182
Health
care
for US veterans and others
SIR,-Dan Greenberg’s June 9 column demeans the US Department of Veterans Affairs’ medical care delivery system and reflects the hard-heartedness, vested interest, and avarice shared by a diminishing proportion of American physicians and scientists. The American College of Physicians’ position paper recommending a national solution to the inequities of our privately financed patchwork health care delivery system (Ann Intern Med 1990; 112: 637-39, 641-61) proves how widely Greenberg misses the mark. Your publication of this viewpoint demands a response from those who have more extensive VA experience than I have. I refer your readers to the article by J. W. Hollingsworth and P. K. Bondy in the June 28, 1990, issue of the New England Journal of Medicine (p 1851). However, I have had training or faculty experience in seven US academic centres, four of which have VA affiliations, and would make two observations. The first is that the medically complex, severe, multiorgan system disease states of many, if not most, elderly poor VA patients make outcome comparisons with non-VA medical facilities meaningless. Secondly, my personal experiences at financially healthy private or state-supported university medical centres, where rigorous medical insurance tests routinely precede all diagnostic and/or therapeutic manoeuvres, have shown me how urgently we need a the exclusion of 37 million US citizens from this funded so-called health care system.! The unfairness of privately this exclusion daily chafes at every socially conscious physician. To suggest, as Greenberg does, that the veterans who need this system be issued with "gold-plated medical insurance policies" so that 3-2 million individuals can diminish the rolls of the uninsured and underinsured by less than 10%, begs the question as to why these men and women and more than 32 million others in the US so desperately need a system of basic health care delivery. "Gold plating" would be an addition to the wallets of physicians and hospitals currently refusing to serve this small fraction of the much larger US population of the medically underprovided for. Greenberg’s vigorous criticism of the VA system, which treats all who enter it as equals and does the best it can with what it has for everyone of them, is, I hope, one of the last roars of the wounded dinosaurs advocating total reliance upon the hopelessly inequitable American medical care system. His recommendation for dispersal of public funds directly to insurance companies and the private medical establishment to cover this particular 9% of underserved Americans is naive. It deflects attention from the desperate need for a central solution that could well use the VA system, so thoroughly denigrated in his column, as the infrastructure for an effective and fair solution to the intolerable American health care dilemma.
solution
system to the new one for them to be reanalysed, and in Europe software phantoms are being developed as part of a quality assurance programme For gamma cameras simple phantoms are already available, notably for the technical aspects of studies. The value of more complex phantoms is doubted: generally phantoms cannot
replace patients.
The Administration of Radioactive Substances Advisory Committee’s (ARSAC) advice on research studies with radionuclides is that, whenever possible, volunteers should be aged 50 or over, the number of individuals participating in a project should be the minimum necessary to obtain the information required, and consideration should be given to the risk to an individual who is involved in a series of research investigations.3.3 Physics and Nuclear Medicine Department, Dudley Road Hospital, Birmingham B18 7QH, UK
L. K.
HARDING,
Chairman, ARSAC
J, Summer D. Irradiation of normal volunteers in nuclear medicine.J Nucl Med 1989; 30: 2062-63. 2. Britton KE, Busemann-Sokole E. Quality assurance in nuclear medicine software and ’COST’. Nucl Med Commun 1990; 11: 334-38. 3. Anon. Notes for guidance on the administration of radioactive substances to persons for the purpose of diagnosis, treatment or research. London: Department of Health, 1988. 1. Paterson
to
VA Medical Center, Albany, NY 12208, USA, and Albany Medical College
WILLIAM J. M. HRUSHESKY
Leadership Commission on Health Care. For the health of a nation: a shared responsibility. Ann Arbor, Michigan. Health Administration Press, 1989.
