BMJ-mortality amenable to med care.pdf

doi:10.1136/bmj.327.7424.1129 2003;327;1129- BMJ Ellen Nolte and Martin McKee mortality amenable to health care Measuring the health of nations: analysis of http://bmj.com/cgi/content/full/327/7424/1129 Updated information and services can be found at: These include: References http://bmj.com/cgi/content/full/327/7424/1129#otherarticles 7 online articles that cite this article can be accessed at: http://bmj.com/cgi/content/full/327/7424/1129#BIBL This article cites 18 articles, 5 of which can be accessed free at: Rapid responses http://bmj.com/cgi/eletter-submit/327/7424/1129 You can respond to this article at: http://bmj.com/cgi/content/full/327/7424/1129#responses free at: One rapid response has been posted to this article, which you can access for service Email alerting box at the top left of the article Receive free email alerts when new articles cite this article - sign up in the Topic collections (1689 articles) Global health (2669 articles) Other Public Health Articles on similar topics can be found in the following collections Correction http://bmj.com/cgi/content/full/328/7438/494-b available online at: have been appended to the original article in this reprint. The correction is A correction has been published for this article. The contents of the correction Notes To order reprints follow the "Request Permissions" link in the navigation box http://resources.bmj.com/bmj/subscribers go to: BMJTo subscribe to on 10 September 2007 bmj.comDownloaded from Papers Measuring the health of nations: analysis of mortality amenable to health care Ellen Nolte, Martin McKee Abstract Objective To assess whether and how the rankings of the world?s health systems based on disability adjusted life expectancy as done in the 2000 World Health Report change when using the narrower concept of mortality amenable to health care, an outcome more closely linked to health system performance. Design Analysis of mortality amenable to health care (including and excluding ischaemic heart disease). Main outcome measure Age standardised mortality from causes amenable to health care Setting 19 countries belonging to the Organisation for Economic Cooperation and Development. Results Rankings based on mortality amenable to health care (excluding ischaemic heart disease) differed substantially from rankings of health attainment given in the 2000 World Health Report.No country retained the same position. Rankings for southern European countries and Japan, which had performed well in the report, fell sharply, whereas those of the Nordic countries improved. Some middle ranking countries (United Kingdom, Netherlands) also fell considerably; New Zealand improved its position. Rankings changed when ischaemic heart disease was included as amenable to health care. Conclusion The 2000 World Health Report has been cited widely to support claims for the merits of otherwise different health systems. High levels of health attainment in well performing countries may be a consequence of good fortune in geography, and thus dietary habits, and success in the health effects of policies in other sectors. When assessed in terms of achievements that are more explicitly linked to health care, their performance may not be as good. Introduction In its 2000 World Health Report, the World Health Organization published a set of rankings of the world?s health systems. 1 In brief, the overall performance of the health systems was assessed as a composite measure including level and distribution of health attainment, responsiveness of the health system, and degree of fair- ness of financing. Aggregate performance was com- pared with what might be expected given the country?s level of economic and educational development. This approach has attracted intensive debate, rang- ing from the implied values underlying the approach to technical considerations. 23 Despite the volume of debate, a recent review characterised this process as a dialogue of the deaf. 4 One issue still unresolved is the attribution of health attainment to health systems. 5 The World Health Report refers to growing evidence of health gains to be achieved from health care and from health related policies in other sectors, such as vehicle safety. However, many determinants of health still lie outside health care. One possible solution uses mortality data at a population level that are available in many countries and is based on the concept that deaths from certain causes should not occur in the presence of timely and effective health care. This has given rise to the development of a variety of terms including ?avoidable mortality? and ?mortality amenable to medical/health care.? 6 Originally developed in the mid-1970s to measure the quality of health care, the concept was subsequently adopted widely, especially in Europe. 