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This week in BMJ Saturday 22 March 1997

Evidence that sleep apnoea is bad for health is weak

Obstructive sleep apnoea is claimed to be a major public health hazard. Treatment is with nasal continuous positive airways pressure. On p 851 Wright et al report a systematic review examining the evidence of association of the syndrome with morbidity and mortality and the effectiveness of treatment with continuous positive airways pressure. They found weak or conflicting evidence of an association between obstructive sleep apnoea and vascular morbidity and mortality, and they think there is little basis for alarming patients about the medical consequences of the syndrome. Only one of the 44 studies they identified was a randomised controlled trial. Small changes in daytime sleepiness were consistently found, but evidence of other effects on health was weak.

Snoring and breathing pauses are widely underdiagnosed in the UK

In the public domain snoring is commonly accepted as benign, affecting mostly middle aged or elderly men. Researchers, on the other hand, explore disordered breathing during sleep intensively because of its impact on health and its cognitive repercussions. The prevalence of disordered breathing during sleep, such as snoring, breathing pauses, and obstructive sleep apnoea, is not well known in the general population. A  survey by Ohayon et al (p 860) underlines the importance of these symptoms and thus the necessity to have them identified. A major consequence of such symptoms is daytime sleepiness with an increased risk of accidents at work or on the roads. Though people with disordered breathing during sleep use health care resources more than other people, only a few are followed up for disordered breathing and many receive drugs that are contraindicated in people with disordered breathing during sleep.

Breast cancer screening programmes are justifiable

Breast cancer screening is one of the most extensive and expensive health service activities recently introduced as a public health policy. Hakama et al (p 864) compared mortality from breast cancer among women invited for screening at the start of Finland's screening programme in 1987-9 with that among women who were not invited. They estimated that the screening programme led to a 24% reduction in mortality from breast cancer, with one death prevented per 10 000 screens. It may be difficult to justify breast screening as a public health policy on the basis of the average mortality effect only. It also depends on its effects on quality of life and what the resources would be used for if screening was not done. The authors say that, given all the different dimensions in the effect, breast screening is probably justifiable as a public health policy.

Education plays small part in changing doctors' practice

An important objective of continuing medical education is to change doctors' behaviour. Quantitative studies investigating the relation between education and change in clinical practice have limitations. In an interview based study of 50 consultants and 50 general practitioners Allery et al (p 870) obtained information on the factors that doctors recognise as changing their clinical practice. The doctors described 361 actual changes in clinical practice, with an average of three reasons per change. The three most frequently mentioned categories of reasons for change were organisational factors, education, and contact with professionals. Education provided one sixth of the reasons for change and was involved in one third of the changes. The authors conclude that the wide range of other factors affecting changes in practice need to be taken into account in the provision and evaluation of education.

Surgical registrars do not get enough surgical experience

Debates on the implications of specialist training for surgical trainees have been long on rhetoric and short on fact. Crofts et al (p 891) used the unique surgical database in Lothian to assess objectively the implications of the recent changes in the NHS. They provided surgeons in south east Scotland with a range of general surgical operations and asked them to state the numbers that trainees should undertake during training. The numbers of operations required were then compared against those actually performed. Their report suggests that current trainees will receive only half the surgical experience recommended. The demands of training and service are to a large extent incompatible and consultants are trapped in the middle. An important advance would be for contracts to include the minimum number of operations to be performed by trainees.