1
325 SURGICAL AUDIT SIR,-The surgeons of the Lothian Health Board should be congratulated on their demonstration of the value of clinical audit (Jan 4, p 23). They highlight the usefulness of audit in "planning and management of clinical services, monitoring increased specialisation and changes in clinical practice, planning postgraduate medical education, and demonstrating the effect of changes in the availability of resource". All of these benefits are in addition to the wealth of important statistics of a purely clinical nature. Their results have enhanced the role of the clinician in management and "should be an incentive to others". Such benefits are surely the cornerstone of the new management philosophy ofthe Health Service. Many surgical teams attempt to assess their work load and performance by "manual" audit-a tedious and error prone exercise which, in our experience, provided limited useful information. Statistics derived from regional Hospital Activity Analysis (HAA) are seriously inaccurate,l and the results of HAA, even when available, are usually a year or more out of date, are almost incomprehensible, and lack information on complications or outcome. Thus there is an urgent need for systems to handle simple clinical data and provide timely and accurate reports. I have been involved in developing such a system which, besides providing clinical and management audit statistics, also acts as a "surgical management system" (ie, it handles waiting lists, booking, admission and operating lists, and discharge summaries). At least one other audit system, designed to run on a microcomputer, is being developed. These systems are complementary to patient administration system (PAS) requirements and provide Korner compatible information including the automatic coding of diagnosis and operation. While I accept that I comment from a potentially biased position, I am, as a surgeon, nonetheless concerned that there are at present no clear-cut funds to which either clinicians or managers can turn for the implementation of these systems. Clinicians should not allow themselves to be persuaded that the implementation of a mainframe based PAS in their district will permit any clinically useful clinical analysis. There is nothing in the Korner recommendations or in PAS specification that is likely to effect any material change to the serious shortcomings of regional statistics noted above. At present most health regions are drafting their information technology strategies. I suggest that clinicians examine these strategies carefully to satisfy themselves that clinical systems are given appropriate priority and resource allocation. The cost of implementation of a system is of the same order as a good quality operating table. I would echo the comment of the Lothian surgeons that "Health Authorities should be encouraged to invest in the modest requirements for the support of clinical audit". Ashford Hospital, London Road, Ashford, Middlesex TW1 5 3AA BRIAN W. ELLIS 1. Whates PD, Birzgalis AR, Irving M. Accuracy of Hospital Activity Analysis codes. Br Med J 1982; 284: 1857-58. COST EFFECTIVENESS IN ONCOLOGY SIR,-Dr Rees (Dec 21/28, p 1405) singles out a Medical Research Council trial of cisplatin and methotrexate in advanced bladder cancer for analysis in his article, which is very critical of oncological research and in which he suggests unworthy motives for phase II trials in his preoccupation with cost rather than quality of patient care. Phase II trials are not an end in themselves and their purpose is not solely to demonstrate efficacy: they are an integral part of the process whereby new treatments are developed that are of benefit to society. It is unfortunate, but inevitable, that such clinical research is expensive because ehtical considerations dictate that new chemotherapy schedules are tested first in the palliative situation where cost effectiveness will be poor. Once efficacy has been demonstrated the schedule can be used as part of primary curative treatment in which situation cost effectiveness is very different. It is, as Rees suggests, predictable that there will be a substantial response rate to the novel form of treatment being tested in the MRC trial he mentions; that much had been suggested in pilot studies. It is precisely because the pilot studies are suggestive that a formal phase II study is needed to establish whether this form of treatment is effective enough to be used at a stage of bladder cancer at which it may be expected to influence survival. Used when the tumour is potentially curable, this regimen could be cost effective by avoiding high-dose radiotherapy or radical surgery. But this potential role and benefit cannot be established until preliminary trials such as the MRC ones have been done. They are unlikely to be cost effective in themselves but they form a necessary step in the evaluation of treatment which may be of economic as well as clinical benefit. To judge such trials in terms of cost alone is to miss the point. Medical Research Council, 20 Park Crescent, London W1N 4AL R. R. HALL, Chairman, MRC Sub-Group in Advanced Bladder Cancer B. RICHARDS Chairman, MRC Working Party on Urological Cancer SIR,-Wanting to reduce the costs of cancer management, we studied 294 files of patients treated for fifteen different cancers in 1980 in the radiotherapy/oncology department at Besancon,l and we repeated this study, with fewer files, in 1985. As in the UK the French national health service (Securite Sociale) meets all expenses for the diagnosis and treatment of cancer. Inpatient curative treatments are expensive, from FF29 374 (2937) for a gastric carcinoma to FF82 316 (8231) for a bronchial carcinoma that is operated on. This high cost is due to the expense of hospital admission and can be reduced by decreasing the length of hospital stay. Outpatient treatment should reduce costs. Nevertheless transport expenses can be very high if the patient attends by an ambulance or a taxi rather than by public transport (which is sometimes inconvenient in rural areas). For example, outpatient treatment of a patient with carcinoma of the tonsils treated by radiotherapy is about FF8000 (800) but transport may cost FF150 (Ll5) to FF33 000 (3300) according to the type of transportation and the distance. Transport costs also contribute significantly to residence in hospices or simple hotels close to the treatment centre or to asking for the patient to be brought in by car, by a parent or on his own if that is physically possible. Radiotherapy-Oncology Department, University Hospital, 25030 Besançon, France S. SCHRAUB 1. Schraub S, Altwegg T, Bosset JF. Coût du traitement des cancers. Gaz Méd France 1980; 38: 4633-39. OCCUPATIONAL HAZARDS OF CHEMICALS SiR,-’Your Round the World’ item on the regulation of danger industries in the United States (Jan 4, p 33) draws attention to a substantial public health issue. Lamentably, the day has gone when a health agency could ticket a harmful substance for regulation. Several factors mentioned in the article-notably, the dubious "price-of-life" approach, a contentious presidential executive order directing the Office of Management and Budget (OMB) to review new regulations before they are effected, and surreptitious OMB/industry contracts-are constituting a major assault on occupational health in America. The rights of workers and community residents to know about chemical hazards in their workplaces and environment is also an area of current concern and controversy. In January 1981, the Occupational Safety and Health Administration (OSHA) published a "notice of proposed rulemaking", which would have required employers to inform workers of the precise identity of hazardous chemicals in their workplaces and to provide information about hazards possibly associated with exposure to such substances. This

