Nicholas J Wald, Philip Murphy, Philippa Major, Carol Parkes, Joy Townsend, Chris Frost
Abstract
Objective - To compare one view (oblique) and two view (oblique and craniocaudal) mammography in breast cancer screening.
Design - Randomised controlled trial.
Setting - Nine breast screening centres in England.
Subjects - 40,163 women aged 50-64 attending their first breast screening examination.
Interventions - Women were randomised to have one view mammography, two view mammography, or two view mammography in which one view was read by one reader and both views were read by another.
Main outcome measures - Prevalence of cancer detected, recall rates, cost per cancer detected, and marginal cost per extra cancer detected.
Results - Two view mammography detected 24% more women with breast cancer (95% confidence interval 16% to 31%) than one view mammography. Prevalence of detected cancer was 6.84 with two view mammography and 5.52 per 1,000 women with one view. The proportion of women recalled for assessment was 15% lower (95% confidence interval 6% to 23%) with two view (6 97%) than with one view (8.16%) mammography. The cost of two view screening was higher (£26.46 compared with £22.00 per examination) but the average cost per cancer detected was similar (£5,330 compared with £5,310) and the marginal cost per extra cancer detected with two views was similar to the average cost (£5,400).
Conclusion - Two view mammography is medically more effective than one view; it detects more cancers and reduces recall rates; it is also similarly cost effective financially.
Cancer Research Campaign Cancer Screening Research Group Wolfson Institute of Preventive Medicine St Bartholomew's Hospital Medical College London EC1M 6BQ Nicholas J Wald professor Philip Murphy computer programmer Philippa Major research assistant Carol Parkes lecturer Chris Frost statisticianMedical Research Council Epidemiology and Medical Care Unit Wolfson Institute of Preventive Medicine St Bartholomew's Hospital Medical College London EC1M 6BQ Joy Townsend senior scientist
Correspondence to: Professor Wald.
Elizabeth Barrett-Connor, Deborah Goodman-Gruen
Abstract
Objectives - To examine the association between androstenedione, total and bioavailable testosterone, oestrone, and total and bioavailable oestradiol concentrations and the risk of death from cardiovascular and ischaemic heart disease.
Design - 19 year old population based prospective study with 99.9% follow up.
Setting - Rancho Bernardo, California.
Subjects - 651 postmenopausal women, none taking oestrogen.
Main outcome measures - Concentrations of plasma sex hormones measured by radioimmunoassay in an endocrinology research laboratory. Cardiovascular and ischaemic heart disease deaths assessed by death certificate; 85% of 30% sample validated by record review.
Results - Age adjusted concentrations of sex hormones did not differ significantly in women with and without a history of heart disease at baseline and did not predict cardiovascular death or death from ischaemic heart disease. Most 95% confidence intervals for the age adjusted relative risk of cardiovascular death or death from ischaemic heart disease were narrow, and all included one. Endogenous oestrogen concentrations were not associated with significantly more favourable risk factors for heart disease, and testosterone was not associated with less favourable risk factors.
Conclusion - These prospective data do not support a causal or preventive role for endogenous oestrogens or androgens and cardiovascular mortality in older women.
Department of Family and Preventive Medicine University of California San Diego La Jolla California 92093-0607 Elizabeth Barrett-Connor professor and chair Deborah Goodman-Gruen medical fellow
Correspondence to: Dr Barrett-Connor.
P M Grosheide, J W Wladimiroff, R A Heijtink, J A Mazel, G C M L Christiaens, A S M Nuijten, S W Schalm, and the Dutch Study Group on Prevention of Neonatal Hepatitis
Abstract
Objective - To develop a low cost, high compliance screening programme for identification of carriers of hepatitis B surface antigen in the obstetric population of the Netherlands.
Design - A seven year open, descriptive study of screening for hepatitis B surface antigen as part of routine prenatal laboratory testing at 14 weeks of gestation. Compliance with programme evaluated by checking delivery records (hospitals) or registration of births in the 30 participating municipalities (rural area).
Setting - Three large city hospitals (two tertiary referral centres) and one rural area with a large number of home deliveries.
Subjects - 99,706 pregnant women applying for prenatal care for the first time.
Main outcome measures - Proportion of pregnant women routinely screened; prevalence of hepatitis B surface antigen in large cities and rural area.
Results - Uptake of screening reached 97% in the hospitals after inclusion of 10% screened at delivery; the estimated uptake in the rural area was more than 95%. Prevalence of hepatitis B surface antigen was 1.6% in the large cities and 0.3% in the rural area. For screening at delivery the prevalence was 2.5 times higher (4%, P less than 0.01) than for screening at week 14 of gestation.
Conclusion - Incorporation of universal testing for hepatitis B surface antigen into routine prenatal laboratory testing is practical; high compliance is achieved when screening is supplemented with rapid screening at delivery for those who escaped routine prenatal care.