7?10 The 2000 World Health Report approvingly cited research on amenable mortality but then used a much broader measure of health, disability adjusted expect- ancy, without attempting to disaggregate mortality that is and is not amenable to health care. The broad defi- nition of a health system that this implies is, however, inconsistent with the scope of the other two measures used in the report, responsiveness and fairness of financing, which relate directly to the healthcare system. An important question emerging from this debate is whether and how rankings of health systems change when using a more clearly defined measure of health system outcome, mortality amenable to health care. We compared the results achieved by the two approaches in industrialised countries. Methods Mortality and population data were extracted from WHO mortality files for 1998 (1997 for Canada). 11 Data include deaths, coded according to the ninth and 10th revisions of the international classification of dis- eases, by sex and five year age bands (with infant deaths listed separately). Data were examined for the countries of western Europe, the United States, Canada, Australia, New Zea- land, and Japan, countries with high quality mortality data by cause of death. We excluded countries if data were unavailable for years more recent than 1996 (Bel- European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, London WC1E 7HT Ellen Nolte lecturer in public health Martin McKee professor of European public health Correspondence to: E Nolte ellen.nolte@ lshtm.ac.uk bmj.com 2003;327:1129 page 1 of 5BMJ VOLUME 327 15 NOVEMBER 2003 bmj.com on 10 September 2007 bmj.comDownloaded from gium, Switzerland) and those with small populations (Luxemburg, Iceland). The selection of causes of death considered amenable to health care was derived from a recent review of ?avoidable? mortality. 6 The detailed justifica- tion for selection of conditions is set out in that review but, in brief, the final list was a modification of work by Tobias and Jackson, who updated earlier work by Mackenbach and Charlton and coworkers (table). 81213 As in our earlier work, an age limit was set at 75 years, as avoidability of death and reliability of death certification become increasingly questionable at older ages. We recognise that any upper age limit is essentially arbitrary, but this value is consistent with life expectancy at birth in many industrialised countries. However the logic of this would suggest setting differ- ent limits for men and women because of the sex gap in life expectancy. We recognise this as an important issue for debate, but we do not believe that it has yet been resolved. Different age limits were set for diabetes mellitus (under 50) because the preventability of deaths at older ages from diabetes remains controversial. For some other causes, a limit of 15 years was set (see table) as related deaths other than in childhood are likely to reflect some other disease process. The age limit for leukaemia was extended to 44 years because of recent evidence showing substantial improvements in mor- tality from leukaemia in the European Union up to age 44 since 1960. 14 To calculate mortality from conditions amenable to health care, we combined single causes and groups of causes. We computed age standardised death rates per 100 000 population, for both sexes combined, by direct standardisation to the European standard popula- tion. 15 Ischaemic heart disease was treated separately, as the precise contribution of health care to reductions in deaths from this condition remains unresolved. 16 However, accumulating evidence suggests its impact to be considerable, indicating that up to 50% of premature mortality from ischaemic heart disease may be amenable to health care. 12 To account for this we ran two sets of analyses, with and without ischaemic heart disease. Where we included ischaemic heart disease we assumed 50% of deaths under the age of 75 to be ame- nable to health care. Based on age standardised death rates derived in this way we constructed rankings for the countries included in this analysis, supplemented with similar rankings for data on disability adjusted life expectancy for 1999, which were taken from the 2000 World Health Report. 