are continued for years there will be an overall effect on the demand for inpatient care by the users of the services. In our study we analysed the effects of general health check ups using as the main index the percentage of people who received it, and we discussed the findings not in terms of individuals but of populations. The health screening programme in Japan was started on the basis of incomplete evidence. I regard it as a large scale experiment in an intermediate stage. All those concerned with the promotion of health should find this experiment of interest; the promotion of better health of the population has been recommended by the World Health Organisation as a goal for all countries. And for mutual understanding between countries, we should be patient enough to form correct ideas about the evidence offered. KOZO TATARA Osaka University Medical School,
Osaka, Japan 1 Marmot MG, Haines A. Health check ups for all? BMJ7 1991;302:604-5. (16 March.) 2 Tatara K, Shinsho F, Suzuki M, et al. Relation between use of health check ups starting in middle age and demand for inpatient care by elderly people in Japan. BMJ 1991;302: 615-8. (16 March.)
Postoperative urinary retention SIR,-Mr P H O'Reilly stated that betanechol (a cholinergic agent) could be used against postoperative urinary retention.' Betanechol acts primarily on the postganglionic effector cells, with a relatively selective muscarinic action on the smooth muscle of the bladder.2 Thus betanechol increases the intravesical pressure but produces no relaxation in the bladder outlet.' Indeed, betanechol has been shown to be virtually useless in humans and to do no more than increase bladder discomfort and distress.45 According to this, betanechol cannot be recommended as the drug of choice in the management of postoperative urinary retention. A better therapeutic approach against postoperative urinary retention mnay be indoramin, which Mr O'Reilly also recommended. Indoramin is a competitive inhibitor at the ul receptor level, sharing part of the procainamide structure.6 The al receptor antagonist acts by reducing tone in the bladder outlet, thereby decreasing outflow resistance and facilitating micturition.' The most selective al receptor antagonist for the moment is prazosin, which has been shown to be very effective in treating postoperative urinary retention.8 The new °t1 receptor antagonist alfuzosine is also very selective and has, furthermore, a high affinity for the a, receptors located in the bladder outlet.9 Alfuzosine is recommended for symptoms of benign prostatic hypertrophy but also seems promising in the treatment of postoperative urinary retention (unpublished data). In conclusion, selective ul receptor antagonists such as prazosin and perhaps alfuzosine are the drugs of choice in the pharmacological management of postoperative urinary retention. Parasympathomimetics should be avoided. If al receptor antagonists are contraindicated or if pharmacological treatment fails, emptying the bladder by intermittent catheterisation'° or by an indwelling suprapubic catheter is the management of choice.
I O'Reilly PH. Postoperative urinary retention in men. BMJ 1991;302:864. (13 April.) 2 Finkbeiner AE. Is betanechol chloride clinically effective in promoting bladder emptying? A literature review. J Urol 1985;134:443-9. 3 Durant PAC, Yaksh TL. Drug effects on urinary bladder tone during spinal morphine-induced inhibition of the micturition reflex in unanesthetized rats. Anesth Analg 1988;68:325-34. 4 Bromage PR, Camporesi EM, Durant PAC, Nielsen CH. Non-respiratory side effects of epidural morphine. Anesth, Analg 1982;61:490-5. 5 Tammela 'r. Prevention of prolonged voiding problems after unexpected postoperative urinary retention: comparison of
phenoxybenzamine and carbachol.J Urol 1986;136:1254-7. 6 Holmes B, Sorkin EM. Indoramin: a review of its pharmacodynamic and pharmacokinetic properties and therapeutic efficacy in hypertension and related vascular, cardiovascular and airway diseases. Drugs 1986;31:143-80. 7 Caine M. The autonomic pharmacology of the urinary tract. In: Caine M, ed. The pharmacology ofthe urinary tract. Berlin: Springer-Verlag, 1985:5-30. 8 Bradley WE, Sundin T. The physiology and pharmacology of the urinary tract dysfunction. Clin Neuropharmacol 1982;5: 131-58. 9 Jardin A, Bensadoun H, Delauche-Cavallier MC, Attali P. Evaluation of alfuzosine, a new alpha1-adrenergic antagonist in the treatment of benign prostatic hypertrophy: a long term (6 months), placebo-controlled study in 518 patients. Lancet (in press). 10 Anderson JB, Grant JBF. Postoperative retention of urine: a prospective urodynamic study. BMJ 1991;302:894-6. (13 April.)
