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Editor's Choice US editor's choice

Lack of insurance, reassurance, and safety assurance

BMJ 2007; 334 doi: (Published 15 February 2007) Cite this as: BMJ 2007;334:0-a0-a
  1. Douglas Kamerow (dkamerow{at}

    Among industrialized countries, only the United States lacks universal health insurance for its residents. Instead we have a patchwork quilt of coverage, sponsored by the Federal government, individual states, employers, and individuals. Karen Davis documents the number of uninsured people in America, analyzes the problems associated with lack of coverage, and explores some possible remedies (doi: 10.1136/bmj.39091.493588.BE). About 16% of Americans are uninsured, almost 50 million people. Unsurprisingly, the uninsured are disproportionately poor, and when they do receive care it is more often of substandard quality. Multiple suggestions for increasing coverage have been made, and several states with relatively small uninsured populations have introduced their own plans to mandate health insurance. However, the current Federal budget deficit and a Congress split almost evenly between Republicans and Democrats make it unlikely that any real national progress will be made.

    Can simple communication influence health outcomes through reassurance? Keith Petrie and colleagues performed a randomized controlled trial of the effect of providing face to face information about the meaning of normal test results (doi: 10.1136/bmj.39093.464190.55). Patients with chest pain who received a pamphlet and a brief discussion of results before their exercise stress test were both more reassured after testing and reported less chest pain one month later than those who received a booklet alone. In a related editorial (doi: 10.1136/bmj.39121.361910.80), Donald Penzien and Jeanetta Rains suggest that there might have been even more benefit if the explanations had been customized to the patients' individual circumstances. Reassurance, when well done, can make a difference.

    When patients enroll in clinical trials, they are assured that their safety is of the utmost importance. One way that investigators increase patient safety is to use an external data and safety monitoring board, an independent group of experts who continuously examine study results not available to the investigators. Gorm Jensen and John Hampton discuss the ramifications of the recent actions of one such board that prematurely terminated a trial testing torcetrapib, a drug to increase high density lipoprotein cholesterol (doi: 10.1136/bmj.39113.534919.80). Unexpectedly, the group receiving the drug had significantly more deaths than the control group did. Data and safety monitoring boards must balance the potential benefits of the drugs being tested—in this case very large, given the world's cardiovascular disease toll—with the safety of the patients in the trial. It is often a difficult call to make.

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