spread of HIV. If anything, it will drive underground those who are in most need of being tested. There are good medical and public health reasons for being tested, but testing must be voluntary and with the full consent of the patient. Voluntary testing in the context of counselling before and after offers an excellent opportunity to help reduce the spread of HIV infection. Such an approach must be taken by caring, compassionate physicians and other care providers who are fully knowledgeable about the medical and social consequences of HIV infection. This epidemic can be contained by education but not by forced testing and legal threats. Who needs to be "protected from legal recrimination" when ordering an HIV antibody test? Not me. I have an easy and reliable way of avoiding legal hassles related to HIV antibody testing: carrying out the test with the knowledge and approval of my patient.
ple aged 35 years and over rather than for the entire population. Given that coronary artery bypass surgery is seldom performed on people under 35 the net effect was to divide the same number of procedures by a smaller population and generate an apparently higher rate. The figure of 131.8 was first reported by the Ottawa Citizen as applicable to the fiscal year 198687 and was subsequently "corrected" to 112.8/100 000. The figures were challenged by Dr. Wilbert Keon, director-general of the Ottawa Heart Institute, and defended by the Statistics Canada authors (Ottawa Citizen, Aug. 17, 1990: Cl). A follow-up story emphasized that the Statistics Canada group stood by their results, noted the true denominator only in passing and neither acknowledged that the original figures were misleading nor explained how the misunderstanding occurred (Ottawa Citizen, Aug. 18, 1990: A14). In fact, Statistics Canada data show that from 1983 the ageIain D. Mackie, MD adjusted rate of coronary artery Director bypass surgery in Ottawa has fallHIV Care Programme en and during 1986-87 was St. Joseph's Health Centre Associate professor of medicine 42.2/100 000, similar to that in University of Western Ontario Montreal, Regina and Quebec London, Ont. City (Rod Riley, Statistics Canada: personal communication, Oct. 2, 1990). The Statistics Canada authors Coronary artery will be publishing a clarification bypass surgery rates (Dr. Cyril Nair, Statistics Canada: in Ottawa personal communication, Sept. 25 and 26, 1990), but what concerns A Statistics Canada bulletin me is the misleading impression published in August 1990' Ottawa residents may have reported the rates of coro- formed from the media coverage. nary artery bypass surgery for resi- Moreover, any misapprehensions dents of various census metropoli- might well have been exacerbated tan areas. The rate for Ottawa was by the article "The Ottawa Heart prominently shown as averaging Institute: It's good, but can we 131.8/100 000 population be- afford it?" (Can Med Assoc J tween 1981 and 1987 - well 1990; 142: 616-620), by Dr. Peter above even the national rate in Morgan and Lynne Cohen, which the United States. Unfortunately, proved controversial among the authors did not explain that CMAJ readers (see the Letters secthe rates were calculated for peo- tion in the July 1 and Sept. 1,
1990, issues) and was reprinted by the Ottawa Citizen after the release of the Statistics Canada report. If we are to have an informed public debate about the direction of health care in Canada better strategies must be developed to communicate concepts and new data - not just from the bench and bedside but also from ongoing health services research. As matters stand, a glance at virtually any newspaper is enough to suggest that misinformation and misinterpretation remain the rule rather than the exception. C. David Naylor, MD Clinical Epidemiology Unit and Department of Medicine Sunnybrook Health Science Centre Toronto, Ont.