What should be done about asymptomatic hypercholesterolaemia? SIR,-We are grateful for Dr Gilbert R Thompson's recent editorial' about our report on asymptomatic hypercholesterolaemia.2 Unfortunately, Dr Thompson somewhat oversimplified our clinical conclusions in stating that we propose screening mainly middle aged men with other risk factors. For middle aged men we indicated that the evidence could support either a conservative scheme of testing when other risk factors are present or a more aggressive scheme that included testing all men "regardless of their risk profile." Recommendations for other groups were also given in detail.2 Dr Thompson wisely warned that testing on the basis of a family history ofcoronary heart disease or physical signs of hyperlipidaemia would detect only 30% of people with a serum cholesterol concentration over 8 mmol/l. Why, then, would we even entertain the above noted conservative scheme? Firstly, simply taking middle aged men with any risk factors (for example, diabetes mellitus, obesity, family history of premature coronary heart disease or dyslipidaemia, hypertension, cigarette smoking) would result in over half of adult men being tested in many nations. Consider also coronary heart disease events in two middle aged asymptomatic men-one whose only risk factor is a total cholesterol concentration of 7 8 mmolIl and another who smokes and has a cholesterol concentration of 6-9 mmol/l. At every age from 45 onwards the smoker has a greater risk of coronary heart disease, finishing up with a risk about 30% higher by age 65.' Regardless of the case finding strategy, special attention must be paid to people with multiple reversible risk factors. Lastly, the editorial emphasised that we are epidemiologists, not clinicians. Unlike Dr Thompson, we are not clinical lipidologists. Our group, however, included three general practitioners and a general physician-whose perspectives may be germane to practical clinical
policies. C DAVID NAYLOR ANTONI BASINSKI
BO J HANSEN
Clinical Epidemiology Unit, Sunnybrook Health Science Centre, University of Toronto, North York,
Department of Surgery, Hillerod Hospital, DK-3400 Hillerod, Denmark JACOB ROSENBERG Department of Surgical Gastroenterology, Hvidovre University Hospital, DK-2650, Hvidovre, Denmark
BMJ
VOLUME
302
1
JUNE
Ontario, Canada M4N 3M5 1 Thompson GR. What should be done about asymptomatic h)ypercholesterolaemia? BMJ7 1991;302:605-6. (16 March.)
1991
2 Toronto Working Group on Cholesterol Policy (Navlor CD, Basinski A, Frank JW, Rachlis MM). Asymptomatic hypercholesterolaemia: a clinical policy review. J Clin Epidemniol 1990;43: 1029-12 1. 3 McGee D. The Framingham study: an epidemiological investigation ofcardiovasculardisease (section 28). The probability ofdeveloping certamn cardiovascular diseases in eight years at specified values of some characterzstics. Bethesda, Maryland: US Department of Health, Education, and Welfare, 1973. (DHEW publication No 74-618.)
Picking up the tab for erythropoietin SIR,-The correction to Dr Roger Gabriel's thoughtful editorial on erythropoietin, carrying the denial, presumably from the Department of Health, that an arrangement exists for general practitioners to prescribe growth hormone once again underlines the lack of direction from central government for the prescribing of expensive drugs. ' Following the development of regional prescribing policies, hospital doctors and general practitioners are meeting-usually under the auspices of local drug and therapeutic committees -to discuss the most appropriate arrangements for prescribing for their patients. For this approach to succeed it is crucial for the method of funding to follow the pattern of prescribing devised jointly by the hospital and the general practitioners. This is particularly vital for very expensive drugs, those that may cost thousands of pounds for a treatment or each year for more chronic use. Such expensive drugs have specific indications for defined conditions; their efficacy is clinically proved; and there are no clinical, ethical, or supply constraints. These drugs, which include erythropoietin and growth hormone, present a dilemma to local committees, simply because of a lack of funds. The government in its booklet issued to the general public (The Health Service, The NHS Reforms and You) states that patients will continue to get their prescriptions even if the medicines are expensive. Moreover, in Improving Prescribing (Working Paper 2 of Working for Patients) it states: "Every patient being cared for by a General Practitioner will . .. always be able to get the drugs he or she needs, including high cost medicines, for as long as they are needed." The problem with both of these statements is that no one with experience in prescribing or supplying such medicines during the past 24 months believes that this is achievable with very expensive drugs either now or in the future. We consider that very expensive drugs can be funded only by making commensurate cuts in services elsewhere given the tightening financial restraints which encircle the "new" health service. The conclusion is that these drugs must be included in "rationalisation of the service," which in simple terms equals rationing of resources: a situation that has always been present in health care but, surprisingly, has only recently entered the vocabulary of health ministers. Rationing of health care raises two important issues. The first is a need for consistent and honest dialogue with the public, and the second is the development of appropriate systems for rationing the use of very expensive drugs. The first issue may be achieved only through a gradual process of information and education rather than sensational and speculative articles in the popular press whereas the second issue requires the development of clear direction from central government rather than delegation to impoverished district health authorities. The ultimate aim of rationing is to ensure that maximum value for money (cost-benefit, costutility, and, most appropriately, quality of life) is achieved within the narrow context of the drug's use and the wider context of health care priorities. Arguably this may be best achieved centrally, where expertise and control can be most effectively
1335
Osaka, Japan 1 Marmot MG, Haines A. Health check ups for all? BMJ7 1991;302:604-5. (16 March.) 2 Tatara K, Shinsho F, Suzuki M, et al. Relation between use of health check ups starting in middle age and demand for inpatient care by elderly people in Japan. BMJ 1991;302: 615-8. (16 March.)
