unfortunate. Since Bill 94 passed, anyone in Ontario who wants better or quicker treatment has to go to the United States and pay far more there than one would have to pay here via extra-billing. What a marvellous achievement! Thus, such "extras" have been pushed even further into the reserve of the rich. Although I am not a socialist, I feel sad that the bottom-line effect of Bill 94 was to further disadvantage some of the less wealthy people in this province. Hardly a laudable effect. To perhaps misquote, "May the Lord protect me from the well intentioned but ill advised." Thomas J. Muckle, MD Director of laboratories Chedoke Division Chedoke-McMaster Hospitals Hamilton, Ont.
[Members of the group reply.]
of Bill 94, it appears that Muckle has not done his homework. There is no evidence of which we are aware of a massive flow of patients to the United States after the passage of Bill 94 or of lowincome people being disadvantaged by the banning of extra-billing. If such evidence exists we would be most interested in seeing it. More important, and contrary to Muckle's suggestions, user fees and extra-billing do deter lowincome people from obtaining necessary services.'-6 We do not advocate uninformed decision-making. Decisions about the allocation of health care resources should be well informed, regardless of who decides. However, we argue that an open and democratic process and the appropriate use of scientific information, rather than unfounded assertions based on ideology, are the best protection against poor advice.
Dr. Muckle implies that physD. Oxman, MD icians rather than the public Andrew Donald Woodside, MD should make decisions about the Gordon H. Guyatt, MD allocation of health care resources. For the Medical Reform Group Our disagreement is perhaps a of Ontario PO Box 366, Stn. J difference of values. We place a Toronto, Ont. high value on democracy. We also question whether physicians are best able to direct the allocation References of health care resources. There is ample evidence that individual 1. Evans RG: Strained Mercv, ButterToronto, 1984 decisions made by physicians for 2. worths, Williamson JW, German PS, Weiss R individual patients do not result et al: Health science information manin an efficient or effective use of agement and continuing education of physicians: a survey of U.S. primary societal resources.' Indeed, given care practitioners and their opinion the rapid evolution and disarray leaders. .-Inn Intern Med 1989: 110: of medical knowledge it is not 151-160 surprising that many physicians 3. Stoddart GL. Woodward CA: 7The Ef: fect olf Physician Extra-hilling on Pafind it difficult to keep up on their tienits 4ccess to Care and Attitudes Toown and that often what physward the Ontario Health Systemn (backicians do is inconsistent with sciground paper prepared for Health Serentific evidence.2 Furthermore, vices Review '79; Hall E. special commissioner), Dept of National Health the effectiveness of most clinical and Ottawa, 1980 interventions has not been proper- 4. BeckWelfare, RG, Horne JM: An AnalYtical ly evaluated; and, even when it Overviewv of the Saskatchewan Co-payhas been, clinical decisions must ment Experiment in Hospital and Ambulatory Care Settings, Ontario Council take into account not only scienHealth, Toronto, 1978 tific evidence but also patient 5. of Boulet JA, Henderson DM: Distribupreferences. tional and Redistributional A4spects oft As to the ''bottom-line effect"~ (,overn;n>1it Health Insuran1ce Provgrams1 1288
CAN MED ASSOC J 1990; 143 (1I2)
in Canada (discussion paper 146), Economic Council of Canada, Ottawa, 1979 6. Badgley RF, Smith RD: User Charges for Health Services, Ontario Council of Health, Toronto, 1979: 121-162
Safety of contrast media O n the basis of 337 647 cases Katayama and colleagues' have established that the risk of death is 1/168 000 for patients given either lowosmolar or high-osmolar agents. The Conseil d'6valuation des technologies de la sante du Quebec2 has analysed all original reports from Jan. 1, 1980, to Dec. 31, 1989, and has determined that the risk of death is 0.9/100 000 and is not reduced by using lowosmolar agents. At its 67th annual meeting, Sept. 24 to 26, 1990, in Nashville, Tenn., the American College of Radiology adopted as policy the report of its Committee on Drugs and Contrast Media entitled Current Criteria for the Use of Water Soluble Contrast Agents for Intravenous Injections. The policy recognizes the need to assess patients for risk regardless of the medium used and to have equipment and trained staff immediately available for resuscitation. It replaces the guidelines of May 1988 and is available on request from the American College of Radiology, 1891 Preston White Dr., Reston, VA 22091. A straw vote was held before the policy was adopted. (The elected councillors each represent approximately 100 radiologists and are very aware of activities in their communities; only two states were not represented.) By a show of hands, only one death had resulted from the use of a highosmolar contrast agent and five from the use of low-osmolar agents in the United States last year. The important fact for radiol-
ogists and referring physicians is that the new contrast agents have not altered the risk of death. Whichever agent is used, risk factors must be assessed and a resuscitation team be available as soon as a reaction occurs. The Ontario Ministry of Health funds the new contrast agents completely; the Quebec ministry does not fund these agents at all. But this has nothing to do with the risk of death. Patient comfort, the higher incidence of severe reactions with the older agents and the arterial use of the new ones are not fully addressed in the two reports and the policy decision of the American
College of Radiology. Douglas W. MacEwan, MD, FACR, FRCPC Professor of radiology University of Manitoba Winnipeg, Man.