Department of Internal Medicine II University Hospital Dijkzigt Dr Molewaterplein 40 3015 GD Rotterdam Netherlands P M Grosheide research physician S W Schalm professor of medicineDepartment of Obstetrics University Hospital Dijkzigt Rotterdam J W Wladimiroff professor
Department of Virology Erasmus University Rotterdam R A Heijtink virologist
Prins Bernhardlaan 43 7622 BE Borne J A Mazel general practitioner
Department of Gynaecology and Obstetrics Academic Hospital Utrecht G C M L Christiaens obstetrician
State School of Training for Midwives Rotterdam A S M Nuijten obstetrician
Correspondence to: Professor Schalm.
P M Grosheide, J M Klokman-Houweling, M A E Conyn-van Spaendonck, and the National Hepatitis B Steering Committee
Abstract
Objectives - To launch a programme for the prevention of perinatal infection with hepatitis B in the Netherlands.
Design - Routine antenatal screening and intervention programme.
Setting - Community antenatal programme, the Netherlands.
Subjects - Infants of mothers who were carriers of hepatitis B detected by routine screening.
Interventions - Infants of infected mothers received hepatitis B immunoglobulin at birth and four doses of hepatitis B vaccine in conjunction with routine immunisation at 3, 4, 5, and 11 months of age.
Main outcome measures - Results of screening and immunisation from 1989-92.
Results - The coverage of screening increased from 46% in 1989 to 84% in 1992. Hepatitis B surface antigen was detected in 2,145 women (0.44%). The coverage of postnatal immunoprophylaxis in 1,645 neonates born to mothers who were carriers of hepatitis B was 85% (1,391); in 3% (42) there was a delay in administration of immunoglobulin of over 24 hours. In 1991, 96% (537), 95% (532), 94% (525), and 87% (489) of the infants received the first, second, third, and fourth dose of vaccine, respectively. There was considerable variation in the timing of vaccination; 17% (258) of the infants received their first dose more than two weeks late. Of the 59% (583) of infants who received the fourth dose more than two weeks beyond target age, 14% (141) also received their first dose too late.
Conclusions - A prevention programme for perinatal hepatitis B in an area of low prevalence, when incorporated into existing health care, is feasible and achieves satisfactory coverage rates. Intensive follow up is needed to improve adherence to the immunisation schedule.
Department of Infectious Diseases Epidemiology National Institute of Public Health and Environmental Protection Bilthoven Netherlands P M Grosheide epidemiologist J M Klokman-Houweling statistical analyst M A E Conyn-van Spaendonck epidemiologist
Correspondence to: Dr Klokman-Houweling, RIVM, CIE/PB 75, PO Box 1, 3720 BA Bilthoven, Netherlands.
Rebecca Surender, Jean Bradlow, Angela Coulter, Helen Doll, Sarah Stewart Brown
Abstract
Objective - To compare outpatient referral patterns in fundholding and non-fundholding practices before and after the NHS reforms in April 1991.
Design - Prospective collection of data on general practitioners' referrals to specialist outpatient clinics between June 1990 and January 1994 and detailed comparisons of three phases - October 1990 to March 1991 (phase 1), October 1991 to March 1992 (phase 2), and October 1993 to January 1994 (phase 3).
Setting - 10 first wave fundholding practices and six non-fundholding practices in the Oxford region.
Subjects - Patients referred to consultant outpatient clinics.
Results - NHS referral rates increased in fundholding practices in phase 2 and phase 3 of the study by 8.1/1000 patients a year (95% confidence interval 5.7 to 10.5), an increase of 7.5% from phase 1 (107.3/1000) to phase 3 (115.4/1000). Non-fund holders' rates increased significantly, by 25.3/1000 patients (22.5-28.1), an increase of 26.6% from phase 1 (95.0/1000) to phase 3 (120.3/1000). The fundholders' referral rates to private clinics decreased by 8.8%, whereas those from non-fundholding practices increased by 12.2%. The proportion of referrals going outside district boundaries did not change significantly. Three of the four practices entering the third and fourth wave of fundholding increased their referral rates significantly in the year before becoming fundholders.
Conclusions - No evidence existed that budgetary pressures caused first wave fundholders to reduce referral rates, although the method of budget allocation may have encouraged general practitioners to inflate their referral rates in the preparatory year. Despite investment in new practice based facilities, no evidence yet exists that fundholding encourages a shift away from specialist care.
Health Services Research Unit Department of Public Health and Primary Care University of Oxford Radcliffe Infirmary Oxford OX2 6HE Rebecca Surender research officer Helen Doll statistician Sarah Stewart Brown directorUnit of Health Care Epidemiology Department of Public Health and Primary Care University of Oxford Jean Bradlow honorary research associate
King's Fund Development Centre London W1M 0AN Angela Coulter director
Correspondence to: Professor Coulter.