Postoperative urinary retention SIR,-Mr P H O'Reilly stated that betanechol (a cholinergic agent) could be used against postoperative urinary retention.' Betanechol acts primarily on the postganglionic effector cells, with a relatively selective muscarinic action on the smooth muscle of the bladder.2 Thus betanechol increases the intravesical pressure but produces no relaxation in the bladder outlet.' Indeed, betanechol has been shown to be virtually useless in humans and to do no more than increase bladder discomfort and distress.45 According to this, betanechol cannot be recommended as the drug of choice in the management of postoperative urinary retention. A better therapeutic approach against postoperative urinary retention mnay be indoramin, which Mr O'Reilly also recommended. Indoramin is a competitive inhibitor at the ul receptor level, sharing part of the procainamide structure.6 The al receptor antagonist acts by reducing tone in the bladder outlet, thereby decreasing outflow resistance and facilitating micturition.' The most selective al receptor antagonist for the moment is prazosin, which has been shown to be very effective in treating postoperative urinary retention.8 The new °t1 receptor antagonist alfuzosine is also very selective and has, furthermore, a high affinity for the a, receptors located in the bladder outlet.9 Alfuzosine is recommended for symptoms of benign prostatic hypertrophy but also seems promising in the treatment of postoperative urinary retention (unpublished data). In conclusion, selective ul receptor antagonists such as prazosin and perhaps alfuzosine are the drugs of choice in the pharmacological management of postoperative urinary retention. Parasympathomimetics should be avoided. If al receptor antagonists are contraindicated or if pharmacological treatment fails, emptying the bladder by intermittent catheterisation'° or by an indwelling suprapubic catheter is the management of choice.
I O'Reilly PH. Postoperative urinary retention in men. BMJ 1991;302:864. (13 April.) 2 Finkbeiner AE. Is betanechol chloride clinically effective in promoting bladder emptying? A literature review. J Urol 1985;134:443-9. 3 Durant PAC, Yaksh TL. Drug effects on urinary bladder tone during spinal morphine-induced inhibition of the micturition reflex in unanesthetized rats. Anesth Analg 1988;68:325-34. 4 Bromage PR, Camporesi EM, Durant PAC, Nielsen CH. Non-respiratory side effects of epidural morphine. Anesth, Analg 1982;61:490-5. 5 Tammela 'r. Prevention of prolonged voiding problems after unexpected postoperative urinary retention: comparison of
phenoxybenzamine and carbachol.J Urol 1986;136:1254-7. 6 Holmes B, Sorkin EM. Indoramin: a review of its pharmacodynamic and pharmacokinetic properties and therapeutic efficacy in hypertension and related vascular, cardiovascular and airway diseases. Drugs 1986;31:143-80. 7 Caine M. The autonomic pharmacology of the urinary tract. In: Caine M, ed. The pharmacology ofthe urinary tract. Berlin: Springer-Verlag, 1985:5-30. 8 Bradley WE, Sundin T. The physiology and pharmacology of the urinary tract dysfunction. Clin Neuropharmacol 1982;5: 131-58. 9 Jardin A, Bensadoun H, Delauche-Cavallier MC, Attali P. Evaluation of alfuzosine, a new alpha1-adrenergic antagonist in the treatment of benign prostatic hypertrophy: a long term (6 months), placebo-controlled study in 518 patients. Lancet (in press). 10 Anderson JB, Grant JBF. Postoperative retention of urine: a prospective urodynamic study. BMJ 1991;302:894-6. (13 April.)
