al inflexible modes of health care delivery. John Rizos, MD, CCFP (EM) Emergency physician Kitchener-Waterloo and St. Mary's
hospitals Kitchener, Ont.
Reference 1. Hellstern R: The impact of ambulatory care centers on emergency medicine. Emerg Med Clin North Am 1987; 5:
we should allow it, encourage it and promote it. Rather than doing more studies we should get on with the business of facilitating the best possible resolution of the birthing process by applying what is already known. However, we all may benefit from the collection of data in an ongoing manner for future analysis so that we may adjust our course in the pursuit of excellence in serving our patients.
103-117 Stefan Semchyshyn, MD 22 Old Short Hills Rd. Livingston, NJ
Vaginal birth after previous cesarean section ail Goldman and colleagues' paper "Effects of patient, physician and hospital characteristics on the likelihood of vaginal birth after previous cesarean section [VBAC] in Quebec" (Can Med Assoc J 1990; 143: 1017-1024) is timely. The notion that prior cesarean section makes a current pregnancy high risk appears to be crucial to the authors' findings. A positive aspect of the high-risk label is the fact that VBAC is more likely to be managed at better equipped hospitals, by more experienced obstetricians. A negative aspect is that the physicians and hospitals handling repeat cesarean section are more likely to be less experienced. My approach to a high-risk situation, regardless of its nature, is to render high-risk care so that the patient will be at low risk in the end. After all, that is what prenatal care is all about: facilitating the best, most normal ending possible. I am proud when a patient at extremely high risk ends her pregnancy at term giving birth vaginally in the home-like atmosphere of a birthing room. Now that there is plenty of evidence that VBAC is safe and more than 50% likely to succeed in any individual trial of labour' G
632
CAN MED ASSOC J 1991; 144 (6)
Reference 1. Rosen MG, Dickinson JC: Vaginal birth after cesarean: a meta-analysis of
indicators for success. Obstet Gvnecol 1990: 76: 865-869
Assessing new technology T n he article "Kidney stones and lithotripters: critical analysis of the introduction of extracorporeal shock wave lithotripsy [ESWL] into Canada" (Can Med Assoc J 1990; 143: 1299-1303), by Drs. Lawrence C. Wiser, Richard H.M. Plain and John B. Dossetor, fills us with horror! The authors recommend that no equipment be introduced into Canada unless its efficacy has been established by a randomized controlled trial (RCT). They cite lithotripsy as an example of the unproven use of new and sometimes expensive technology that has not been properly evaluated. Having investigated several hundred patients with kidney stones who had been treated with lithotripsy by urologists, we cannot fail to be impressed by the safety, ease and simplicity of this technique for most such patients. Furthermore, as stated in the article, it is cost effective. What a difference from the old days of op?en surgery. Does one need an
RCT to demonstrate that an orange is different from a lemon? What about the introduction of hemodialysis, in which one of us was privileged to be a participant in this country? We shudder to think of randomizing patients to live or die. Surely we do not need more bureaucratic intrusion into our lives. New equipment can and should be evaluated at university centres. However, this evaluation does not necessarily have to involve an RCT. Once its safety and efficacy have been established a new technology should be made available within our health care system in an appropriate and rational distribution. Michael Kaye, MB, FRCPC Division of Nephrology Montreal General Hospital Sarah S. Prichard, MD, FRCPC Division of Nephrology Royal Victoria Hospital Montreal, Que.
[The authors reply.] Drs. Kaye and Prichard, with their apparent call for maintenance of the status quo in Canada in regard to technology assessment, remind us of the "traditional" medical approach to this issue described by Spodick.' Be that as it may, these authors exhibit several misperceptions about what our paper was attempting to point out.
We did not recommend "that no equipment be introduced into Canada" until completion of an RCT. Rather, we recommended that no new medical device "may
be offered for sale" in Canada before its efficacy and effectiveness have been established by scientific means through a "research protocol" incorporating random assignment. In doing so we were suggesting that the evaluation of a technology be done scientifically at the time of implementation, before its diffusion. We did not say, nor did we
hospitals Kitchener, Ont.
