Editor's Choice

Complicated questions—difficult answers

BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7523.0-f (Published 27 October 2005) Cite this as: BMJ 2005;331:0-f
  1. Jane Smith, deputy editor (jsmith{at}bmj.com)

    Scientific thinking gives a special place to simple solutions and explanations, but getting to those solutions is often messy. This week's journal offers a rich crop of complicated questions—and even more complicated answers.

    Take, for example, the question of how many patients bring MRSA with them when they are admitted to hospital? In their study of admissions to Oxfordshire hospitals over seven years David Wyllie and colleagues found that a quarter of cases of MRSA bacteraemia occur in patients who have just arrived from the community, that this proportion is increasing, and that MRSA on admission is strongly associated with previous hospital contact (p 992). They suggest that surveillance for MRSA infection needs to take account of these cases that arrive from the community but seem to be associated with previous health care, a suggestion endorsed by Georgia Duckworth and Andre Charlett in their editorial (p 976).

    But David Speigelhalter has a caution for surveillance systems—or rather for the governments that set targets based on them. He illustrates how changes in rates of infection within hospitals are hard to measure because of chance variability and regression to the mean (p 1013). What this means is that at hospital level a change in rates may not accurately reflect a change in underlying risk, and vice versa.

    Government action comes more seriously under attack in two articles on orphan drugs. On p 1016Christopher McCabe and colleagues demolish the arguments for treating the cost effectiveness of orphan drugs differently from that of other drugs. They conclude that to treat them differently amounts to valuing the health gain of two individuals differently because one has a rare and one a common disease. Orphan status is likely to become more common as diseases become separated into genetically distinct conditions—and with it the burden on healthcare costs.

    That impact on costs is illustrated by Amanda Burls and colleagues (p 1019), who describe how health commissioners in the West Midlands decided not to fund enzyme replacement therapy for lysosomal storage disorders because it was poorly cost effective. The Department of Health then decided to move commissioning for these diseases to national level. The national advisory group has allowed the treatment—but without providing a budget. West Midlands thus now has to fund a treatment it had decided not to and “important services cannot be commissioned.” The authors argue that this “fudge” is neither efficient nor fair. It is, however, a result of the refusal by British governments to recognise the need to ration—and support fair ways of doing so. Clearly governments don't like facing up to what Edward Wilson describes in his letter on funding trastuzumab (p 1023) as these “terrible decisions.”

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