CMAJ 1997;157:857
© 1997 Canadian Medical Association
Canadians are witnessing an unprecedented downsizing of clinics and hospitals and a drastic reduction in the number of hospital beds across the country, changes driven primarily by cuts in transfer payments. Can our health care system get by without these resources? Evidence is increasing to suggest that it probably can. In this issue we present findings from 2 studies indicating that some health care resources are wasted.
Endometrial cancer is the most frequent gynecologic cancer in Canada. Of the approximately 3000 women in whom this cancer is diagnosed annually, most have limited disease and a good prognosis. How closely should they be followed in our offices and clinics? Olu Agboola and colleagues at the University of Ottawa examined the records of 432 patients who had been referred to their centre for follow-up of endometrial cancer (page 879). Cancer recurred in 50 of these women. The authors determined that despite close follow-up the recurrent cancer was detected during a routine follow-up visit in only 25 women; recurrence was discovered in the interval between routine visits in 23 of the other 25 cases. There was no statistically significant difference in survival between these 2 groups. Marsha Cohen of the University of Toronto questions whether we now have enough evidence to abandon routine follow-up of endometrial cancer and other common neoplasms, such as breast and colorectal cancer (page 899). The University of Ottawa study and others have consistently shown no benefit of intensive follow-up over less intensive -- and less expensive -- follow-up. Furthermore, as Cohen points out, the psychosocial support provided with intensive follow-up may not confer a benefit; rather, the intense surveillance may provoke anxiety and discomfort.
Carolyn DeCoster and associates at the University of Manitoba reviewed the medical records of a sample of all patients admitted for medical conditions to Manitoba hospitals in 199394 (page 889). Using a standardized set of objective criteria, they found that nearly 51% of the patients admitted did not need acute care. Of those who did require acute care at admission, more than 50% no longer needed such care 1 week after admission and were still occupying acute care beds when they could have been discharged. Overall, 67% of all hospital days were for nonacute care. In an accompanying editorial Duncan Hunter of the Health Information Partnership, Eastern Ontario Region, cautions that although the bed occupancy may have been for nonacute care and on that basis inappropriate, it would have been equally inappropriate to discharge patients to their homes if they had insufficient social and medical support (page 901).
Jason Ford and colleagues of the University of British Columbia report an interesting case of a young man presenting with atypical symptoms of pheochromocytoma, reminding us of the unusual presentations of this rare tumour (page 923). Much more commonly, adrenal masses are detected during imaging examinations of the abdomen performed for other reasons. Teik Ooi refers to these tumours as "incidentalomas" (page 903). Should they be ignored, investigated, sampled for biopsy or removed? Ooi proposes a diagnostic strategy for these masses.
Our cover image, based on a photograph taken in Alberta in 1918, is a reminder of the devastation caused by the Spanish flu epidemic early in this century. In this issue's Public Health section, we begin a 3-part series on influenza (page 927). -- JH
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