porting the distribution of birth weights as an index of the reproductive health of the population. Our rate of low birth weight was 5.9% (17/288), consistent with the Canadian average quoted. Stefan C.W. Grzybowski, MD, MCISc, CCFP Alan S. Cadesky, MD, CCFP Queen Charlotte Islands Health Care
Society Queen Charlotte Islands, BC William E. Hogg, MD, MSc, FCFP University of Western Ontario London, Ont.
References 1. Rosenblatt RA, Teinken J, Shoemach P: Is obstetrics safe in small hospitals? The evidence from New Zealand's regionalised perinatal system. Lancet 1985; 2: 429-432 2. Black DP, Fyfe IM: The safety of obstetric services in small communities in northern Ontario. Can Med Assoc J 1984; 130: 571-576 3. Hogg W, Lemelin J: The case for small rural hospital obstetrics. Can Fam Physician 1986; 32: 2135-2139 4. Bonham GH: The measurement of birth outcome. Can J Public Health 1988; 79:385
"cyclothon" events - many benefitting hospitals - that do not make helmet wear mandatory. Until the medical profession becomes more adamant and consistent in its approach to bicycle helmet wear we will continue to see deaths and devastating injuries associated with bicycling. Deborah J. Davis, MD, CM Children's Hospital of Eastern Ontario Ottawa, Ont.
How does CMAJ reconcile the photograph on its front cover of children wearing bicycle helmets to promote the CMA's bicycle helmet campaign with the advertisement for antihistamines showing a young woman speeding along on her bicycle and not wearing a helmet?
Jean-Pierre Trudel National director, public affairs Sandoz Canada Inc. Dorval, Que.
C. Anthony Ryan, MB Codirector Pediatric Intensive Care Unit University of Alberta Hospitals Edmonton, Alta.
D_ r. Martin G. Cole's article "Effectiveness of three types of geriatric medical services: lessons for geriatric psychiatric services" (Can Med Assoc J 1991; 144: 1229-1240) is quite enlightening with regard to the outcome of different types of geriatric medical services. Most geriatric psychiatrists will agree that continuing care and preventive interventions have a better impact on health outcome. However, some inconsistencies in the article make questionable the conclusion that development of external geriatric psychiatric services rather than inpatient programs should receive priority. Such a conclusion could be misinterpreted to mean a call to abandon specialized inpatient programs or to provide only community services and not a continuum of services. A continuurn is the preferred option, and development of community resources in parallel with complementary hospital services is the most appropriate way to go. Geriatric psychiatric services should not be evaluated or prejudged according to the same criteria as geriatric medical services.
[The advertisers respond:]
Inconsistencies in bicycle helmet campaign
We agree completely about the helmetless bicycle rider in our Seldane advertisement. Merrell Dow is a safety-conscious company and will not use this advertisement in
T n he CMA bicycle helmet campaign is a worthwhile, albeit overdue, endeavour, but it suffers somewhat from a lack of emphasis on adult helmet wear. The delightful cover photograph on the June 1, 1991, issue of CMAJ is an excellent start to the campaign. However, the advertising in the same issue epitomizes the medical profession's inconsistent approach to the safety of bicycling and other sports. Of the three people on bicycles in two advertisements (pages 1392 and 1466) none is wearing a helmet. Similar inconsistencies are evident in the number of health care professionals who cycle to work without helmets and the various
future.
DECEMBER 1, 1991
Prevention Program, in May 1991. Since September 1991 we have been running a new advertisement, in which cyclists are not illustrated. Because of the overwhelming response to the bicycle helmet campaign and the commitment of Sandoz to safety and injury prevention the company has ensured that cyclists in future advertisements will be wearing helmets.
Gary Handelsman Director Marketing and public affairs Merrell Dow Pharmaceuticals (Canada) Inc. Richmond Hill, Ont.