1. National
Ethics of
healthy subjects in nuclear medicine
SIR,-Dr Railton and colleagues (June 16, p 1466) argue that it may be ethically acceptable for normal subjects to be examined by nuclear medicine techniques to establish a normal range. The letter in the Journal of Nuclear Medicine 2 that they cite, which sensibly argues against the use of dose limits in medical research, not
recommends that ethics committees should make informed judgments about studies on normal subjects, on the basis of the evidence of risks and benefits. Railton et al further suggest that irradiation of normal subjects might be required with a new gamma camera and computer system, to establish normal ranges. This is rarely necessary, though problems may arise with computer programs that calculate indices such as cardiac ejection fraction. Sometimes it is possible to compare systems by transferring stored data from the old computer
Long-term
use
of copper intrauterine devices
SIR,-Following publication of our statement on long-term use of copper intrauterine devices (June 2, p 1322), I should like to add one more point. It is now generally accepted that any copper intrauterine device licensed currently in the UK, which is fitted in a woman over the age of 40, may remain in the uterus until menopause. National Association of Family Planning Doctors, 27 Sussex Place, London NW1 4RG, UK
DOROTHY TACCHI
Pressure sores: do mattresses work? SIR,-Your June 2 editorial
on pressure sores rightly focuses on rather than treatment. Prevention still depends prevention primarily on the skills of nurses and others, but the high intensity ward environment, the shortage of nurses, and the increase in numbers of high-risk elderly patients mean multidisciplinary care must be complemented by specialised equipment. A bewildering range of products is available.1 Selection criteria include ease of use and maintenance, acceptability to the patient, and cost, but the most vital aspect is efficacy. Manufacturers do not seem to have been evaluating their products before marketing to sustain their claims of efficacy. We have done a survey of the evidence manufacturers and suppliers provided about pressure-relieving equipment. Twenty-four manufacturers were written to and asked to provide information on the efficacy of their products. All replied supplying information about 48 products, and many enclosed glossy marketing brochures. For 24 (50%) products no evidence of efficacy was available; for 10 there was only anecdotal support, usually as case histories with no controls or measurement of outcome. One firm supplied newspaper cuttings about their mattress. 10 products had been subjected to laboratory evaluation but only 4 mattress systems had been studied by clinical trial, only 2 of the trials being well designed and randomised. The disappointing paucity of information apart, few manufacturers attempted to describe the clinical circumstances for which their products should or should not be used. Padding mattresses containing polyester fibres are of little value in preventing pressure sores in patients with fractured neck of femur, for exampleSurprisingly the three manufacturers of large cell ripple mattresses did not seem to be aware of published work supporting this type of system. 3,4 Nor did they provide evidence of
Health
care
for US veterans and others
SIR,-Dan Greenberg’s June 9 column demeans the US Department of Veterans Affairs’ medical care delivery system and reflects the hard-heartedness, vested interest, and avarice shared by a diminishing proportion of American physicians and scientists. The American College of Physicians’ position paper recommending a national solution to the inequities of our privately financed patchwork health care delivery system (Ann Intern Med 1990; 112: 637-39, 641-61) proves how widely Greenberg misses the mark. Your publication of this viewpoint demands a response from those who have more extensive VA experience than I have. I refer your readers to the article by J. W. Hollingsworth and P. K. Bondy in the June 28, 1990, issue of the New England Journal of Medicine (p 1851). However, I have had training or faculty experience in seven US academic centres, four of which have VA affiliations, and would make two observations. The first is that the medically complex, severe, multiorgan system disease states of many, if not most, elderly poor VA patients make outcome comparisons with non-VA medical facilities meaningless. Secondly, my personal experiences at financially healthy private or state-supported university medical centres, where rigorous medical insurance tests routinely precede all diagnostic and/or therapeutic manoeuvres, have shown me how urgently we need a the exclusion of 37 million US citizens from this funded so-called health care system.! The unfairness of privately this exclusion daily chafes at every socially conscious physician. To suggest, as Greenberg does, that the veterans who need this system be issued with "gold-plated medical insurance policies" so that 3-2 million individuals can diminish the rolls of the uninsured and underinsured by less than 10%, begs the question as to why these men and women and more than 32 million others in the US so desperately need a system of basic health care delivery. "Gold plating" would be an addition to the wallets of physicians and hospitals currently refusing to serve this small fraction of the much larger US population of the medically underprovided for. Greenberg’s vigorous criticism of the VA system, which treats all who enter it as equals and does the best it can with what it has for everyone of them, is, I hope, one of the last roars of the wounded dinosaurs advocating total reliance upon the hopelessly inequitable American medical care system. His recommendation for dispersal of public funds directly to insurance companies and the private medical establishment to cover this particular 9% of underserved Americans is naive. It deflects attention from the desperate need for a central solution that could well use the VA system, so thoroughly denigrated in his column, as the infrastructure for an effective and fair solution to the intolerable American health care dilemma.
solution
system to the new one for them to be reanalysed, and in Europe software phantoms are being developed as part of a quality assurance programme For gamma cameras simple phantoms are already available, notably for the technical aspects of studies. The value of more complex phantoms is doubted: generally phantoms cannot
replace patients.
