Design - A life table method was used to model the effect of treatment with a statin on survival over 10 years in men and women aged 45-64. The costs of intervention were estimated from the direct costs of treatment, offset by savings associated with a reduction in coronary angiographies, non-fatal myocardial infarctions, and revascularisation procedures. The robustness of the model to various assumptions was tested in a sensitivity analysis.
Setting - Population of a typical district health authority.
Main outcome measure - Cost per life year saved.
Results - The average cost effectiveness of treating men aged 45-64 with no history of coronary heart disease and a cholesterol concentration >6.5 mmol/l for 10 years with a statin was £136,000 per life year saved. The average cost effectiveness for patients with pre-existing coronary heart disease and a cholesterol concentration >5.4 mmol/l was £32,000. These averages hide enormous differences in cost effectiveness between groups at different risk, ranging from £6,000 per life year in men aged 55-64 who have had a myocardial infarction and whose cholesterol concentration is above 7.2 mmol/l to £361,000 per life year saved in women aged 45-54 with angina and a cholesterol concentration of 5.5-6.0 mmol/l.
Conclusions - Lowering serum cholesterol concentration in patients with and without preexisting coronary heart disease is effective and safe, but treatment for all those in whom treatment is likely to be effective is not sustainable within current NHS resources. Data on cost effectiveness data should be taken into account when assessing who should be eligible for treatment.
Cambridge and Huntingdon Health Commission,
Fulbourn Hospital,
Cambridge
CB1 5EF
P D P Pharoah,senior registrar in public health
Health Services Research Group,
Department of Community Medicine,
Institute of Public Health,
University of Cambridge,
Cambridge
CB2 2SR
W Hollingworth,health economist
Correspondence to: Dr P D P Pharoah
Department of Community Medicine,
Institute of Public Health,
Cambridge
CB2 2SR
Design - Cross sectional survey among schoolchildren aged 9-11 years. Skin prick tests, pulmonary function tests, and bronchial challenge in the children and self completion of a written questionnaire by the children's parents.
Subjects - 1,958 children in a rural area in southern Bavaria, Germany.
Main outcome measures - Prevalence of asthma, hay fever, and atopic dermatitis as determined by parents' answers to a questionnaire; the atopic status of the child assessed by skin prick tests; and bronchial responsiveness to cold air challenge in the children.
Results - After possible confounders were controlled for, the risk of developing hay fever (odds ratio=0.57; 95% confidence interval 0.34 to 0.98), atopy defined as at least one positive reaction to a panel of common aeroallergens (0.67; 0.49 to 0.93), sensitisation to pollen (0.60; 0.41 to 0.87), and of bronchial hyperresponsiveness (0.55 ;0.34-0.90) was significantly lower in children living in homes where coal or wood was used for heating than in children living in homes with other heating systems.
Conclusions - Factors directly or indirectly related to the heating systems used in rural Bavarian homes decrease the susceptibility of children to becoming atopic and to developing bronchial hyperresponsiveness.
University Children's Hospital,
D80337 Munich,
Germany
Erika von Mutius, paediatrician
Sabina Illi, statistician
Thomas Nicolai,paediatrician
Respiratory Sciences Center,
Department of Paediatrics,
University of Arizona,
Tucson,
AZ 85724,
USA
Fernando D Martinez, paediatric respiratory physician
Correspondence and reprint requests for reprints to: Dr E von Mutius
Universitatskinderklinik,
Lindwurmstr 4, D 80337
Munchen, Germany.
Design - A population based comparison of outcomes up to school age. Data obtained from maternity, health visitor, and school medical records and handicap register.
Setting - Grampian region 1981-90.
Subject - l,645 infants delivered alive at term after breech presentation.
Main outcome measures - Handicap, developmental delay, neurological deficit, psychiatric referral.
Results - Elective caesarean section was performed in 590 (35.9%) cases. The remainder (1055; 64.1%) were intended vaginal deliveries. Handicap or other health problem was recorded in 269 (19.4%) of 1,387 infants for whom records were available. Proportions of elective caesarean sections and intended vaginal deliveries in this group were 37.2% (100 cases) and 62.8% (169) respectively, almost the same as in the total cohort. There were no significant differences between elective caesarean section and planned vaginal delivery in terms of severe handicap or any other outcome measure. Case records were obtained for 23 of 27 infants with severe handicap. 11 (47.8%) were delivered by elective caesarean section. Of these, three had undiagnosed congenital abnormalities and seven were unexplained. Of the 12 (52.2%) planned vaginal deliveries, in only one was handicap possibly attributable to delivery and four cases were unavoidable even if elective caesarean section had been planned.