Reference 1. Hellstern R: The impact of ambulatory care centers on emergency medicine. Emerg Med Clin North Am 1987; 5:
we should allow it, encourage it and promote it. Rather than doing more studies we should get on with the business of facilitating the best possible resolution of the birthing process by applying what is already known. However, we all may benefit from the collection of data in an ongoing manner for future analysis so that we may adjust our course in the pursuit of excellence in serving our patients.
103-117 Stefan Semchyshyn, MD 22 Old Short Hills Rd. Livingston, NJ
Vaginal birth after previous cesarean section ail Goldman and colleagues' paper "Effects of patient, physician and hospital characteristics on the likelihood of vaginal birth after previous cesarean section [VBAC] in Quebec" (Can Med Assoc J 1990; 143: 1017-1024) is timely. The notion that prior cesarean section makes a current pregnancy high risk appears to be crucial to the authors' findings. A positive aspect of the high-risk label is the fact that VBAC is more likely to be managed at better equipped hospitals, by more experienced obstetricians. A negative aspect is that the physicians and hospitals handling repeat cesarean section are more likely to be less experienced. My approach to a high-risk situation, regardless of its nature, is to render high-risk care so that the patient will be at low risk in the end. After all, that is what prenatal care is all about: facilitating the best, most normal ending possible. I am proud when a patient at extremely high risk ends her pregnancy at term giving birth vaginally in the home-like atmosphere of a birthing room. Now that there is plenty of evidence that VBAC is safe and more than 50% likely to succeed in any individual trial of labour' G
632
CAN MED ASSOC J 1991; 144 (6)
Reference 1. Rosen MG, Dickinson JC: Vaginal birth after cesarean: a meta-analysis of
indicators for success. Obstet Gvnecol 1990: 76: 865-869
Assessing new technology T n he article "Kidney stones and lithotripters: critical analysis of the introduction of extracorporeal shock wave lithotripsy [ESWL] into Canada" (Can Med Assoc J 1990; 143: 1299-1303), by Drs. Lawrence C. Wiser, Richard H.M. Plain and John B. Dossetor, fills us with horror! The authors recommend that no equipment be introduced into Canada unless its efficacy has been established by a randomized controlled trial (RCT). They cite lithotripsy as an example of the unproven use of new and sometimes expensive technology that has not been properly evaluated. Having investigated several hundred patients with kidney stones who had been treated with lithotripsy by urologists, we cannot fail to be impressed by the safety, ease and simplicity of this technique for most such patients. Furthermore, as stated in the article, it is cost effective. What a difference from the old days of op?en surgery. Does one need an
RCT to demonstrate that an orange is different from a lemon? What about the introduction of hemodialysis, in which one of us was privileged to be a participant in this country? We shudder to think of randomizing patients to live or die. Surely we do not need more bureaucratic intrusion into our lives. New equipment can and should be evaluated at university centres. However, this evaluation does not necessarily have to involve an RCT. Once its safety and efficacy have been established a new technology should be made available within our health care system in an appropriate and rational distribution. Michael Kaye, MB, FRCPC Division of Nephrology Montreal General Hospital Sarah S. Prichard, MD, FRCPC Division of Nephrology Royal Victoria Hospital Montreal, Que.
[The authors reply.] Drs. Kaye and Prichard, with their apparent call for maintenance of the status quo in Canada in regard to technology assessment, remind us of the "traditional" medical approach to this issue described by Spodick.' Be that as it may, these authors exhibit several misperceptions about what our paper was attempting to point out.
We did not recommend "that no equipment be introduced into Canada" until completion of an RCT. Rather, we recommended that no new medical device "may
be offered for sale" in Canada before its efficacy and effectiveness have been established by scientific means through a "research protocol" incorporating random assignment. In doing so we were suggesting that the evaluation of a technology be done scientifically at the time of implementation, before its diffusion. We did not say, nor did we
