Comment on Rytter, et al: “Effects of armed conflict on access to emergency health care in Palestinian West Bank:” BMJ 13 May 2006
Editor, The study reported by Rytter et-al(1) implies healthcare was
adversely affected by “conflict-related delay”. Although we feel these
data highlight the high humanitarian standards of the IDF (82% of patients
arrived without delay) we have some unresolved methodological issues.
Patients with a "conflict-related delay" were more likely to be
hospitalised than those delayed for other reasons (32% vs 18% P<_0.001 by="by" fisher-exact="fisher-exact" test="test" why="why" was="was" this="this" patients="patients" were="were" categorised="categorised" either="either" as="as" delayed="delayed" or="or" not="not" they="they" did="did" quantify="quantify" the="the" delay="delay" explaining="explaining" _="_" we="we" assumed="assumed" that="that" quantification="quantification" of="of" their="their" would="would" be="be" too="too" inaccurate.="inaccurate." noted="noted" transportation="transportation" time="time" so="so" capable="capable" assessing="assessing" passage="passage" all="all" conditions="conditions" have="have" prognoses="prognoses" worsen="worsen" due="due" to="to" and="and" no="no" attempt="attempt" made="made" assess="assess" whether="whether" earlier="earlier" arrival="arrival" expected="expected" change="change" final="final" outcome.="outcome." suggest="suggest" underestimated="underestimated" impact="impact" conflict="conflict" delays="delays" excluding="excluding" those="those" denied="denied" medical="medical" treatment.="treatment." what="what" is="is" evidence="evidence" such="such" people="people" exist="exist" p="p"/>They do not mention the possibility of overestimation by recall bias
(people with serious conditions feel delays are more important). Was the
average-length of hospitalisation affected? Did patients or doctors know
the purpose of the survey? We disagree that “..defining a level of
“acceptable delay” makes no sense.” Few conditions appreciably worsen due
to a 10-second delay for a document-check. There were no patients with
“combined-delay” suggesting that being delayed by conflict protects
against being delayed for other reasons!
We frequently treat Palestinians within our hospital and are often
approached by doctors in Nablus, Bethlehem and other areas of the West
Bank requesting assistance. Patients are frequently transferred directly
to our Neurology ward and this has always occurred with full co-operation
of the IDF.
1) Rytter MJ, Kjaeldgaard AL, Bronnum-Hansen H, Helweg-Larsen K.
Effects of armed conflict on access to emergency health care in
Palestinian West Bank: systematic collection of data in emergency
departments. BMJ. 2006 May 13;332(7550):1122-4.
Marc Gotkine BSc (Hons) MBBS Lond. (Hons) Department of Neurology,
Hadassah University Hospital, Jerusalem, Israel
Oded Abramsky MD, PhD, FRCP, Emeritus Dean, Hebrew University Medical
School, Department of Neurology, Hadassah University Hospital, Jerusalem,
Israel
Competing interests:
None declared
Competing interests:
No competing interests
30 May 2006
Marc Gotkine
Neurologist
Oded Abramsky, Emeritus Dean, Hebrew University Medical School, Jerusalem, Israel
Department of Neurology, Hadassah University Hospital, POB 12000, Jerusalem, 91120, Israel
Rapid Response:
Comment on Rytter, et al: “Effects of armed conflict on access to emergency health care in Palestinian West Bank:” BMJ 13 May 2006
Editor, The study reported by Rytter et-al(1) implies healthcare was
adversely affected by “conflict-related delay”. Although we feel these
data highlight the high humanitarian standards of the IDF (82% of patients
arrived without delay) we have some unresolved methodological issues.
Patients with a "conflict-related delay" were more likely to be
hospitalised than those delayed for other reasons (32% vs 18% P<_0.001 by="by" fisher-exact="fisher-exact" test="test" why="why" was="was" this="this" patients="patients" were="were" categorised="categorised" either="either" as="as" delayed="delayed" or="or" not="not" they="they" did="did" quantify="quantify" the="the" delay="delay" explaining="explaining" _="_" we="we" assumed="assumed" that="that" quantification="quantification" of="of" their="their" would="would" be="be" too="too" inaccurate.="inaccurate." noted="noted" transportation="transportation" time="time" so="so" capable="capable" assessing="assessing" passage="passage" all="all" conditions="conditions" have="have" prognoses="prognoses" worsen="worsen" due="due" to="to" and="and" no="no" attempt="attempt" made="made" assess="assess" whether="whether" earlier="earlier" arrival="arrival" expected="expected" change="change" final="final" outcome.="outcome." suggest="suggest" underestimated="underestimated" impact="impact" conflict="conflict" delays="delays" excluding="excluding" those="those" denied="denied" medical="medical" treatment.="treatment." what="what" is="is" evidence="evidence" such="such" people="people" exist="exist" p="p"/>They do not mention the possibility of overestimation by recall bias
(people with serious conditions feel delays are more important). Was the
average-length of hospitalisation affected? Did patients or doctors know
the purpose of the survey? We disagree that “..defining a level of
“acceptable delay” makes no sense.” Few conditions appreciably worsen due
to a 10-second delay for a document-check. There were no patients with
“combined-delay” suggesting that being delayed by conflict protects
against being delayed for other reasons!
We frequently treat Palestinians within our hospital and are often
approached by doctors in Nablus, Bethlehem and other areas of the West
Bank requesting assistance. Patients are frequently transferred directly
to our Neurology ward and this has always occurred with full co-operation
of the IDF.
1) Rytter MJ, Kjaeldgaard AL, Bronnum-Hansen H, Helweg-Larsen K.
Effects of armed conflict on access to emergency health care in
Palestinian West Bank: systematic collection of data in emergency
departments. BMJ. 2006 May 13;332(7550):1122-4.
Marc Gotkine BSc (Hons) MBBS Lond. (Hons) Department of Neurology,
Hadassah University Hospital, Jerusalem, Israel
Oded Abramsky MD, PhD, FRCP, Emeritus Dean, Hebrew University Medical
School, Department of Neurology, Hadassah University Hospital, Jerusalem,
Israel
Competing interests:
None declared
Competing interests: No competing interests