1 Rankings were then compared for perform- ance in terms of both disability adjusted life expectancy and amenable mortality. Causes of death considered amenable to health care Cause of death Age International classification of diseases 9th revision 10th revision Intestinal infections 0-14 001-9 A00-9 Tuberculosis 0-74 010-8, 137 A15-9, B90 Other infections (diphtheria, tetanus, poliomyelitis) 0-74 032, 037, 045 A36, A35, A80 Whooping cough 0-14 033 A37 Septicaemia 0-74 038 A40-1 Measles 1-14 055 B05 Malignant neoplasm of colon and rectum 0-74 153-4 C18-21 Malignant neoplasm of skin 0-74 173 C44 Malignant neoplasm of breast 0-74 174 C50 Malignant neoplasm of cervix uteri 0-74 180 C53 Malignant neoplasm of cervix uteri and body of uterus 0-44 179, 182 C54, C55 Malignant neoplasm of testis 0-74 186 C62 Hodgkin?s disease 0-74 201 C81 Leukaemia 0-44 204-8 C91-5 Diseases of the thyroid 0-74 240-6 E00-7 Diabetes mellitus 0-49 250 E10-4 Epilepsy 0-74 345 G40-1 Chronic rheumatic heart disease 0-74 393-8 I05-9 Hypertensive disease 0-74 401-5 I10-3, I15 Cerebrovascular disease 0-74 430-8 I60-9 All respiratory diseases (excluding pneumonia and influenza) 1-14 460-79, 488-519 J00-9, J20-99 Influenza 0-74 487 J10-1 Pneumonia 0-74 480-6 J12-8 Peptic ulcer 0-74 531-3 K25-7 Appendicitis 0-74 540-3 K35-8 Abdominal hernia 0-74 550-3 K40-6 Cholelithiasis and cholecystitis 0-74 574-5.1 K80-1 Nephritis and nephrosis 0-74 580-9 N00-7, N17-9, N25-7 Benign prostatic hyperplasia 0-74 600 N40 Maternal death All 630-76 O00-99 Congenital cardiovascular anomalies 0-74 745-7 Q20-8 Perinatal deaths, all causes, excluding stillbirths All 760-79 P00-96, A33 Misadventures to patients during surgical and medical care All E870-6, E878-9 Y60-9, Y83-4 Ischaemic heart disease* 0-74 410-4 I20-5 *See text. Papers page 2 of 5 BMJ VOLUME 327 15 NOVEMBER 2003 bmj.com on 10 September 2007 bmj.comDownloaded from Results Figure 1 shows the rankings for the 19 countries included in our analysis based on disability adjusted life expectancy and on amenable mortality without ischaemic heart disease, showing that no country retained the same rank with both methods. Twelve of the countries moved more than two ranks. Major losses using amenable mortality were seen for Japan (from 1 to 13), Greece (7 to 12), and the United Kingdom (10 to 18). Large gains were seen for Canada (9 to 4), Nor- way (11 to 2), Finland (13 to 8), Germany (14 to 6), Denmark (17 to 10), and New Zealand (19 to 15). A few broad trends were observed in groups of countries that, at least in other respects, share particular charac- teristics. The Nordic countries ranked higher using amenable mortality, in several cases noticeably so. Southern European countries, whose high rankings have often been attributed to the known effects of a Mediterranean diet, had all fallen. The situation with the non-European countries is more mixed. Australia remained among the top five ranking countries with both measures whereas New Zealand, despite being placed four ranks higher with amenable mortality, remained in the bottom half of the ranking. Figure 2 shows the rankings of the 19 countries for disability adjusted life expectancy compared with mor- tality amenable to health care with ischaemic heart dis- ease. Rankings changed for all but two (Mediterranean) countries. Major losses were again seen for Greece (from 7 to 12) and particularly for the United Kingdom (10 to 19) but also for the Netherlands (8 to 11) and Australia (2 to 7). The Nordic countries generally showed substantial improvements in their rankings, especially Denmark (17 to 10) and Norway (11 to 5), but not Finland (13 to 15). With the exception of Greece, southern European countries retained either similar ranks to the report (Italy, Portugal) or improved (Spain, France). For the other countries the rankings based on amenable mortality with ischaemic heart disease were essentially similar to those based on amenable mortality without ischaemic heart disease. The only other exception was Japan, which, with the inclusion of ischaemic heart disease, remained among the top five ranking countries. Discussion Rankings based on mortality amenable to health care produce results different from those based on disability adjusted life expectancy, as used in the 2000 Wor ld Health Report. This highlights the problems involved in international comparisons. The quest for accountability has generated an industry engaged in ranking performance in many dif- ferent sectors. This approach developed from control systems in industrial management, where it has long been used with processes where the inputs and products are simple and unambiguous, and there are few if any extraneous factors. It is intuitively appealing, especially to politicians who are anxious to know how public funds are being spent. It is seen as a means to reduce a mass of complex information into a format that almost anyone can understand. Yet its apparent simplicity can be misleading, and many commentators have noted numerous technical problems, ranging from lack of validity to creation of perverse incentives as those involved change their practice or recording methods