Reference 1. Peters S, Chagani K, Paddon P, Nair C: Coronary artery bypasss surgery in Canada. Health Rep 1990; 2 (1): 9-26
The Medical Reform Group has a purpose T Nhe ideals of the Medical
Reform Group (Can Med Assoc J 1990; 143: 368369) appear to be lofty, although I have to pause at the idea of an uninformed/inexpert "public" having a direct say in health care resource allocations, as I have to pause at uninformed/inexpert politicians doing the same thing. I don't need a committee to tell me how to treat my patients; I have done my homework, and I know what I am doing. The same principles could surely be better applied in the same way to the distribution of health care resources but appear to be steadfastly refused by our bureaucratic bosses. Regarding Bill 94, certainly it banned extra-billing, but the net result to patients was just plain CAN MED ASSOC J 1990; 143 (12)
1287
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-
ple aged 35 years and over rather than for the entire population. Given that coronary artery bypass surgery is seldom performed on people under 35 the net effect was to divide the same number of procedures by a smaller population and generate an apparently higher rate. The figure of 131.8 was first reported by the Ottawa Citizen as applicable to the fiscal year 198687 and was subsequently "corrected" to 112.8/100 000. The figures were challenged by Dr. Wilbert Keon, director-general of the Ottawa Heart Institute, and defended by the Statistics Canada authors (Ottawa Citizen, Aug. 17, 1990: Cl). A follow-up story emphasized that the Statistics Canada group stood by their results, noted the true denominator only in passing and neither acknowledged that the original figures were misleading nor explained how the misunderstanding occurred (Ottawa Citizen, Aug. 18, 1990: A14). In fact, Statistics Canada data show that from 1983 the ageIain D. Mackie, MD adjusted rate of coronary artery Director bypass surgery in Ottawa has fallHIV Care Programme en and during 1986-87 was St. Joseph's Health Centre Associate professor of medicine 42.2/100 000, similar to that in University of Western Ontario Montreal, Regina and Quebec London, Ont. City (Rod Riley, Statistics Canada: personal communication, Oct. 2, 1990). The Statistics Canada authors Coronary artery will be publishing a clarification bypass surgery rates (Dr. Cyril Nair, Statistics Canada: in Ottawa personal communication, Sept. 25 and 26, 1990), but what concerns A Statistics Canada bulletin me is the misleading impression published in August 1990' Ottawa residents may have reported the rates of coro- formed from the media coverage. nary artery bypass surgery for resi- Moreover, any misapprehensions dents of various census metropoli- might well have been exacerbated tan areas. The rate for Ottawa was by the article "The Ottawa Heart prominently shown as averaging Institute: It's good, but can we 131.8/100 000 population be- afford it?" (Can Med Assoc J tween 1981 and 1987 - well 1990; 142: 616-620), by Dr. Peter above even the national rate in Morgan and Lynne Cohen, which the United States. Unfortunately, proved controversial among the authors did not explain that CMAJ readers (see the Letters secthe rates were calculated for peo- tion in the July 1 and Sept. 1,
1990, issues) and was reprinted by the Ottawa Citizen after the release of the Statistics Canada report. If we are to have an informed public debate about the direction of health care in Canada better strategies must be developed to communicate concepts and new data - not just from the bench and bedside but also from ongoing health services research. As matters stand, a glance at virtually any newspaper is enough to suggest that misinformation and misinterpretation remain the rule rather than the exception. C. David Naylor, MD Clinical Epidemiology Unit and Department of Medicine Sunnybrook Health Science Centre Toronto, Ont.
Reference 1. Peters S, Chagani K, Paddon P, Nair C: Coronary artery bypasss surgery in Canada. Health Rep 1990; 2 (1): 9-26
The Medical Reform Group has a purpose T Nhe ideals of the Medical
Reform Group (Can Med Assoc J 1990; 143: 368369) appear to be lofty, although I have to pause at the idea of an uninformed/inexpert "public" having a direct say in health care resource allocations, as I have to pause at uninformed/inexpert politicians doing the same thing. I don't need a committee to tell me how to treat my patients; I have done my homework, and I know what I am doing. The same principles could surely be better applied in the same way to the distribution of health care resources but appear to be steadfastly refused by our bureaucratic bosses. Regarding Bill 94, certainly it banned extra-billing, but the net result to patients was just plain CAN MED ASSOC J 1990; 143 (12)
1287
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-