Although the messages given by the cover photograph and the Sandoz advertisement seem inconsistent Sandoz has been actively promoting the use of bicycle helmets by financially supporting the campaign in conjunction with the CMA. Furthermore, Sandoz created and published the advertisement in question in 1990 and reserved media space well in advance of the launch of the Canadian Injury
Effectiveness of geriatric medical services
CAN MED ASSOC J 1991; 145 (11)
1421
With many of the hospital geriatric services that Cole reviewed there was no psychiatric involvement, and cognitive impairment was an exclusion criterion. Although there are similarities between geriatric medical and psychiatric services, the differences are more relevant to service planning. The two types of services admit for totally different reasons and therefore have different patient populations, with some overlap. Patients who are referred to psychiatric services have more severe cognitive impairment, social problems and behavioural dysfunction, and there is more likely to be caregiver "burnout." As a result, the outcome for the two groups of patients is necessarily different. When there is a difference in a projected outcome as well as in the population being served, it is improper to use the same model for care delivery or to compare the two services without the appropriate corrections. The first recommendation in the article is premature and unsupported by any evidence in the body of the paper or in any of the reviewed works. Comparing hospital with community geriatric medical services for effectiveness is like comparing a bowl of soup at the beginning of a meal to
dessert for their effectiveness against hunger. In some cases a bowl of soup may be all that is needed; in others a dessert may be needed to fill the void left by a less than satisfying meal. In the reviewed services minimum care was absent for the community patients before intervention, whereas hospitalized patients had already received some services. Thus, the two populations were different. An equivalent amount of service would have a better impact in the community - that is, a threshold effect. The functions of service delivery within the community are different from those of a specialized inpatient program. It is wrong to compare the outcome of services without accounting for the differences in populations and objectives. Cole's article gives a good view of what is currently available within geriatric medical services. It should provide a focus for debate on the direction that geriatric service planning should go in Canada. An understanding of the continuum of services and the dynamics that affect the relationship between external and hospital services is important in service planning: having one without the other reduces the effectiveness of service delivery.
We should be advocating a continuum of services and an integrative model of delivery. As well, we need to embark on demonstration projects on specific models of geriatric psychiatric service delivery without concluding in advance what the outcome should be. M. Oluwafemi Agbayewa, MB, FRCPC Division of Geriatric Psychiatry University of British Columbia Riverview Hospital Port Coquitlam, BC
This article fails to persuade the knowledgeable reader of Dr. Cole's conclusions. The selection of articles is incomplete. Although the searching of two computer databases is laudable, the delay in data entry frequently leads to incomplete discovery of relevant articles. It is also necessary to review current journals and to confer with experts and with those conducting research in this area. This approach would have revealed three additional randomized controlled trials of inpatient geriatric care.' The most recent' was published in May 1990, after the completion of Cole's literature search, although an abstract was available before that time. This study showed a convincing benefit of inpatient
INTRODUCING AN ARTI
U..'
Society Queen Charlotte Islands, BC William E. Hogg, MD, MSc, FCFP University of Western Ontario London, Ont.
References 1. Rosenblatt RA, Teinken J, Shoemach P: Is obstetrics safe in small hospitals? The evidence from New Zealand's regionalised perinatal system. Lancet 1985; 2: 429-432 2. Black DP, Fyfe IM: The safety of obstetric services in small communities in northern Ontario. Can Med Assoc J 1984; 130: 571-576 3. Hogg W, Lemelin J: The case for small rural hospital obstetrics. Can Fam Physician 1986; 32: 2135-2139 4. Bonham GH: The measurement of birth outcome. Can J Public Health 1988; 79:385
"cyclothon" events - many benefitting hospitals - that do not make helmet wear mandatory. Until the medical profession becomes more adamant and consistent in its approach to bicycle helmet wear we will continue to see deaths and devastating injuries associated with bicycling. Deborah J. Davis, MD, CM Children's Hospital of Eastern Ontario Ottawa, Ont.
How does CMAJ reconcile the photograph on its front cover of children wearing bicycle helmets to promote the CMA's bicycle helmet campaign with the advertisement for antihistamines showing a young woman speeding along on her bicycle and not wearing a helmet?
Jean-Pierre Trudel National director, public affairs Sandoz Canada Inc. Dorval, Que.
C. Anthony Ryan, MB Codirector Pediatric Intensive Care Unit University of Alberta Hospitals Edmonton, Alta.
D_ r. Martin G. Cole's article "Effectiveness of three types of geriatric medical services: lessons for geriatric psychiatric services" (Can Med Assoc J 1991; 144: 1229-1240) is quite enlightening with regard to the outcome of different types of geriatric medical services. Most geriatric psychiatrists will agree that continuing care and preventive interventions have a better impact on health outcome. However, some inconsistencies in the article make questionable the conclusion that development of external geriatric psychiatric services rather than inpatient programs should receive priority. Such a conclusion could be misinterpreted to mean a call to abandon specialized inpatient programs or to provide only community services and not a continuum of services. A continuurn is the preferred option, and development of community resources in parallel with complementary hospital services is the most appropriate way to go. Geriatric psychiatric services should not be evaluated or prejudged according to the same criteria as geriatric medical services.