References 1. Katayama H, Yamaguchi K, Kozuka T et al: Adverse reactions to ionic and nonionic contrast media. A report from the Japanese Committee on the Safety of Contrast Media. Radiology 1990; 175: 62 1-628 2. Evaluation of Low vs High Osmolar Contrast Media. Report Submitted to
the Ministry of Health and Social Services of Quebec, Conseil d'evaluation des technologies de la sante du Quebec, Montreal, 1990
Periodic health examination, 1990 update: 3. Interventions to prevent lung cancer other than smoking cessation I believe there are important errors and misconceptions in this article by the Canadian Task Force on the Periodic Health Examination (Can Med Assoc J 1990; 143: 269-272). It is critical that the primary
prevention of lung cancer be through prevention of first-time smoking. Although we have over 5 million Canadian smokers today' there are generations of children to come who, if present patterns persist, will end up replacing the 35 000 who die yearly from their habit.2'3 The prevention of lung cancer in Canadian smokers must obviously be through cessation. There is considerable evidence that all physicians could (and should) play a much more active role in persuading their smoking patients to quit. In addition, the federal government must improve on its paltry budget to this end. Expenditures forecast for 1990-91 on the National Program to Reduce Tobacco Use are $3.3 million, compared with $38.4 million on AIDS prevention and $41.4 million on the National Drug Strategy.4 Tobacco is the leading cause of preventable disease and death and brings to the government billions of dollars in revenue. Beta-carotene may have some merit for committed smokers and ex-smokers, but promoting it to reduce the risk of cancer in smokers is very likely to have an undesirable result. When low-tar, ultrafiltered cigarettes were marketed many smokers switched to them rather than quit. Although reduced tar (and in this instance increased p-carotene) does appear to partially reduce carcinogenic potential there is no evidence that it reduces cardiovascular risk in men or women. Urging smokers to reduce the risk of lung cancer by chewing carrots may have the secondary effect of decreasing the number who stop smoking and thus the potential reduction in the number who die of cardiovascular disease. A campaign to prevent lung cancer must acknowledge the risks of the product, the ruthlessness and dishonesty of the industry (which, to this day, denies tobacco's health risks) and the need for
an enormous human, medical, social, financial and legislative commitment to the prevention of firsttime smoking. David S. Esdaile, MD Co-chairman Physicians for a Smoke-Free Canada PO Box 4849, Stn. E Ottawa, Ont.
References 1. Smoking behaviour of Canadians. Health Promotion 1989; 28 (1): 13 2. Collishaw NE, Tostowaryk W, Wigle DT: Mortality attributable to tobacco use in Canada. Can J Public Health 1988; 79: 166-169 3. CMA Policy Summary: Smoking and health - 1987 update. Can Med Assoc J 1987; 136: 1104A 4. QuickFacts. In Health and Welfare Canada 1991 Estimates: Part III. Expenditure Plan, Dept of National Health and Welfare, Ottawa, 1990
[The chairman of the task force
responds:] We agree with Dr. Esdaile that the primary prevention of lung cancer must be through the prevention of smoking: we pointed this out in our update and cited our earlier report on the topic.' The 1990 update is concerned with preventing the disease in ex-smokers and committed smokers - primarily the former, since their numbers are steadily increasing in this country.2 There was no suggestion in our report that fl-carotene had any effect on cardiovascular disease or that it exerted a protective effect with regard to tobacco-induced cancers other than lung cancer. The title of the report should have clarified that for most readers. Most adults in this country who persist in smoking are not uninformed of the risks they are taking; they continue because they find it too difficult to give up cigarettes. It is doubtful that they will forgo quitting in the belief that an increase in fl-carotene consumption will ensure that their habit does not kill them. Any smokers who use this as an excuse CAN MED ASSOC J 1990; 143 (12)
1289
[Members of the group reply.]