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Page 1: COST EFFECTIVENESS IN ONCOLOGY

325

SURGICAL AUDIT

SIR,-The surgeons of the Lothian Health Board should becongratulated on their demonstration of the value of clinical audit(Jan 4, p 23). They highlight the usefulness of audit in "planningand management of clinical services, monitoring increased

specialisation and changes in clinical practice, planningpostgraduate medical education, and demonstrating the effect ofchanges in the availability of resource". All of these benefits are inaddition to the wealth of important statistics of a purely clinicalnature. Their results have enhanced the role of the clinician in

management and "should be an incentive to others". Such benefitsare surely the cornerstone of the new management philosophy oftheHealth Service.

Many surgical teams attempt to assess their work load andperformance by "manual" audit-a tedious and error prone exercisewhich, in our experience, provided limited useful information.Statistics derived from regional Hospital Activity Analysis (HAA)are seriously inaccurate,l and the results of HAA, even whenavailable, are usually a year or more out of date, are almost

incomprehensible, and lack information on complications or

outcome. Thus there is an urgent need for systems to handle simpleclinical data and provide timely and accurate reports.

I have been involved in developing such a system which, besidesproviding clinical and management audit statistics, also acts as a"surgical management system" (ie, it handles waiting lists, booking,admission and operating lists, and discharge summaries). At leastone other audit system, designed to run on a microcomputer, is

being developed. These systems are complementary to patientadministration system (PAS) requirements and provide Kornercompatible information including the automatic coding of diagnosisand operation.While I accept that I comment from a potentially biased position,

I am, as a surgeon, nonetheless concerned that there are at presentno clear-cut funds to which either clinicians or managers can turnfor the implementation of these systems.Clinicians should not allow themselves to be persuaded that the

implementation of a mainframe based PAS in their district willpermit any clinically useful clinical analysis. There is nothing in theKorner recommendations or in PAS specification that is likely toeffect any material change to the serious shortcomings of regionalstatistics noted above.At present most health regions are drafting their information

technology strategies. I suggest that clinicians examine these

strategies carefully to satisfy themselves that clinical systems aregiven appropriate priority and resource allocation. The cost ofimplementation of a system is of the same order as a good qualityoperating table. I would echo the comment of the Lothian surgeonsthat "Health Authorities should be encouraged to invest in themodest requirements for the support of clinical audit".

