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I have only just read Edwards & Hensher's article summarising
hospital productivity statistics since 1982, which includes
some figures from earlier years (1). These are indeed 'easily
accessible and usable', and for this they should be
congratulated. While the authors' purpose is to assist
discussion of current problems such as difficulties in
admitting emergencies, the dramatic trends shown by their
figures require more explanation than they give. To better
understand why is not only of historical interest, for the
reasons may also help us to predict future demands and
capacity to cope. I submit that the major change causing these
trends has been the gradual realisation that it is no longer
necessary to rest patients in order for them to recover. If
this argument is accepted, and as Rest is now rarely
prescribed, I am pessimistic that the authors' prediction of
improvements in productivity will continue indefinitely.
While hospital and bed closures are highlighted by the paper,
the major revolution their statistics show is the marked
decline in length of stay (LOS). Though the figures are not
strictly comparable, a decline from a 49 day mean inpatient LOS
in 1949 to one of under 6 days in 1994 is remarkable. Even
using the comparable figures for acute cases in Figure 1, LOS
has halved since 1970. Advances such as TB chemotherapy,
antibiotics, polio immunisation, minimal access surgery and
better anaesthesia no doubt partly explain this. Counteracting
this is a longer life expectancy with the elderly's less
readily treatable chronic conditions and the longer time they
take to recover. However the major unsung 'revolution' of the
last half century has been the profession's gradual abandonment
of Rest as a major component of treatment, and I contend that
that the debunking of this fashion is the major reason we now
discharge patients earlier.
Hilton's 1863 textbook 'Rest and Pain' (2) was first on the
essential reading list handed to me on starting my student
clinical studies in 1958 and on the wards we were brainwashed
with his principles. It was always correct to answer 'Rest,
Sir' when asked about the treatment of nearly any condition,
and the long time patients stayed in hospital confirmed its
application. It was unheard of to be allowed out of bed before
the temperature was normal or home before the stitches were
out. Over 10 years after the discovery of effective
chemotherapy TB patients were still being forcibly rested in
bed for months or years. Sanatoria and other long stay
hospitals were specially built to ensure Rest for this and
other conditions. Six weeks flat on your back was the norm for
a heart attack, and for a mother to leave hospital with her new
baby in a day as happens now would have been considered
criminal neglect. Later, as a trainee orthopaedic surgeon, I
was indoctrinated with Hugh Owen Thomas' 19th century dictum
that 'Rest should be Forced, Uninterrupted, and Prolonged' for
the management of fractures and most orthopaedic problems (3).
This strongly held belief that Rest was essential to recovery
from nearly every condition had virtually no scientific basis.
While the complications of Rest were well recognised, few
questionned its necessity until the 1940s (4,5). The first
convincing evidence of its inutility for a few conditions was
not published until the late 1950s, and for many it came much
later. It has since taken up to half a century for our
profession to be coerced kicking and screaming to abandon it; a
long time to apply evidenced based medicine. Some of the EMB
has been recently summarised (6). In my own speciality, Rest
for acute back pain has been only recently debunked, though
many still find it hard not to advise it (7). The treatment of
chronic fatigue syndrome was only last year discussed in a BMJ
editorial from which, and subsequent correspondence, it is
clear that Rest remains popular in spite of the evidence.(8)
It can be no coincidence that the ever shorter LOSs described
in the paper mirrors this gradual abandonment of Rest. The rise
in popularity of day case surgery, so reluctantly adopted by
most surgeons, has also been largely determined by this. It is
my view that most of my profession, though not necessarily our
patients (ref), now accept that Rest has no place and practice
accordingly; hospital managers and private insurers are not
slow to question those who do not. In my opinion the fad is now
all but dead and there is only a little mileage left in further
shortening hospital stays for this reason.
The costs of this fashion for Rest have been huge. It is indeed
most fortunate that its demise has coincided with the
marvellous but expensive medical advances of recent years
allowing us to effectively treat so many more conditions. It is
horrendous to contemplate how we would cope, whether as
physician, manager, insurer or taxpayer, if we were still
applying Hilton's concept. It can also be argued that the major
expansion of hospitals and beds (and also much social welfare
provision) in the decades after the 1880s was in large part
due to the widespread application of this misconceived dogma
subsequent to Hilton; acting on this victorian version of EBM
was a bit faster then than now! But that is another story yet
to be fully told.
References:
1 Edwards M and Hensher J, Hospital provision,
ctivity, and productivity in England since the
1980s. BMJ 1999;319:911-14
P> 2 Hilton J. Rest and Pain. 1863: Edition by Walls EW
and Philipp EE. London, G Bell & Son, 1953.
3 Keith A, Menders of the Maimed. London, Henry Frowde
and Hodder & Stoughton, 1919, 46-47
4 Symposium. The use and abuse of bed rest. JAMA
1944;125:1083-90
5 Asher RAJ. The dangers of going to bed. BMJ 1947;
2:967
6 Allen C, Glasziou P, Del Mar C. Bed Rest: a
potentially harmful treatment needing more careful
evaluation. Lancet 1999; 354:1229-33
7 Frankel BSM, Moffetta JK, Keen S, Jackson D.
Guidelines for low back pain: Changes in GP
management. Family Practice 1999;16(3):216-222
8 Sharpe M and Wessely S. Putting the rest cure to
rest - again. BMJ 1998:316:796-800
Shorter hospital stays because Rest no longer prescribed
I have only just read Edwards & Hensher's article summarising
hospital productivity statistics since 1982, which includes
some figures from earlier years (1). These are indeed 'easily
accessible and usable', and for this they should be
congratulated. While the authors' purpose is to assist
discussion of current problems such as difficulties in
admitting emergencies, the dramatic trends shown by their
figures require more explanation than they give. To better
understand why is not only of historical interest, for the
reasons may also help us to predict future demands and
capacity to cope. I submit that the major change causing these
trends has been the gradual realisation that it is no longer
necessary to rest patients in order for them to recover. If
this argument is accepted, and as Rest is now rarely
prescribed, I am pessimistic that the authors' prediction of
improvements in productivity will continue indefinitely.