of Bill 94, it appears that Muckle has not done his homework. There is no evidence of which we are aware of a massive flow of patients to the United States after the passage of Bill 94 or of lowincome people being disadvantaged by the banning of extra-billing. If such evidence exists we would be most interested in seeing it. More important, and contrary to Muckle's suggestions, user fees and extra-billing do deter lowincome people from obtaining necessary services.'-6 We do not advocate uninformed decision-making. Decisions about the allocation of health care resources should be well informed, regardless of who decides. However, we argue that an open and democratic process and the appropriate use of scientific information, rather than unfounded assertions based on ideology, are the best protection against poor advice.
Dr. Muckle implies that physD. Oxman, MD icians rather than the public Andrew Donald Woodside, MD should make decisions about the Gordon H. Guyatt, MD allocation of health care resources. For the Medical Reform Group Our disagreement is perhaps a of Ontario PO Box 366, Stn. J difference of values. We place a Toronto, Ont. high value on democracy. We also question whether physicians are best able to direct the allocation References of health care resources. There is ample evidence that individual 1. Evans RG: Strained Mercv, ButterToronto, 1984 decisions made by physicians for 2. worths, Williamson JW, German PS, Weiss R individual patients do not result et al: Health science information manin an efficient or effective use of agement and continuing education of physicians: a survey of U.S. primary societal resources.' Indeed, given care practitioners and their opinion the rapid evolution and disarray leaders. .-Inn Intern Med 1989: 110: of medical knowledge it is not 151-160 surprising that many physicians 3. Stoddart GL. Woodward CA: 7The Ef: fect olf Physician Extra-hilling on Pafind it difficult to keep up on their tienits 4ccess to Care and Attitudes Toown and that often what physward the Ontario Health Systemn (backicians do is inconsistent with sciground paper prepared for Health Serentific evidence.2 Furthermore, vices Review '79; Hall E. special commissioner), Dept of National Health the effectiveness of most clinical and Ottawa, 1980 interventions has not been proper- 4. BeckWelfare, RG, Horne JM: An AnalYtical ly evaluated; and, even when it Overviewv of the Saskatchewan Co-payhas been, clinical decisions must ment Experiment in Hospital and Ambulatory Care Settings, Ontario Council take into account not only scienHealth, Toronto, 1978 tific evidence but also patient 5. of Boulet JA, Henderson DM: Distribupreferences. tional and Redistributional A4spects oft As to the ''bottom-line effect"~ (,overn;n>1it Health Insuran1ce Provgrams1 1288
CAN MED ASSOC J 1990; 143 (1I2)
in Canada (discussion paper 146), Economic Council of Canada, Ottawa, 1979 6. Badgley RF, Smith RD: User Charges for Health Services, Ontario Council of Health, Toronto, 1979: 121-162
Safety of contrast media O n the basis of 337 647 cases Katayama and colleagues' have established that the risk of death is 1/168 000 for patients given either lowosmolar or high-osmolar agents. The Conseil d'6valuation des technologies de la sante du Quebec2 has analysed all original reports from Jan. 1, 1980, to Dec. 31, 1989, and has determined that the risk of death is 0.9/100 000 and is not reduced by using lowosmolar agents. At its 67th annual meeting, Sept. 24 to 26, 1990, in Nashville, Tenn., the American College of Radiology adopted as policy the report of its Committee on Drugs and Contrast Media entitled Current Criteria for the Use of Water Soluble Contrast Agents for Intravenous Injections. The policy recognizes the need to assess patients for risk regardless of the medium used and to have equipment and trained staff immediately available for resuscitation. It replaces the guidelines of May 1988 and is available on request from the American College of Radiology, 1891 Preston White Dr., Reston, VA 22091. A straw vote was held before the policy was adopted. (The elected councillors each represent approximately 100 radiologists and are very aware of activities in their communities; only two states were not represented.) By a show of hands, only one death had resulted from the use of a highosmolar contrast agent and five from the use of low-osmolar agents in the United States last year. The important fact for radiol-
ogists and referring physicians is that the new contrast agents have not altered the risk of death. Whichever agent is used, risk factors must be assessed and a resuscitation team be available as soon as a reaction occurs. The Ontario Ministry of Health funds the new contrast agents completely; the Quebec ministry does not fund these agents at all. But this has nothing to do with the risk of death. Patient comfort, the higher incidence of severe reactions with the older agents and the arterial use of the new ones are not fully addressed in the two reports and the policy decision of the American
College of Radiology. Douglas W. MacEwan, MD, FACR, FRCPC Professor of radiology University of Manitoba Winnipeg, Man.