to achieve higher rankings, despite leading to worse performance. We have looked at one of many possible issues related to health system rankings that has so far been unexplored. The hypothesis was that a measure of health attainment more closely linked to the health- care system would produce a systematically different ranking. This hypothesis was confirmed, with the 11 9 8 7 6 5 4 3 2 1 10 Norway Norway (56.92) Canada Canada (62.17) Netherlands Netherlands (71.19) Greece Greece (72.34) Italy Italy (68.92) Spain Spain (66.14) Sweden Sweden (50.55) France France (62.69) Australia Australia (60.81) Japan Japan (72.48) Rank Disability adjusted life expectancy United Kingdom United Kingdom (91.10) 19 18 17 16 15 14 13 12 New Zealand New Zealand (74.29) Portugal Portugal (113.02) Denmark Denmark (69.35) Ireland Ireland (81.87) United States United States (80.66) Germany Germany (64.15) Finland Finland (66.45) Austria Austria (72.80) Amenable mortality (standardised death rates; ages 0-74) Fig 1 Comparison of rankings based on disability adjusted life expectancy (1999) and standardised death rates (per 100 000; ages 0-74) from mortality amenable to health care (1998) 11 9 8 7 6 5 4 3 2 1 10 Norway Norway (87.51) Canada Canada (91.80)Netherlands Netherlands (97.26) Greece Greece (98.53) Italy Italy (88.13) Spain Spain (84.11)Sweden Sweden (79.60) France France (75.08) Australia Australia (88.36) Japan Japan (81.41) Rank Disability adjusted life expectancy United Kingdom United Kingdom (133.62)19 18 17 16 15 14 13 12 New Zealand Portugal Portugal (132.07) Denmark Denmark (97.21) Ireland Ireland (129.34) United States United States (114.65) Germany Germany (95.90) Finland Finland (109.64) Austria Austria (106.85) Amenable mortality + 0.5 ischaemic heart disease (standardised death rates; ages 0-74) New Zealand (109.03) Fig 2 Comparison of rankings based on disability adjusted life expectancy (1999) and standardised death rates (per 100 000; ages 0-74) from amenable mortality including ischaemic heart disease (50% of all deaths under age 75) (1998) Papers page 3 of 5BMJ VOLUME 327 15 NOVEMBER 2003 bmj.com on 10 September 2007 bmj.comDownloaded from Nordic countries doing better than in the WHO model of the 2000 report. However we do not argue that amenable mortality should substitute disability adjusted life expectancy even if performance was to be ranked. Firstly, it is impossible to rank all countries by amenable mortality given the widespread absence of data by diagnosis. It should be noted, though, that lack of even total mortality for many countries was not seen as an obsta- cle by the authors of the 2000 World Health Report, who used regression modelling to impute figures for disability adjusted life expectancy. A recent study that looked at the method used in the report to generate data on disability adjusted life expectancy showed that, where actual data became available, the regression result produced a quite different value. 17 Secondly, amenable mortality has itself some limitations. The diagnostic categories and the age range used involve some choices that are inevitably arbitrary. A major limitation is that, for many conditions, death is the final event in a complex chain of processes that involve issues related to underlying social and economic factors, lifestyles, and preventive and curative health care. Partitioning deaths among the categories is an inexact science. The example of ischaemic heart disease is instructive. Accumulating evidence suggests that advances in health care have contributed to the fall in mortality from ischaemic heart disease in many countries, yet it is equally clear that large international differences in mortality are caused primarily by factors outside the healthcare sector. 16 18?21 Thus our second analysis included only 50% of mortality from ischaemic heart disease. Obviously many different proportions could be used, from 40% up to 70%, and the choice may vary by country. 16 22 However, it is important to note that the inclusion of ischaemic heart disease in our measure of healthcare outcomes again changes the rankings of countries compared with those of the 2000 Wor ld Health Report. This highlights the problems associated with rankings that are based on summary measures, as they can be sensitive to underlying definitions and concepts. Furthermore, what is considered amenable to health care will change over time as new pharmaceuti- cals and management strategies are developed. Thus testicular cancer has now become potentially a largely curable disease, although the extent to which this is achieved by different healthcare systems varies. 