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Use of health servicestatistics

Collect more, collect fewer, do better withwhat is collected, ignore altogether-thisspan of opinions was expressed at a confer-ence held in London, UK, by the HealthStatistics Users Group last week. The

range reflected the participants, who in-cluded health service statisticians

(academic and governmental), managers(old-style National Health Service and

opted-out trusts), and health economists.Counting on Accountability was designedto look at the use and abuse of health :statistics. :

It was the "representative" of the con-sumer (ie, the patient) who questioned theneed for accountability at all at the userlevel. Naomi Pfeffer from the City andHackney Community Health Council ineast London (these councils look afterpatients’ interests) pointed out that patientswant hospital beds without waiting, notaccountability. Most important in the col-lection of statistics was respect for thepublic, which she illustrated with examplesof poor ethics in health service research.Her views on the use of formal statisticsversus the power of anecdote to sway

opinion were provocative, given her audi-ence. Many of those present said that bothwere valuable. :John Yates, who is a long-term battler

from the University of Birmingham, scr-u-tinises theatre registers to find out whichsurgeon does the work. Such records arenot collated publicly in any other way. Thetenfold variation in individual workload insome specialties shows a waste of training;it also brings up the question of "skilling",

because the work of low-volume surgeonsis associated with poor outcome. Sometrusts are looking at accountability, if onlyto protect themselves against possible liti-gation. Mistakes and near-misses in theatreare being systematically logged. A near-miss would include patients presenting inthe wrong order on the operating day,slippage of the day’s timetable, or lack ofanaesthetic cover. So, paradoxically, thehospital trusts may be more accountablethan the old-style NHS bureaucracy, andnot just in terms of the balance sheet thatthey have to make available. Whether thepublic can understand balance sheets oreven the management-speak of the trusts(eg, tolerance violation, downsizing) isanother matter. :

Users of health service statistics are

certainly thinking about the ethics of col-lection and the meaning and disseminationof their findings. The various interestgroups obviously look at health statisticswith different priorities, and, ultimately,party politics rule the day. The governmentand its regional and local representatives in vthe health service unsurprisingly highlightthe good news, even if they have to stretchthe data to their limits. Earlier this year, :

Virginia Bottomley, UK Secretary of Statefor Health, was delighted to say that GPfundholders were 3% more efficient, butno-one at this meeting had yet been able tofind out what she meant. :

: Given that the UK health service spends£100 million daily, accountability was seen

as good practice, because the public andpatients, medical staff, managers, and po-liticians must be confident that statistics areaccurately and rationally collected andused. :

David McNamee

Pay cuts?

Canada’s fourth largest province, Alberta,has asked all doctors and health-care

workers to take a voluntary 5% rollback inall salaries, benefits, and fees as part of a bidto slash Can$122 million from the

province’s$4.1 billion health budget. How-ever, government officials made it clear thatthe province will move with layoffs or

legislated cuts in salaries and benefits ifhealth workers do not agree to the rollbacks

by Nov 23. The cut, to take effect on Jan 1,would save the province$37.5 million in thefirst quarter of 1994.

In announcing the measure, PremierRalph Klein indicated optimism that healthworkers will accept the cut, especially sinceprovincial officials project that the rollbackwill save a projected 700 jobs in the currentfiscal year. (Over 1 full year, the rollbackwould save 2800 jobs or roughly$150million.)

Margaret Kerwin, president of the Al-berta Medical Association, says it’s too

early to say whether doctors will accept therollback. However, the president of theAlberta Union of Provincial Employees,which represents about 8500 health-care

workers, has categorically denounced theproposal.The province will also save nearly$80

million by deferral of health constructionprojects; by reducing funding for hospital

capital equipment; and by cutting operat-ing grants to regional and rural acute andchronic care facilities.

Wayne Kondro

Doses of hypnotics

The EC’s Committee for ProprietaryMedicinal Products is recommending newprescribing restrictions on seven short-

acting hypnotics, including Halcion (tria-zolam). The recommendations (EC Com-mission document 111/5519/93) follow atwo-year study into the products sparkedby uproar following the UK’s Halcion ban.The study compares triazolam with six

other benzodiazepine and benzodiazepine-like compounds to see whether there is :truth in Upjohn claims that Halcion’sside-effects and effectiveness are similar tothose of other products in its class. The report says the seven hypnotics

should be contraindicated in patients withmyasthenia gravis, hypersensitivity to

benzodiazepines, severe respiratory in-

sufficiency, sleep apnoea syndrome, andsevere hepatic insufficiency. They shouldnot be given to children. The ad hoc grouprecognised the products’ value in insomniatreatment but considered their use justified

for only short periods when the disorder is :"severe, disabling or subjecting the indivi-dual to extreme distress". Treatmentshould be limited to between a few days and2 weeks with a maximum, including taper-ing off, of 4 weeks for flunitrazepam,temazepam, zoplicone, and zolpidem. Forthe other hypnotics the maximum shouldbe 2 weeks with tapering off tailored to theindividual. Treatment should start with the vlowest recommended dose, and the maxi-mum recommended dose should not beexceeded. The recommended doses are: :

*In exceptional circumstances.tAlso for patients with liver respiratory, or renal impairment.

Sara Lewis ,

Tacrine rejected

Kaiser Permanente Medical Care of

Northern California, a health maintenanceorganisation with more than 2400 000

members, has decided not to add tacrine toits drug formulary. The drug was approvedby the Food and Drug Administration lastmonth (September).Dr Willian Elliott, chairman of the Re-

gional Formulary Committee for KaiserPermanente, said his committee as well asthe HMO’s 15-member committee of thechiefs of its neurology group evaluated thedrug in terms of efficacy, safety, and cost."Tacrine really flunked all three", Elliottsaid.

Elliott acknowledged that it was rare forthe HMO not to list a drug that is the onlyone available for a particular disease. Butconcern about the high incidence of side-effects and drug-induced metabolic abnor-malities outweighed the medication’s

potential benefits. "Even if this drug wasfree we would still have trouble with it",