813
Publicity and unpublished results S!R,—Your correspondence about publicity raises important issues that have wider relevance. Both your contributors (Feb 29, p 556) accept that considerable anxiety can be caused to patients if the results of research are reported in sensational terms by the press and on television before publication in medical journals. However, the media have as keen an appetite for "could have been saved" stories as for "major breakthrough" stories. There is no easier way for those seeking publicity or extra funding to draw attention to a cause than to approach the general press directly stating that a patient has died because a particular resource was not available-and at least four such instances have been widely reported this year. The real story is that anxiety and distress will be caused to patients with similar medical conditions or who attend the same hospitals or unit. Individual doctors who present clinical research or draw funding difficulties to public attention can make a useful contribution to the debate of important issues. However, the media is not the forum for the careful evaluation of research data nor necessarily for balanced argument about resource priorities. Furthermore, public confidence could be diminished if these practices were to become the norm. The Royal Colleges and editors of medical journals are well placed to guide the profession. Under what circumstances should the results of multicentre trials first be presented to the general press? Should there be a minimum number of signatories if serious allegations about lack of resources are to be made to the general media? At present there are no guidelines: recent widespread publicity indicates that there probably now need to be. Barnet and Edgware Hospitals, London EN5
ROBERT WINTER
3DJ, UK
Finnish survey of public opinion about
public expenditure SIR,-Malcolm Dean (Dec 14, p 1511) compares results of public (NHS). He points out the difficulty of posing the right questions. The theme was continued by Dr Richardson and Dr Chamy (Jan 18, p 184), who discuss economic constraints and possible reallocation of public surveys about the UK National Health Service
spending. a long period of steady economic growth and of development welfare and health has ended. The gross domestic product increase in 1990 was 0-4% and in 1991 it was 6-2%. Tax revenues have failed to meet earlier estimates and a fiscal crisis in the public sector is a reality. The issues are no longer what to spend on and how much more money is needed, but how to limit the growth of the public sector and how to make the best use of present
In
Finland,
resources.
In August, 1991, the National Agency for Welfare and Health asked a representative sample of the Finnish population how the public economy ought to be balanced. Of 998 people interviewed, 80% chose to cut expenditure. Other alternatives were supported RESULTS OF PUBLIC SURVEY OF SPENDING CUTS IN PUBLIC SECTOR
only by some respondents: raising taxes (3%), borrowing money (6%), and raising client’s fees (7%). When asked where savings could be made the result was very similar to that of the Cardiff Health Survey (table).1,2 The Cardiff Health Survey has found the right approach by introducing comparisons. In our survey, to note, for example, that 23% of the population sees no possibility of saving in defence expenditure is meaningless, but when compared with the respective figure of 75 % for health care it becomes of value. Answers to survey questions have no natural scale, and therefore comparative reference points are needed. We can then safely conclude that the welfare state is closer to the heart of the Finnish population than defence or agricultural support. National Agency for Welfare and Health, PO Box 220, 00531 Helsinki, Finland
HANNU UUSITALO TUIRE SIHVO
1.
Charny MC, Lewis PA. Does health knowledge affect eating habits? Health Educ J
2.
Charny MC, Farrow SC, Lewis PA. Who is using cervical cancer screening services?
1987; 4: 172-76. Health Trends 1987; 19: 3-5.
Serious intercurrent disease in healthy volunteers in clinical pharmacological research SIR,-Dr Kroon and Dr Cohen (Feb 22, p 504) provide a valuable reminder that screening healthy volunteers for a research study may occasionally yield some distressing surprises. Vazquez and P reported a parallel experience in which three young and
apparently healthy medical students who had volunteered for research studies were found to have previously unsuspected HIV infection, chronic persistent hepatitis, and a focal lesion in the brain, respectively. The serious difficulty we encountered was the emotional stress for the volunteer and the investigator. Both experienced a sudden change in role. The volunteer was transformed from a healthy student with bright prospects into a frightened patient with a potentially life-threatening illness. The researcher was transformed from an objective investigator into an involved counsellor with no experience or guidelines for coping with this unfamiliar and emotionally charged problem. All the volunteers with abnormal findings were eventually referred for specialist care and follow-up. Clinical researchers who recruit healthy controls would be well advised to plan for similar unpleasant surprises. For example, institutional committees that oversee human research might draft guidelines for the management of these sporadic occurrences, with emphasis on prompt counselling and appropriate care for the affected volunteer, and protection of their confidentiality. Informed consent forms might even warn research volunteers that the screening process could reveal some previously unsuspected abnormality. Department of Medicine, New York Medical College, Staten Island, New York 10310, USA 1.
MICHAEL PHILLIPS
Phillips M, Vazquez AJ. Abnormal findings in "normal" research
volunteers.
Controlled Clin Trials 1987; 8: 338-42.