While hospital and bed closures are highlighted by the paper,
the major revolution their statistics show is the marked
decline in length of stay (LOS). Though the figures are not
strictly comparable, a decline from a 49 day mean inpatient LOS
in 1949 to one of under 6 days in 1994 is remarkable. Even
using the comparable figures for acute cases in Figure 1, LOS
has halved since 1970. Advances such as TB chemotherapy,
antibiotics, polio immunisation, minimal access surgery and
better anaesthesia no doubt partly explain this. Counteracting
this is a longer life expectancy with the elderly's less
readily treatable chronic conditions and the longer time they
take to recover. However the major unsung 'revolution' of the
last half century has been the profession's gradual abandonment
of Rest as a major component of treatment, and I contend that
that the debunking of this fashion is the major reason we now
discharge patients earlier.
Hilton's 1863 textbook 'Rest and Pain' (2) was first on the
essential reading list handed to me on starting my student
clinical studies in 1958 and on the wards we were brainwashed
with his principles. It was always correct to answer 'Rest,
Sir' when asked about the treatment of nearly any condition,
and the long time patients stayed in hospital confirmed its
application. It was unheard of to be allowed out of bed before
the temperature was normal or home before the stitches were
out. Over 10 years after the discovery of effective
chemotherapy TB patients were still being forcibly rested in
bed for months or years. Sanatoria and other long stay
hospitals were specially built to ensure Rest for this and
other conditions. Six weeks flat on your back was the norm for
a heart attack, and for a mother to leave hospital with her new
baby in a day as happens now would have been considered
criminal neglect. Later, as a trainee orthopaedic surgeon, I
was indoctrinated with Hugh Owen Thomas' 19th century dictum
that 'Rest should be Forced, Uninterrupted, and Prolonged' for
the management of fractures and most orthopaedic problems (3).
This strongly held belief that Rest was essential to recovery
from nearly every condition had virtually no scientific basis.
While the complications of Rest were well recognised, few
questionned its necessity until the 1940s (4,5). The first
convincing evidence of its inutility for a few conditions was
not published until the late 1950s, and for many it came much
later. It has since taken up to half a century for our
profession to be coerced kicking and screaming to abandon it; a
long time to apply evidenced based medicine. Some of the EMB
has been recently summarised (6). In my own speciality, Rest
for acute back pain has been only recently debunked, though
many still find it hard not to advise it (7). The treatment of
chronic fatigue syndrome was only last year discussed in a BMJ
editorial from which, and subsequent correspondence, it is
clear that Rest remains popular in spite of the evidence.(8)
It can be no coincidence that the ever shorter LOSs described
in the paper mirrors this gradual abandonment of Rest. The rise
in popularity of day case surgery, so reluctantly adopted by
most surgeons, has also been largely determined by this. It is
my view that most of my profession, though not necessarily our
patients (ref), now accept that Rest has no place and practice
accordingly; hospital managers and private insurers are not
slow to question those who do not. In my opinion the fad is now
all but dead and there is only a little mileage left in further
shortening hospital stays for this reason.
The costs of this fashion for Rest have been huge. It is indeed
most fortunate that its demise has coincided with the
marvellous but expensive medical advances of recent years
allowing us to effectively treat so many more conditions. It is
horrendous to contemplate how we would cope, whether as
physician, manager, insurer or taxpayer, if we were still
applying Hilton's concept. It can also be argued that the major
expansion of hospitals and beds (and also much social welfare
provision) in the decades after the 1880s was in large part
due to the widespread application of this misconceived dogma
subsequent to Hilton; acting on this victorian version of EBM
was a bit faster then than now! But that is another story yet
to be fully told.
References:
1 Edwards M and Hensher J, Hospital provision,
ctivity, and productivity in England since the
1980s. BMJ 1999;319:911-14
P> 2 Hilton J. Rest and Pain. 1863: Edition by Walls EW
and Philipp EE. London, G Bell & Son, 1953.
3 Keith A, Menders of the Maimed. London, Henry Frowde
and Hodder & Stoughton, 1919, 46-47
4 Symposium. The use and abuse of bed rest. JAMA
1944;125:1083-90
5 Asher RAJ. The dangers of going to bed. BMJ 1947;
2:967
6 Allen C, Glasziou P, Del Mar C. Bed Rest: a
potentially harmful treatment needing more careful
evaluation. Lancet 1999; 354:1229-33
7 Frankel BSM, Moffetta JK, Keen S, Jackson D.
Guidelines for low back pain: Changes in GP
management. Family Practice 1999;16(3):216-222
8 Sharpe M and Wessely S. Putting the rest cure to
rest - again. BMJ 1998:316:796-800
Competing interests: No competing interests