23 In the future it is plausible that diseases such as prostatic can- cer and AIDS could become amenable, with potentially important consequences for such rankings. The upper age limit is also problematic. We included deaths only up to age 75, although it is also clear that advances in medical care are making an increasingly large contribution to survival of people at older ages. Conversely, there remains uncertainty about the validity of death certification at these ages in many countries, not least because of the problems cre- ated by comorbidity. We also only looked at rankings for both sexes combined, although a subsequent analy- sis showed that in some cases rankings differed by sex (data not shown), largely reflecting the relative import- ance of breast cancer as a cause of premature death in women in the country in question. So how can amenable mortality be used to under- stand the performance of a health system? We argue that it does have some value, but not in terms of the aggregate values (although arguably the rankings pro- duced by amenable mortality have greater face validity than those using disability adjusted life expectancy). Instead, it enables comparison of the elements that make up the overall figure, permitting investigators to dig down to look at specific policies and learn from dif- ferent experiences. In some cases these differences are already recognised, examples including advances in early detection and treatment of stomach cancer in Japan and of melanoma in Australia. 24 25 Of course, whether these policies can or should be transferred between countries depends on the burden of disease involved and other contextual factors. It now seems unlikely that the exercise to rank per- formance of health systems will be repeated, but this does not mean that the quest to identify improved measures of performance will be abandoned. What our study shows is that rankings based on overall health attainment and health attainment that can, however imperfectly, be more closely linked to health care, pro- duce different results. Contributors: EN led the study design and analysis of the data. MM supervised the study and contributed to the generation of the hypothesis and study design. Both authors wrote the paper and will act as guarantors for the paper. Funding: EN is the holder of a fellowship on international benchmarking awarded by the Nuffield Trust. The literature review on which this work was based was funded by an unrestricted educational grant by Merck Sharp & Dohme. MM?s work on health systems? performance is funded through the health systems development knowledge programme of the UK Department for International Development. The guarantors What is already known on this topic The 2000 World Health Report compared the performance of 191 health systems, using health attainment, responsiveness, and fairness of financing Overall health attainment used in the report, disability adjusted life expectancy, does not make it possible to separate the influence of health care from those of other sectors, such as agriculture (and thus diet), education, and fiscal policy Calculation of mortality amenable to health care allows more specific attribution of levels of health attainment to health care What this study adds Rankings based on mortality amenable to health care produce results different from those based on disability adjusted life expectancy Additional inclusion of ischaemic heart disease as an amenable cause of death produces rankings different from those in the WHO 2000 Wor ld Health Report Rankings that are based on summary measures are sensitive to the definitions and concepts underlying them Papers page 4 of 5 BMJ VOLUME 327 15 NOVEMBER 2003 bmj.com on 10 September 2007 bmj.comDownloaded from accept full responsibility for the conduct of the study, had access to the data, and controlled the decision to publish. Competing interests: MM is director of a WHO collaborating centre and a member of several WHO committees. He was a member of the regional reference group for the 2000 Wor ld Health Report. 1 World Health Organization. The world health report 2000. Health systems: improving performance. Geneva: WHO, 2000. 2 Navarro V. The new conventional wisdom: an evaluation of the WHO report, Health systems: improving performance. Int J Health Serv 2001;31:23-33. 3 Almeida C, Braveman P, Gold MR, Schwarcwald CL, Riberio JM, Miglionico A, et al. Methodological concerns and recommendations on policy consequences of the World Health Report 2000. Lancet 2001;357:1692-7. 4 Pedersen K. The World Health Report 2000: dialogue of the deaf? Health Econ 2002;11:93-101. 5 McKee M. Measuring the efficiency of health systems. BMJ 2001;323:295-6. 6 Nolte E, McKee M. Does health care save lives? Avoidable mortality revisited. London: Nuffield Trust. (In press.) 