Day care and
pregnancy hypertension SIR,-Dr Tuffnell and colleagues (Jan 25, p 224) report that the introduction of a daycare unit for hypertension in pregnancy reduces the need for and length of antenatal admissions and did not adversely affect outcomes. Our comparison of a daycare system in Glasgow with an inpatient-based system in Aberdeen has revealed
*eg, day-care, homehelp, residential care teg, pensions, sickness, unemployment secunt’
similar effects.’ The degree to which the reduction in inpatient care will lead to savings for the hospital depends on how the inpatient resources freed are used and on the additional outpatient resource use. We found that, for patients similar to those studied by Tuffnell et al, costs are lower for patients managed by day care but not significantly so. We too found that women are prepared to come to a daycare unit frequently to avoid admission. Most daycare attenders
Publicity and unpublished results S!R,—Your correspondence about publicity raises important issues that have wider relevance. Both your contributors (Feb 29, p 556) accept that considerable anxiety can be caused to patients if the results of research are reported in sensational terms by the press and on television before publication in medical journals. However, the media have as keen an appetite for "could have been saved" stories as for "major breakthrough" stories. There is no easier way for those seeking publicity or extra funding to draw attention to a cause than to approach the general press directly stating that a patient has died because a particular resource was not available-and at least four such instances have been widely reported this year. The real story is that anxiety and distress will be caused to patients with similar medical conditions or who attend the same hospitals or unit. Individual doctors who present clinical research or draw funding difficulties to public attention can make a useful contribution to the debate of important issues. However, the media is not the forum for the careful evaluation of research data nor necessarily for balanced argument about resource priorities. Furthermore, public confidence could be diminished if these practices were to become the norm. The Royal Colleges and editors of medical journals are well placed to guide the profession. Under what circumstances should the results of multicentre trials first be presented to the general press? Should there be a minimum number of signatories if serious allegations about lack of resources are to be made to the general media? At present there are no guidelines: recent widespread publicity indicates that there probably now need to be. Barnet and Edgware Hospitals, London EN5
ROBERT WINTER
3DJ, UK
Finnish survey of public opinion about
public expenditure SIR,-Malcolm Dean (Dec 14, p 1511) compares results of public (NHS). He points out the difficulty of posing the right questions. The theme was continued by Dr Richardson and Dr Chamy (Jan 18, p 184), who discuss economic constraints and possible reallocation of public surveys about the UK National Health Service
spending. a long period of steady economic growth and of development welfare and health has ended. The gross domestic product increase in 1990 was 0-4% and in 1991 it was 6-2%. Tax revenues have failed to meet earlier estimates and a fiscal crisis in the public sector is a reality. The issues are no longer what to spend on and how much more money is needed, but how to limit the growth of the public sector and how to make the best use of present
In
Finland,
resources.
In August, 1991, the National Agency for Welfare and Health asked a representative sample of the Finnish population how the public economy ought to be balanced. Of 998 people interviewed, 80% chose to cut expenditure. Other alternatives were supported RESULTS OF PUBLIC SURVEY OF SPENDING CUTS IN PUBLIC SECTOR
only by some respondents: raising taxes (3%), borrowing money (6%), and raising client’s fees (7%). When asked where savings could be made the result was very similar to that of the Cardiff Health Survey (table).1,2 The Cardiff Health Survey has found the right approach by introducing comparisons. In our survey, to note, for example, that 23% of the population sees no possibility of saving in defence expenditure is meaningless, but when compared with the respective figure of 75 % for health care it becomes of value. Answers to survey questions have no natural scale, and therefore comparative reference points are needed. We can then safely conclude that the welfare state is closer to the heart of the Finnish population than defence or agricultural support. National Agency for Welfare and Health, PO Box 220, 00531 Helsinki, Finland
HANNU UUSITALO TUIRE SIHVO
1.
Charny MC, Lewis PA. Does health knowledge affect eating habits? Health Educ J
2.
Charny MC, Farrow SC, Lewis PA. Who is using cervical cancer screening services?
1987; 4: 172-76. Health Trends 1987; 19: 3-5.
Serious intercurrent disease in healthy volunteers in clinical pharmacological research SIR,-Dr Kroon and Dr Cohen (Feb 22, p 504) provide a valuable reminder that screening healthy volunteers for a research study may occasionally yield some distressing surprises. Vazquez and P reported a parallel experience in which three young and
apparently healthy medical students who had volunteered for research studies were found to have previously unsuspected HIV infection, chronic persistent hepatitis, and a focal lesion in the brain, respectively. The serious difficulty we encountered was the emotional stress for the volunteer and the investigator. Both experienced a sudden change in role. The volunteer was transformed from a healthy student with bright prospects into a frightened patient with a potentially life-threatening illness. The researcher was transformed from an objective investigator into an involved counsellor with no experience or guidelines for coping with this unfamiliar and emotionally charged problem. All the volunteers with abnormal findings were eventually referred for specialist care and follow-up. Clinical researchers who recruit healthy controls would be well advised to plan for similar unpleasant surprises. For example, institutional committees that oversee human research might draft guidelines for the management of these sporadic occurrences, with emphasis on prompt counselling and appropriate care for the affected volunteer, and protection of their confidentiality. Informed consent forms might even warn research volunteers that the screening process could reveal some previously unsuspected abnormality. Department of Medicine, New York Medical College, Staten Island, New York 10310, USA 1.
MICHAEL PHILLIPS
Phillips M, Vazquez AJ. Abnormal findings in "normal" research
volunteers.
Controlled Clin Trials 1987; 8: 338-42.
Day care and
pregnancy hypertension SIR,-Dr Tuffnell and colleagues (Jan 25, p 224) report that the introduction of a daycare unit for hypertension in pregnancy reduces the need for and length of antenatal admissions and did not adversely affect outcomes. Our comparison of a daycare system in Glasgow with an inpatient-based system in Aberdeen has revealed
*eg, day-care, homehelp, residential care teg, pensions, sickness, unemployment secunt’
similar effects.’ The degree to which the reduction in inpatient care will lead to savings for the hospital depends on how the inpatient resources freed are used and on the additional outpatient resource use. We found that, for patients similar to those studied by Tuffnell et al, costs are lower for patients managed by day care but not significantly so. We too found that women are prepared to come to a daycare unit frequently to avoid admission. Most daycare attenders