Conclusion - In selected cases of breech presentation at term planned vaginal delivery with caesarean section if necessary remains as safe as elective caesarean section in terms of long term handicap. It was not possible to determine whether particular babies would have fared better had they been delivered by elective caesarean section.
Department of Obstetrics and Gynaecology,
Aberdeen Maternity Hospital,
Aberdeen
AB9 2ZA
P J Danielian, senior registrar
M H Hall, consultant
Aberdeen University Medical School,
Foresterhill,
Aberdeen
AB9 1FX
J Wang, medical student
Correspondence to: Dr Danielian.
Design - Observational surveys in March 1990 and March 1995. During two weeks in each survey period all pneumococci isolated in public health laboratories in England and Wales were collected and assessed for sensitivity to antibiotics and the distribution of serogroups or serotypes.
Setting - The network of public health laboratories throughout England and Wales.
Subjects - 1,127 individual patient isolates of Streptococcus pneumoniae obtained during the two surveys.
Main outcome measures - Sensitivity or resistance to a range of antibiotics; serogroup or serotype.
Results - The prevalence of intermediate or full resistance to penicillin increased from 1.5% in 1990 to 3.9% in 1995 and resistance to erythromycin increased from 2.8% to 8.6%. About 92% of isolates belonged to serogroups or serotypes included in the currently available pneumococcal vaccine.
Conclusion - Resistance to penicillin and erythromycin has increased among pneumococci in England and Wales. Continued surveillance to assess further increases in the prevalence of pneumococcal resistance to antibiotics is essential.
Antibiotic Reference Unit,
Laboratory of Hospital Infection,
Central Public Health Laboratory,
Colindale,
London
NW9 5HT
Alan P Johnson, clinical scientist
David C E Speller, consultant microbiologist
Marina Warner, medical laboratory scientific officer
Gil Domingue, medical laboratory scientific officer
Streptococcus and Diphtheria Reference Unit,
Respiratory and Systemic Infection Laboratory,
Central Public Health Laboratory,
London
NW9 5HT
Robert C George, consultant microbiologist
Androulla Efstratiou, clinical scientist
Correspondence to: Dr Johnson.
Design - Observational study with 12 months' follow up. Interview and clinical examination before, during, and after treatment of women seeking help for urinary incontinence in general practice.
Setting - General practice in the rural district of Rissa, Norway.
Subjects - 105 women aged 20 or more with urinary incontinence.
Interventions - Treatment with pelvic floor exercises, electrostimulation, oestrogen, anti-cholinergic drugs, bladder training, and protective pads.
Main outcome measures - Subjective and objective measures of urinary incontinence; number of patients referred to a specialist.
Results - After 12 months' follow up 70% (69/99) of the women were cured or much better; the mean score on a 100 mm visual analogue scale decreased from 37 to 20 mm; and the proportion of women who were greatly bothered by their incontinence decreased by 62%. 20% (20/98) of women became continent, and the percentage of women with severe incontinence decreased from 64% (63/99) to 28% (27/98). Mean leakage per 24 hours measured by a pad test decreased from 28 g at the start of treatment to 13 g after 12 months. The number of light weight pads or sanitary towels decreased from 1.6 to 0.6 a day. In all, 17/105 (16%) patients were referred to a specialist.
Conclusions - Urinary incontinence in women can be effectively managed in general practice with fairly simple treatment. Most women will be satisfied with the results.
Medical Office of Health,
Rissa,
Norway
Arnfinn Seim, general practitioner
Bjorg Sivertsen, general practitioner
Department of Gynaecology and Obstetrics,
Trondheim University Hospital,
Trondheim,
Norway
Bjarne C Eriksen, consultant
Division for General Practice,
Department of Public Health and Primary Health Care,
University of Bergen,
Bergen,
Norway
Steinar Hunskaar, professor
Correspondence to: Professor S Hunskaar
Division for General Practice,
Ulriksdal 8c,
N-5009 Bergen,
Norway.