Bradshaw C. Use of secondary prophylaxis against myocardial infarction in the north of England. BMJ 1991;302: 91-2. (12 January.) 2 Agusti A, Arnau JM, Laporte JR, Soler J, Vidal X. Secondary prevention of myocardial infarction: the influence of clinical trials on cliriical practice. EurJ7 Clin Pharmnacol 1989;36(suppl): 253. 3 Held PH, Yusuf S, Furberg CD. Calcium channel blockers in acute myocardial infarction and unstable angina: an overview. BMJ 1989;299:1187-92.

Milk, butter, and heart disease SIR,-The National Audit Office review showed that patients still too often experience long waits in outpatient clinics.' In Princess Royal Hospital, I have established 'a new patient clinic at which patients often do not wait and occasionally see the doctor ahead of their booked time. This has been achieved by assigning appointments of varying lengths when the general practitioner's referral letter is initially reviewed. The computerised patient administration system used by Shropshire district, however, is unable to cope with a booking system in which patients variously need 5, 10, 15, or 20 minute appointments. In the initial stages clinics had to be booked by hand until we found ways of fiddling the computer. Staff in records administration need to bear this in miind when rewriting outpatient administration systems, which I gather they are now doing. Patients attending my follow up fracture clinics do, however, wait, and applying a timed system to these is much harder because patients are booked from several different places: three or four wards, new fracture clinics, previous old fracture clinics, etc. 'A computer program that could cope with appointments of different lengths would enable a timed system to be introduced tomorrow. P C MAY

Princess Royal Hospital, 'I'elford, Shropshiie TF6 6TF I Smith J. Improving outpatient services.

B&M7 1991;302:435. (23

Februarv.)

Picking up the tab for erythropoietin SIR,-There have been a number of papers, leading articles, and correspondence recently regarding the use, availability, and cost of erythropoietin in the treatment of anaemia in chronic renal failure." In the debate about the cost versus the benefits-of the treatment little attention has been paid to the assay of serum ervthropoietin in diagnosis and monitoring treatment. Since introducing this assay at King's, the drug

BMJ

VOLUME

302

13

APRIL

1991

Secondary prophylaxis against myocardial infarction SIR,-Drs Martin Eccles and Colin Bradshaw' do not mention other drugs for secondary prophylaxis against myocardial infarction that might account for the underuse of D adrenergic blockers. We analysed the use of acetylsalicylic acid and adrenergic blockers in 736 patients with myocardial infarction discharged from our centre between 1982 and 1988.2 During this period we saw an increase of the prescription rate of both drugs. In 1988 the prescription rate was 34% (42/122) for D adrenergic blockers, 33% (40/122) for acetylsalicylic acid, and 7% (9/122) for both. For [i adrenergic blockers our results are similar to those of Drs Eccles and Bradshaw. The participation of 13 hospitals in their study in the third international study of infarct survival (ISIS-3) may have induced a higher prescription ofacetylsalicylic acid at hospital discharge. Thirty four per cent (253/736) of our study population had relative contraindications to the use of li adrenergic blockers. We also analysed the prescription of other drugs. In 1988 the prescription rate of calcium channel antagonists amounted to 44% (54/122). They were prescribed more often for patients with previous cardiovascular disease, such as hypertension or angina (table). In addition, we observed that the use of f adrenergic blockers was lower in patients treated with calcium channel agonists. f3 Adrenergic blockers and calcium channel agonists have some common therapeutic uses, such as hypertension and angina, but efficacy for the

SIR,-Professor A G Shaper and colleagues' have referred to data on milk, spreading fats, and heart disease in our Caerphilly prospective heart disease study2 and have presented data on this same topic from their regional heart study. We can certainly confirm what Professor Shaper and colleagues show in their own data. Milk drinking is confounded with many other factors of relevance to heart disease risk, and men who use butter differ in many ways from those who use margarine. The effects of some of these differences on relations with heart disease are substaniial, and difficulties arise because their interrelations are complex. As we said in the progress report, the data are being explored further and we will publish a detailed report in due course. In retrospect, it was unwise for a brief description and preliminary analysis of these data to be included in a privately published report that attempted to summarise a wide range of work on cardiovascular disease. It was particularly unfortunate that the one small section on milk and fats was widely reported and interpreted uncritically in the popular press. I can only apologise for not having foreseen that this was likely to happen, and I now greatly regret not having withheld the data until a more adequate analysis could be submitted to the scientific press. PETER C ELWOOD MRC Epidemiological Unit (South Wales),

Llandough Hospital, I'enarth, Sotith Glamorgan CF6 IXX I Shaper AG, Wannamethee G, Walker M. Milk, butter, and heart disease. BUM7 1991;302:785-6. (30 March.) 2 MRC Epidemiology Unit. Eptdemiological studies of cardiovascular disease. Penarth, South Glamorgan: Llandough Hospital, 1991. (Progress report VII.)

Treatment with ji adrenergic blocking agents (r3AB) or with calcium channel antagonists (CaCA) at hospital discharge after myocardial infarction in 736 patients (49 patients treated with both drugs were excluded) No (%) of patients treated with CaCA No (¼/.) of patients treated with liAB Total With previous cardiovascular disease Without previous cardiovascular disease

154 (64-7) 46 (41 8)

84 (35-3) 64 (58-2)

238 110

Total

200 (57 5)

148 (42-5)

348

Z.= 16- 12 (p-- 0-0006). 913

Secondary prophylaxis against myocardial infarction.

blueprints for individual clinics because clinic arrangements must reflect the nature of the work carried out at that clinic. But we found signs in so...
276KB Sizes 0 Downloads 0 Views