References 1. Katayama H, Yamaguchi K, Kozuka T et al: Adverse reactions to ionic and nonionic contrast media. A report from the Japanese Committee on the Safety of Contrast Media. Radiology 1990; 175: 62 1-628 2. Evaluation of Low vs High Osmolar Contrast Media. Report Submitted to
the Ministry of Health and Social Services of Quebec, Conseil d'evaluation des technologies de la sante du Quebec, Montreal, 1990
Periodic health examination, 1990 update: 3. Interventions to prevent lung cancer other than smoking cessation I believe there are important errors and misconceptions in this article by the Canadian Task Force on the Periodic Health Examination (Can Med Assoc J 1990; 143: 269-272). It is critical that the primary
prevention of lung cancer be through prevention of first-time smoking. Although we have over 5 million Canadian smokers today' there are generations of children to come who, if present patterns persist, will end up replacing the 35 000 who die yearly from their habit.2'3 The prevention of lung cancer in Canadian smokers must obviously be through cessation. There is considerable evidence that all physicians could (and should) play a much more active role in persuading their smoking patients to quit. In addition, the federal government must improve on its paltry budget to this end. Expenditures forecast for 1990-91 on the National Program to Reduce Tobacco Use are $3.3 million, compared with $38.4 million on AIDS prevention and $41.4 million on the National Drug Strategy.4 Tobacco is the leading cause of preventable disease and death and brings to the government billions of dollars in revenue. Beta-carotene may have some merit for committed smokers and ex-smokers, but promoting it to reduce the risk of cancer in smokers is very likely to have an undesirable result. When low-tar, ultrafiltered cigarettes were marketed many smokers switched to them rather than quit. Although reduced tar (and in this instance increased p-carotene) does appear to partially reduce carcinogenic potential there is no evidence that it reduces cardiovascular risk in men or women. Urging smokers to reduce the risk of lung cancer by chewing carrots may have the secondary effect of decreasing the number who stop smoking and thus the potential reduction in the number who die of cardiovascular disease. A campaign to prevent lung cancer must acknowledge the risks of the product, the ruthlessness and dishonesty of the industry (which, to this day, denies tobacco's health risks) and the need for
an enormous human, medical, social, financial and legislative commitment to the prevention of firsttime smoking. David S. Esdaile, MD Co-chairman Physicians for a Smoke-Free Canada PO Box 4849, Stn. E Ottawa, Ont.
References 1. Smoking behaviour of Canadians. Health Promotion 1989; 28 (1): 13 2. Collishaw NE, Tostowaryk W, Wigle DT: Mortality attributable to tobacco use in Canada. Can J Public Health 1988; 79: 166-169 3. CMA Policy Summary: Smoking and health - 1987 update. Can Med Assoc J 1987; 136: 1104A 4. QuickFacts. In Health and Welfare Canada 1991 Estimates: Part III. Expenditure Plan, Dept of National Health and Welfare, Ottawa, 1990
[The chairman of the task force
responds:] We agree with Dr. Esdaile that the primary prevention of lung cancer must be through the prevention of smoking: we pointed this out in our update and cited our earlier report on the topic.' The 1990 update is concerned with preventing the disease in ex-smokers and committed smokers - primarily the former, since their numbers are steadily increasing in this country.2 There was no suggestion in our report that fl-carotene had any effect on cardiovascular disease or that it exerted a protective effect with regard to tobacco-induced cancers other than lung cancer. The title of the report should have clarified that for most readers. Most adults in this country who persist in smoking are not uninformed of the risks they are taking; they continue because they find it too difficult to give up cigarettes. It is doubtful that they will forgo quitting in the belief that an increase in fl-carotene consumption will ensure that their habit does not kill them. Any smokers who use this as an excuse CAN MED ASSOC J 1990; 143 (12)
1289