What should be done about asymptomatic hypercholesterolaemia? SIR,-We are grateful for Dr Gilbert R Thompson's recent editorial' about our report on asymptomatic hypercholesterolaemia.2 Unfortunately, Dr Thompson somewhat oversimplified our clinical conclusions in stating that we propose screening mainly middle aged men with other risk factors. For middle aged men we indicated that the evidence could support either a conservative scheme of testing when other risk factors are present or a more aggressive scheme that included testing all men "regardless of their risk profile." Recommendations for other groups were also given in detail.2 Dr Thompson wisely warned that testing on the basis of a family history ofcoronary heart disease or physical signs of hyperlipidaemia would detect only 30% of people with a serum cholesterol concentration over 8 mmol/l. Why, then, would we even entertain the above noted conservative scheme? Firstly, simply taking middle aged men with any risk factors (for example, diabetes mellitus, obesity, family history of premature coronary heart disease or dyslipidaemia, hypertension, cigarette smoking) would result in over half of adult men being tested in many nations. Consider also coronary heart disease events in two middle aged asymptomatic men-one whose only risk factor is a total cholesterol concentration of 7 8 mmolIl and another who smokes and has a cholesterol concentration of 6-9 mmol/l. At every age from 45 onwards the smoker has a greater risk of coronary heart disease, finishing up with a risk about 30% higher by age 65.' Regardless of the case finding strategy, special attention must be paid to people with multiple reversible risk factors. Lastly, the editorial emphasised that we are epidemiologists, not clinicians. Unlike Dr Thompson, we are not clinical lipidologists. Our group, however, included three general practitioners and a general physician-whose perspectives may be germane to practical clinical
policies. C DAVID NAYLOR ANTONI BASINSKI
BO J HANSEN
Clinical Epidemiology Unit, Sunnybrook Health Science Centre, University of Toronto, North York,
Department of Surgery, Hillerod Hospital, DK-3400 Hillerod, Denmark JACOB ROSENBERG Department of Surgical Gastroenterology, Hvidovre University Hospital, DK-2650, Hvidovre, Denmark
BMJ
VOLUME
302
1
JUNE
Ontario, Canada M4N 3M5 1 Thompson GR. What should be done about asymptomatic h)ypercholesterolaemia? BMJ7 1991;302:605-6. (16 March.)
1991
2 Toronto Working Group on Cholesterol Policy (Navlor CD, Basinski A, Frank JW, Rachlis MM). Asymptomatic hypercholesterolaemia: a clinical policy review. J Clin Epidemniol 1990;43: 1029-12 1. 3 McGee D. The Framingham study: an epidemiological investigation ofcardiovasculardisease (section 28). The probability ofdeveloping certamn cardiovascular diseases in eight years at specified values of some characterzstics. Bethesda, Maryland: US Department of Health, Education, and Welfare, 1973. (DHEW publication No 74-618.)
Picking up the tab for erythropoietin SIR,-The correction to Dr Roger Gabriel's thoughtful editorial on erythropoietin, carrying the denial, presumably from the Department of Health, that an arrangement exists for general practitioners to prescribe growth hormone once again underlines the lack of direction from central government for the prescribing of expensive drugs. ' Following the development of regional prescribing policies, hospital doctors and general practitioners are meeting-usually under the auspices of local drug and therapeutic committees -to discuss the most appropriate arrangements for prescribing for their patients. For this approach to succeed it is crucial for the method of funding to follow the pattern of prescribing devised jointly by the hospital and the general practitioners. This is particularly vital for very expensive drugs, those that may cost thousands of pounds for a treatment or each year for more chronic use. Such expensive drugs have specific indications for defined conditions; their efficacy is clinically proved; and there are no clinical, ethical, or supply constraints. These drugs, which include erythropoietin and growth hormone, present a dilemma to local committees, simply because of a lack of funds. The government in its booklet issued to the general public (The Health Service, The NHS Reforms and You) states that patients will continue to get their prescriptions even if the medicines are expensive. Moreover, in Improving Prescribing (Working Paper 2 of Working for Patients) it states: "Every patient being cared for by a General Practitioner will . .. always be able to get the drugs he or she needs, including high cost medicines, for as long as they are needed." The problem with both of these statements is that no one with experience in prescribing or supplying such medicines during the past 24 months believes that this is achievable with very expensive drugs either now or in the future. We consider that very expensive drugs can be funded only by making commensurate cuts in services elsewhere given the tightening financial restraints which encircle the "new" health service. The conclusion is that these drugs must be included in "rationalisation of the service," which in simple terms equals rationing of resources: a situation that has always been present in health care but, surprisingly, has only recently entered the vocabulary of health ministers. Rationing of health care raises two important issues. The first is a need for consistent and honest dialogue with the public, and the second is the development of appropriate systems for rationing the use of very expensive drugs. The first issue may be achieved only through a gradual process of information and education rather than sensational and speculative articles in the popular press whereas the second issue requires the development of clear direction from central government rather than delegation to impoverished district health authorities. The ultimate aim of rationing is to ensure that maximum value for money (cost-benefit, costutility, and, most appropriately, quality of life) is achieved within the narrow context of the drug's use and the wider context of health care priorities. Arguably this may be best achieved centrally, where expertise and control can be most effectively
1335