Ashford Hospital,London Road,Ashford, Middlesex TW1 5 3AA BRIAN W. ELLIS

1. Whates PD, Birzgalis AR, Irving M. Accuracy of Hospital Activity Analysis codes. BrMed J 1982; 284: 1857-58.

COST EFFECTIVENESS IN ONCOLOGY

SIR,-Dr Rees (Dec 21/28, p 1405) singles out a Medical ResearchCouncil trial of cisplatin and methotrexate in advanced bladdercancer for analysis in his article, which is very critical of oncologicalresearch and in which he suggests unworthy motives for phase IItrials in his preoccupation with cost rather than quality of patientcare.

Phase II trials are not an end in themselves and their purpose isnot solely to demonstrate efficacy: they are an integral part of theprocess whereby new treatments are developed that are of benefit tosociety. It is unfortunate, but inevitable, that such clinical researchis expensive because ehtical considerations dictate that new

chemotherapy schedules are tested first in the palliative situationwhere cost effectiveness will be poor. Once efficacy has beendemonstrated the schedule can be used as part of primary curativetreatment in which situation cost effectiveness is very different.

It is, as Rees suggests, predictable that there will be a substantialresponse rate to the novel form of treatment being tested in theMRC trial he mentions; that much had been suggested in pilotstudies. It is precisely because the pilot studies are suggestive that aformal phase II study is needed to establish whether this form oftreatment is effective enough to be used at a stage of bladder cancerat which it may be expected to influence survival. Used when thetumour is potentially curable, this regimen could be cost effective byavoiding high-dose radiotherapy or radical surgery. But this

potential role and benefit cannot be established until preliminarytrials such as the MRC ones have been done. They are unlikely to becost effective in themselves but they form a necessary step in theevaluation of treatment which may be of economic as well as clinicalbenefit.To judge such trials in terms of cost alone is to miss the point.

Medical Research Council,20 Park Crescent,London W1N 4AL

R. R. HALL,Chairman, MRC Sub-Group inAdvanced Bladder Cancer

B. RICHARDSChairman, MRC Working Party onUrological Cancer

SIR,-Wanting to reduce the costs of cancer management, westudied 294 files of patients treated for fifteen different cancers in1980 in the radiotherapy/oncology department at Besancon,l andwe repeated this study, with fewer files, in 1985. As in the UK theFrench national health service (Securite Sociale) meets all expensesfor the diagnosis and treatment of cancer. Inpatient curativetreatments are expensive, from FF29 374 (2937) for a gastriccarcinoma to FF82 316 (8231) for a bronchial carcinoma that isoperated on. This high cost is due to the expense of hospitaladmission and can be reduced by decreasing the length of hospitalstay. Outpatient treatment should reduce costs. Nevertheless

transport expenses can be very high if the patient attends by anambulance or a taxi rather than by public transport (which issometimes inconvenient in rural areas). For example, outpatienttreatment of a patient with carcinoma of the tonsils treated byradiotherapy is about FF8000 (800) but transport may cost FF150(Ll5) to FF33 000 (3300) according to the type of transportationand the distance. Transport costs also contribute significantly toresidence in hospices or simple hotels close to the treatment centreor to asking for the patient to be brought in by car, by a parent or onhis own if that is physically possible.

Radiotherapy-Oncology Department,University Hospital,25030 Besançon, France S. SCHRAUB

1. Schraub S, Altwegg T, Bosset JF. Coût du traitement des cancers. Gaz Méd France

1980; 38: 4633-39.

OCCUPATIONAL HAZARDS OF CHEMICALS

SiR,-’Your Round the World’ item on the regulation of dangerindustries in the United States (Jan 4, p 33) draws attention to asubstantial public health issue. Lamentably, the day has gone whena health agency could ticket a harmful substance for regulation.Several factors mentioned in the article-notably, the dubious"price-of-life" approach, a contentious presidential executive orderdirecting the Office of Management and Budget (OMB) to reviewnew regulations before they are effected, and surreptitiousOMB/industry contracts-are constituting a major assault on

occupational health in America.The rights of workers and community residents to know about

chemical hazards in their workplaces and environment is also anarea of current concern and controversy. In January 1981, theOccupational Safety and Health Administration (OSHA) publisheda "notice of proposed rulemaking", which would have requiredemployers to inform workers of the precise identity of hazardouschemicals in their workplaces and to provide information abouthazards possibly associated with exposure to such substances. This