Of course, simple rules cannot solve complex semantic problems resulting from atypical study designs, but they may be applied to the designs most frequently used in clinical research. ALFREDO MORABIA Clinical Epidemiology Unit, Hopital Cantonal Universitaire, CH1205 Geneva, Switzerland 1 Vandenbroucke JP. Prospective or retrospective: what's in a name? BMJ 1991;302:249-50. (2 February.)
Rationing health care SIR,-Professor Rudolf Klein's editorial reviews one American state's attempt at a logical solution to the greatest problem now facing all organised health services.' The Independent of 29 January quoted various speakers for different interests about the rationing that takes place in the NHS now.2 No country and no health care system provides every practicable kind of health care for every citizen now, nor will this be possible in future. Some things will have to be left undone and the choice of those things is not solely a medical affair-nor should it be managerial. Led by Dr Kitzhaber, who happens to be medical, the Oregon senate has tried to define priorities, and has suffered much criticism for doing so. Some doctors may believe that their duty to do everything possible for the patients presently in their care debars them from making decisions or advising on the other kinds of choice that must be made for the community and kept under constant review. Yet failure to provide broadly based medical advice on those choices will leave them to someone else with less understanding. It is this that Oregon seems to be trying to avoid. If there is to be medical consideration of these issues a broadly based group with participation by others, including non-professionals, is needed. The royal colleges of medicine, nursing, and midwives and the specialist faculties and societies have often examined aspects of their own special interests and proffered good advice. There is a conference of medical royal colleges and their faculties, which has achieved some coordination; but this is not enough. Professor Klein's concluding sentence should concern all the health professions and those who work with them in the NHS. He wrote, "This means not only a willingness to argue in public but also developing a system in which they have partners in dialogue: a system that is conspicuously lacking at present." For over two decades the United States Institute of Medicine, with funds contributed by six charitable foundations and often by the government or others for particular projects, has provided something of the help Britain needs. There is a major opportunity here for a professional initiative; if that is not forthcoming the resultant vacuum will have to be filled by management, possibly with too small or ill balanced professional contributions. GEORGE GODBER Cambridge CB l 4NZ 1 Klein R. On the Oregon trail: rationing health care. BM3r 1991;302:1-2. (5 January.) 2 O'Sullivan J. NHS treatment of minor ills may end. Independent 1991 Jan 29:9.
Trials of homoeopathy SIR,-Although democracy has its evident social virtues, majority opinion does not necessarily rule OK in science and medicine. Dr Jos Kleijnen and colleagues' quote the work of Fisher et aP as showing a positive effect of homoeopathic treatment and they assign this work their highest quality rating in rheumatology but they did not BMJ
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2 MARCH 1991
quote the subsequent paper on these data, which stated, "This re-analysis shows that the trial of Fisher et al provides no firm evidence for the efficacy of homoeopathic treatment for fibrositis."3 We see here an example of publication bias where the positive results appear in one journal (BMJ) and the refutation in another (Lancet). That bias extends beyond the professional literature. In the BBC's QED television programme directed by Tony Edwards in January 1991 devoted to homoeopathy the positive results of Fisher et al were quoted at length but Colquhoun's refutation was not mentioned-even though Colquhoun appeared expressing his general views on the implausibility of a positive result when the compounds were administered in such,a dilute form that there was no evidence that the patients received a single molecule of the "active" compound. The review of Dr Kleijnen and colleagues emphasises the value of quality over quantity. In particular they point to the difficulty of keeping secrets so that it is necessary to check every blind trial to see that it is in fact blind. However, as they state, "Double blinding was not checked in any trial of homoeopathy." P D WALL
University College London, London WC I E 6BT 1 Kleijnen J, Knipschild P, ter Riet G. Clinical trials of homoeopathy. BMJ 1991;302:316-23. (9 February.) 2 Fisher P, Greenwood A, Huskinsson E, Turner C, Belon P. Effect of homoeopathic treatment on fibrositis. BMJ 1989; 299:365-6. 3 Colquhoun D. Re-analysis of clinical trial of homoeopathic treatment of fibrositis. Lancet 1990;336:441-2.