The Administration of Radioactive Substances Advisory Committee’s (ARSAC) advice on research studies with radionuclides is that, whenever possible, volunteers should be aged 50 or over, the number of individuals participating in a project should be the minimum necessary to obtain the information required, and consideration should be given to the risk to an individual who is involved in a series of research investigations.3.3 Physics and Nuclear Medicine Department, Dudley Road Hospital, Birmingham B18 7QH, UK
L. K.
HARDING,
Chairman, ARSAC
J, Summer D. Irradiation of normal volunteers in nuclear medicine.J Nucl Med 1989; 30: 2062-63. 2. Britton KE, Busemann-Sokole E. Quality assurance in nuclear medicine software and ’COST’. Nucl Med Commun 1990; 11: 334-38. 3. Anon. Notes for guidance on the administration of radioactive substances to persons for the purpose of diagnosis, treatment or research. London: Department of Health, 1988. 1. Paterson
to
VA Medical Center, Albany, NY 12208, USA, and Albany Medical College
WILLIAM J. M. HRUSHESKY
Leadership Commission on Health Care. For the health of a nation: a shared responsibility. Ann Arbor, Michigan. Health Administration Press, 1989.
1. National
Ethics of
healthy subjects in nuclear medicine
SIR,-Dr Railton and colleagues (June 16, p 1466) argue that it may be ethically acceptable for normal subjects to be examined by nuclear medicine techniques to establish a normal range. The letter in the Journal of Nuclear Medicine 2 that they cite, which sensibly argues against the use of dose limits in medical research, not
recommends that ethics committees should make informed judgments about studies on normal subjects, on the basis of the evidence of risks and benefits. Railton et al further suggest that irradiation of normal subjects might be required with a new gamma camera and computer system, to establish normal ranges. This is rarely necessary, though problems may arise with computer programs that calculate indices such as cardiac ejection fraction. Sometimes it is possible to compare systems by transferring stored data from the old computer
Long-term
use
of copper intrauterine devices
SIR,-Following publication of our statement on long-term use of copper intrauterine devices (June 2, p 1322), I should like to add one more point. It is now generally accepted that any copper intrauterine device licensed currently in the UK, which is fitted in a woman over the age of 40, may remain in the uterus until menopause. National Association of Family Planning Doctors, 27 Sussex Place, London NW1 4RG, UK
DOROTHY TACCHI
Pressure sores: do mattresses work? SIR,-Your June 2 editorial
on pressure sores rightly focuses on rather than treatment. Prevention still depends prevention primarily on the skills of nurses and others, but the high intensity ward environment, the shortage of nurses, and the increase in numbers of high-risk elderly patients mean multidisciplinary care must be complemented by specialised equipment. A bewildering range of products is available.1 Selection criteria include ease of use and maintenance, acceptability to the patient, and cost, but the most vital aspect is efficacy. Manufacturers do not seem to have been evaluating their products before marketing to sustain their claims of efficacy. We have done a survey of the evidence manufacturers and suppliers provided about pressure-relieving equipment. Twenty-four manufacturers were written to and asked to provide information on the efficacy of their products. All replied supplying information about 48 products, and many enclosed glossy marketing brochures. For 24 (50%) products no evidence of efficacy was available; for 10 there was only anecdotal support, usually as case histories with no controls or measurement of outcome. One firm supplied newspaper cuttings about their mattress. 10 products had been subjected to laboratory evaluation but only 4 mattress systems had been studied by clinical trial, only 2 of the trials being well designed and randomised. The disappointing paucity of information apart, few manufacturers attempted to describe the clinical circumstances for which their products should or should not be used. Padding mattresses containing polyester fibres are of little value in preventing pressure sores in patients with fractured neck of femur, for exampleSurprisingly the three manufacturers of large cell ripple mattresses did not seem to be aware of published work supporting this type of system. 3,4 Nor did they provide evidence of