7 Rutstein DD, Berenberg W, Chalmers TC, Child CG, Fishman AP, Perrin EB. Measuring the quality of medical care. N Engl J Med 1976;294:582-8. 8 Charlton JRH, Hartley RM, Silver R, Holland WW. Geographical variation in mortality from conditions amenable to medical intervention in England and Wales. Lancet 1983;i:691-6. 9 Poikolainen K, Eskola J. The effect of health services on mortality: decline in death rates from amenable and non-amenable causes in Finland, 1969-1981. Lancet 1986;1:199-202. 10 Holland WW, ed. European community atlas of ?avoidable death.? Oxford: Oxford University Press, 1988. (Commission of the European Communities Health Services Research Series No 3.) 11 World Health Organization. WHO mortality database. www.who.int/ whosis/mort/dowmnload.htm (accessed Feb 2003). 12 Tobias M, Jackson G. Avoidable mortality in New Zealand, 1981-97. Aust NZ J Public Health 2001;25:12-20. 13 Mackenbach J. How important have medical advances been? In: Sussex J, ed. Improving population health in industrialised countries. London: Office of Health Economics, 2000:53-69. 14 Levi F, Lucchini F, Negri E, Barbui T, La Vecchia C. Trends in mortality from leukaemia in subsequent age groups. Leukaemia 2000;15:1980-5. 15 Waterhouse JAH, Muir CS, Correa P, Powell J, eds. Cancer incidence in five continents. Lyon: International Agency for Research on Cancer, 1976. 16 Capewell S, Morrison CE, McMurrey JJ. Contribution of modern cardio- vascular treatment and risk factor changes to the decline in coronary heart disease mortality in Scotland between 1975 and 1994. Heart 1999,81:380-6. 17 Law CK, Yip PSF. Healthy life expectancy in Hong Kong special admin- istrative region of China. Bull WHO 2003;81:43-7. 18 Bots ML, Grobee DE. Decline of coronary heart disease mortality in the Netherlands from 1978 to 1985: contribution of medical care and changes over time in presence of major cardiovascular risk factors. J Car- diovasc Risk 1996;3:271-6. 19 Capewell S, Beaglehole R, Seddon M, McMurray J. Explanation for the decline in coronary heart disease mortality rates in Auckland, New Zea- land, between 1982 and 1993. Circulation 2000;102:1511-6. 20 Tunstall-Pedoe H, Vanuzzo D, Hobbs M, Mähönen M, Cepatis Z, Kuulas- maa K, et al. Estimation of contribution of changes in coronary care to improving survival, event rates, and coronary heart disease mortality across the WHO MONICA Project populations. Lancet 2000;355:688- 700. 21 Beaglehole R. Global cardiovascular disease prevention: time to get seri- ous. Lancet 2001;358:661-3. 22 Hunink MGM, Goldman L, Tosteson ANA, Mittleman MA, Goldman PA, Williams LW, et al. The recent decline in mortality from coronary heart disease, 1980-1990. JAMA 1997;277:535-42. 23 Levi F, La Vecchia C, Boyle P, Lucchini F, Negri E. Western and eastern European trends in testicular cancer mortality. Lancet 2001;357:1853-4. 24 Adachi Y, Kitano S, Sugimachi K. Surgery for gastric cancer: 10-year experience worldwide. Gastric Cancer 2001;4:166-74. 25 Marks R. The changing incidence and mortality of melanoma in Australia. Recent Results Cancer Res 2002;160:113-21. (Accepted 5 September 2003) Papers page 5 of 5BMJ VOLUME 327 15 NOVEMBER 2003 bmj.com on 10 September 2007 bmj.comDownloaded from Remedial action is necessary if this lack of professional capacity is common. If it is the problem could be addressed by brief training courses on arsenic and public health for all medical practitioners in Bangladesh. Millions of Bangladeshis may be at risk of life threatening complications of chronic arsenic ingestion. Contributors and guarantor: This work forms the substance of an M Phil thesis submitted by RM to the Australian National University for examination on 14 November 2002 and recently accepted for the degree. RMD, GR, and BC were joint supervisors of the research. All four authors participated in study design, interpretation of results, and drafting of the paper. RM conducted the interviews and prepared the main draft of the table and paper. Funding: The work was funded jointly from the personal finances of RM. Competing interests: None declared. Ethical approval: The work was not submitted to ethics review on the basis that this was a simple, voluntary survey, in which participants understood that they could decline to participate in a study whose purpose was fully explained by the interviewer. 1 British Geological Survey. Arsenic contamination of groundwater. www.bgs.ac.uk/arsenic/home.html (accessed 23 Oct 2003). 2 MacDonald R. Providing clean water: lessons from Bangladesh. BMJ 2001;322:626-7. 