SIR,-By almost supernatural coincidence two overviews of trials of homoeopathy have appeared in the medical press in the past six months.' 2 I thought it might be fruitful to conduct an overview of the overviews. Both studies are literature reviews and not statistical overviews or meta-analyses as suggested by Dr Jos Kleijnen and colleagues.' A statistical meta-analysis demands a knowledge of data on individual patients and analysis of both published and unpublished trials. Inevitably, both studies are flawed and cannot be guaranteed free of publication bias. The number of studies that are cited varies significantly between the two reviews, with 107 trials referenced by Dr Kleijnen and colleagues and only 40 by Hill and Doyon (p
Rationing health care SIR,-Professor Rudolf Klein's editorial reviews one American state's attempt at a logical solution to the greatest problem now facing all organised health services.' The Independent of 29 January quoted various speakers for different interests about the rationing that takes place in the NHS now.2 No country and no health care system provides every practicable kind of health care for every citizen now, nor will this be possible in future. Some things will have to be left undone and the choice of those things is not solely a medical affair-nor should it be managerial. Led by Dr Kitzhaber, who happens to be medical, the Oregon senate has tried to define priorities, and has suffered much criticism for doing so. Some doctors may believe that their duty to do everything possible for the patients presently in their care debars them from making decisions or advising on the other kinds of choice that must be made for the community and kept under constant review. Yet failure to provide broadly based medical advice on those choices will leave them to someone else with less understanding. It is this that Oregon seems to be trying to avoid. If there is to be medical consideration of these issues a broadly based group with participation by others, including non-professionals, is needed. The royal colleges of medicine, nursing, and midwives and the specialist faculties and societies have often examined aspects of their own special interests and proffered good advice. There is a conference of medical royal colleges and their faculties, which has achieved some coordination; but this is not enough. Professor Klein's concluding sentence should concern all the health professions and those who work with them in the NHS. He wrote, "This means not only a willingness to argue in public but also developing a system in which they have partners in dialogue: a system that is conspicuously lacking at present." For over two decades the United States Institute of Medicine, with funds contributed by six charitable foundations and often by the government or others for particular projects, has provided something of the help Britain needs. There is a major opportunity here for a professional initiative; if that is not forthcoming the resultant vacuum will have to be filled by management, possibly with too small or ill balanced professional contributions. GEORGE GODBER Cambridge CB l 4NZ 1 Klein R. On the Oregon trail: rationing health care. BM3r 1991;302:1-2. (5 January.) 2 O'Sullivan J. NHS treatment of minor ills may end. Independent 1991 Jan 29:9.
Trials of homoeopathy SIR,-Although democracy has its evident social virtues, majority opinion does not necessarily rule OK in science and medicine. Dr Jos Kleijnen and colleagues' quote the work of Fisher et aP as showing a positive effect of homoeopathic treatment and they assign this work their highest quality rating in rheumatology but they did not BMJ
VOLUME 302
2 MARCH 1991
quote the subsequent paper on these data, which stated, "This re-analysis shows that the trial of Fisher et al provides no firm evidence for the efficacy of homoeopathic treatment for fibrositis."3 We see here an example of publication bias where the positive results appear in one journal (BMJ) and the refutation in another (Lancet). That bias extends beyond the professional literature. In the BBC's QED television programme directed by Tony Edwards in January 1991 devoted to homoeopathy the positive results of Fisher et al were quoted at length but Colquhoun's refutation was not mentioned-even though Colquhoun appeared expressing his general views on the implausibility of a positive result when the compounds were administered in such,a dilute form that there was no evidence that the patients received a single molecule of the "active" compound. The review of Dr Kleijnen and colleagues emphasises the value of quality over quantity. In particular they point to the difficulty of keeping secrets so that it is necessary to check every blind trial to see that it is in fact blind. However, as they state, "Double blinding was not checked in any trial of homoeopathy." P D WALL
University College London, London WC I E 6BT 1 Kleijnen J, Knipschild P, ter Riet G. Clinical trials of homoeopathy. BMJ 1991;302:316-23. (9 February.) 2 Fisher P, Greenwood A, Huskinsson E, Turner C, Belon P. Effect of homoeopathic treatment on fibrositis. BMJ 1989; 299:365-6. 3 Colquhoun D. Re-analysis of clinical trial of homoeopathic treatment of fibrositis. Lancet 1990;336:441-2.
SIR,-By almost supernatural coincidence two overviews of trials of homoeopathy have appeared in the medical press in the past six months.' 2 I thought it might be fruitful to conduct an overview of the overviews. Both studies are literature reviews and not statistical overviews or meta-analyses as suggested by Dr Jos Kleijnen and colleagues.' A statistical meta-analysis demands a knowledge of data on individual patients and analysis of both published and unpublished trials. Inevitably, both studies are flawed and cannot be guaranteed free of publication bias. The number of studies that are cited varies significantly between the two reviews, with 107 trials referenced by Dr Kleijnen and colleagues and only 40 by Hill and Doyon (p