[The advertisers respond:]
Inconsistencies in bicycle helmet campaign
We agree completely about the helmetless bicycle rider in our Seldane advertisement. Merrell Dow is a safety-conscious company and will not use this advertisement in
T n he CMA bicycle helmet campaign is a worthwhile, albeit overdue, endeavour, but it suffers somewhat from a lack of emphasis on adult helmet wear. The delightful cover photograph on the June 1, 1991, issue of CMAJ is an excellent start to the campaign. However, the advertising in the same issue epitomizes the medical profession's inconsistent approach to the safety of bicycling and other sports. Of the three people on bicycles in two advertisements (pages 1392 and 1466) none is wearing a helmet. Similar inconsistencies are evident in the number of health care professionals who cycle to work without helmets and the various
future.
DECEMBER 1, 1991
Prevention Program, in May 1991. Since September 1991 we have been running a new advertisement, in which cyclists are not illustrated. Because of the overwhelming response to the bicycle helmet campaign and the commitment of Sandoz to safety and injury prevention the company has ensured that cyclists in future advertisements will be wearing helmets.
Gary Handelsman Director Marketing and public affairs Merrell Dow Pharmaceuticals (Canada) Inc. Richmond Hill, Ont.
Although the messages given by the cover photograph and the Sandoz advertisement seem inconsistent Sandoz has been actively promoting the use of bicycle helmets by financially supporting the campaign in conjunction with the CMA. Furthermore, Sandoz created and published the advertisement in question in 1990 and reserved media space well in advance of the launch of the Canadian Injury
Effectiveness of geriatric medical services
CAN MED ASSOC J 1991; 145 (11)
1421
With many of the hospital geriatric services that Cole reviewed there was no psychiatric involvement, and cognitive impairment was an exclusion criterion. Although there are similarities between geriatric medical and psychiatric services, the differences are more relevant to service planning. The two types of services admit for totally different reasons and therefore have different patient populations, with some overlap. Patients who are referred to psychiatric services have more severe cognitive impairment, social problems and behavioural dysfunction, and there is more likely to be caregiver "burnout." As a result, the outcome for the two groups of patients is necessarily different. When there is a difference in a projected outcome as well as in the population being served, it is improper to use the same model for care delivery or to compare the two services without the appropriate corrections. The first recommendation in the article is premature and unsupported by any evidence in the body of the paper or in any of the reviewed works. Comparing hospital with community geriatric medical services for effectiveness is like comparing a bowl of soup at the beginning of a meal to
dessert for their effectiveness against hunger. In some cases a bowl of soup may be all that is needed; in others a dessert may be needed to fill the void left by a less than satisfying meal. In the reviewed services minimum care was absent for the community patients before intervention, whereas hospitalized patients had already received some services. Thus, the two populations were different. An equivalent amount of service would have a better impact in the community - that is, a threshold effect. The functions of service delivery within the community are different from those of a specialized inpatient program. It is wrong to compare the outcome of services without accounting for the differences in populations and objectives. Cole's article gives a good view of what is currently available within geriatric medical services. It should provide a focus for debate on the direction that geriatric service planning should go in Canada. An understanding of the continuum of services and the dynamics that affect the relationship between external and hospital services is important in service planning: having one without the other reduces the effectiveness of service delivery.
We should be advocating a continuum of services and an integrative model of delivery. As well, we need to embark on demonstration projects on specific models of geriatric psychiatric service delivery without concluding in advance what the outcome should be. M. Oluwafemi Agbayewa, MB, FRCPC Division of Geriatric Psychiatry University of British Columbia Riverview Hospital Port Coquitlam, BC
This article fails to persuade the knowledgeable reader of Dr. Cole's conclusions. The selection of articles is incomplete. Although the searching of two computer databases is laudable, the delay in data entry frequently leads to incomplete discovery of relevant articles. It is also necessary to review current journals and to confer with experts and with those conducting research in this area. This approach would have revealed three additional randomized controlled trials of inpatient geriatric care.' The most recent' was published in May 1990, after the completion of Cole's literature search, although an abstract was available before that time. This study showed a convincing benefit of inpatient
INTRODUCING AN ARTI
U..'