3 Smith AH, Lingas EO, Rahman M. Contamination of drinking water by arsenic in Bangladesh: a public health emergency. Bull WHO 2000;78:1093-103. (Accepted 25 September ) Perceptions of clinicians and representatives from arsenic mitigation agencies about the role of doctors in the management of the arsenic problem in Bangladesh Group 1* Group 2? Hospital based clinicians (n=42) Frequency of seeing patients with arsenicosis: Daily 16 0 One or more cases in a month 4 0 One or more cases in past six months 0 3 Unsure of having seen any arsenicosis patients 0 19 Self reported ability to identify symptoms and signs of arsenicosis: Adequate 17 4 Inadequate 3 18 Self reported understanding of pathophysiology of arsenicosis: Adequate 9 1 Incomplete 4 9 Do not know 7 12 Received training or guidelines on managing arsenicosis: Yes 81 No 12 21 Understanding of the nature of the problem: A public health issue 17 11 Not sure of the nature of the problem 3 11 Involvement in any government arsenic mitigation policy and activity: Yes 30 No 17 22 Representatives from arsenic mitigation agency (n=17) Role of respondent?s agency in the arsenic mitigation programme: Patient identification, management, and training of doctors 5 Tube well testing for arsenic, supply of alternative water supply, increasing awareness of arsenic: 3 Arsenic and other health related research 2 All the above 4 General focus on health and health system 1 Patient identification and applied geology 1 Organising public health professionals 1 Effectiveness of government action on the arsenic problem: Not effective 7 No comment 10 Perceived problems in mitigation efforts: Lack of understanding about the public health nature of the problem 7 Lack of proper coordination and poor management 2 Lack of training manpower 2 No emphasis on research activities 1 Centralisation of power and poor governance 1 Misuse of fund on transport and travelling abroad 1 Lack of transparency 1 All above 2 Views on desirable role of doctors in mitigation programmes: (1) Best practice criteria for clinical management and epidemiology 3 (2) Mass awareness and more training to health workers 1 (3) Knowledge about public health nature and new research 1 (4) Health hazards of alternative technology 1 (5) Invention and validation of alternative technology 1 (6) Responses 1-4 5 (7) Responses 1-5 5 *Clinicians from Dhaka Community Hospital, Dhaka Medical College Hospital, and the Post Graduate Medical University Hospital, selected because of their known active involvement in care of arsenicosis. ?Clinicians from Sir Salimullah Medical College/Mitford Hospital and Shahid Suhrawardy General Hospital, selected randomly from staff lists to provide a group of doctors of comparable seniority to doctors in group 1. Corrections and clarifications British cancer death rates fell by 12% between 1972 and 2002 Cancer Research UK has alerted us to an error in the data for female incidence of cancers that it supplied for the graph in this news article by Zosia Kmietowicz (7 February, p 303): the male and female curves for incidence are both correct, but the female curve should appear for the same period as the male curve (1975 to 2000). All rates for incidence and mortality shown on the graph are for Great Britain. The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy The authors of this paper by Ray Garry and colleagues appeared in the wrong order (17 January, pp 129-33). Although the authors submitted the correct order, this was somehow scrambled by us during the editorial process?unfortunately our attempts to unearth how this happened have failed. The authors should have been listed in the following order: Ray Garry, Jayne Fountain, Su Mason, Jeremy Hawe, Vicky Napp, Jason Abbott, Richard Clayton, Graham Phillips, Mark Whittaker, Richard Lilford, Stephen Bridgman, Julia Brown. We apologise to the authors for this mistake. Measuring the health of nations: analysis of mortality amenable to health care The authors of this paper, Ellen Nolte and Martin McKee, have alerted us to an error in their data processing, which affects figures 1 and 2 in their paper (BMJ 2003;327:1129-32). Deaths from colon cancer had been mistakenly excluded for Denmark, Finland, Germany, Norway, and Sweden. In figure 1 the standardised death rates for ?amenable mortality? for these countries are 81.43, 71.81, 74.42, 66.50, and 58.46 respectively. In figure 2 the respective values for ?amenable mortality plus ischaemic heart disease? are 109.29, 114.99, 106.17, 97.09, and 87.50 respectively. In recalculating the data for those countries, the authors also discovered a minor miscalculation for the UK values (which should be 87.46 in figure 1 and 129.98 in figure 2). The revised values slightly affect the rankings (although not the United Kingdom), but the authors state that the revisions do not at all affect the overall conclusion of their paper. Papers 494 BMJ VOLUME 328 28 FEBRUARY 2004 bmj.com on 10 September 2007 bmj.comDownloaded from