BMJ

Market failure
Author(s): Rudiger Pittrof
Source: BMJ: British Medical Journal, Vol. 339, No. 7723 (26 September 2009), pp. 709-710
Published by: BMJ
Stable URL: http://www.jstor.org/stable/25672735
Accessed: 14-09-2015 07:01 UTC

Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at http://www.jstor.org/page/
info/about/policies/terms.jsp

JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content
in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship.
For more information about JSTOR, please contact support@jstor.org.

BMJ and BMJ Funder are collaborating with JSTOR to digitize, preserve and extend access to BMJ: British Medical Journal.

http://www.jstor.org

This content downloaded from 202.92.156.11 on Mon, 14 Sep 2015 07:01:57 UTC
All use subject to JSTOR Terms and Conditions
These lettersare selected fromrapid responses posted
^%
onbmj.com. made12daysafter
isusually
Selection print
pubUcationofthearticletowhichtheyrespond.
PYLORIANDULCERS
HELICOBACTER
Against reductionism
Bothpositionsinthehead tohead debate
"Does Helicobacterpylorireallycause
a pathophysiological
duodenal ulcers?"reflect
reductionism thatshouldhave longsince
become obsolete.12Justas highcholesterolis
not"thecause" ofmyocardialinfarction butone
ofmany riskfactors,Hpylori isbest seen as one
among several risk factors for ulcer.
The evidence:most people livingwith
Helicobacterneverdevelopulcers,some
30% ofpatientswithulcerdo notharbourH
(witha substantialproportion
pylori infection
also lacking exposure to non-steroidal
inflammatorydrugs),and some patientswhose
Helicobactercolonisationhas been eliminatedby
antibioticssubsequentlydevelop new ulcers.34
These factsmake itclearthatotherriskfactors,
gastricacid hypersecretion,
including smoking,
psychologicalstress,and geneticpredisposition,
even inthe
playa part inulcerformation
many cases whereHpylori isprobablydirectly
implicated.
The lateralthinkingexemplifiedbyMarshall
andWarrenshould intheend help scientists
toarriveat a new levelofunderstandingof
disease.5 Insteadofsimplyassigningone
"cause" at a timeourthinking
will expand to
encompass the more complex?and
ofmultiplefactors
interesting?interactions
thatcome intoplay inthedevelopmentofmost
medical conditions.
Susan Levenstein physician,
AventinoMedical Group,Rome,
00153 susanlevenstein@gmaiLcom
Italy
Competing interests:
None declared.
1 FordAC,TalleyNj.Does Helicobacterpylorireallycause
duodenal ulcers?Yes. BMJ2009;339:b2784. (14August.)
2 HobsleyM, ToveyFl,BardhanKD,Holton J.Does
Helicobacterpylorireallycause duodenal ulcers?No. BMJ
2009;339:b2788. (14August.)
3 Aro P,StorskrubbT, Ronkainen J,Bolling-Sternevald
E, EngstrandL,ViethM, etal. Peptic ulcerdisease
ina general adult population: theKalixanda study:
a randompopulation-based study.Am JEpidemiol
2006;163:1025-34.
BMJ 126SEPTEMBER 20091 VOLUME 339
I
| _P I I P. tm___|
4 Miwa H,Sakaki N,Sugano K,Sekine H, HiguchiK,Uemura
N,et al. Recurrent
pepticulcers inpatientsfollowing
some hospitals recordedthese
Historically,
successfulHelicobacterpylorieradication:a multicenter procedures as day case admissions, others as
5
studyof4940 patients.Helicobacter2004;9:9-16.
Marshall Bj,WarrenR.Unidentifiedcurvedbacilli inthe
outpatientprocedures. Itdid notmatter:the
stomachofpatientswithgastritisand peptic ulceration. patientgot thetest,and thehospitalgotpaid
k?ncefl984;i:1311-5. undertheblockcontract.Underpaymentby
Cite thisas: BMJ2009;339:b385 5
results,however,thehospitalgetsmore income
fora day case admissionwithprocedurethan
ANDPIOGLITAZONE
ROSIGLITAZONE foran outpatientprocedure.Astutebusiness
managerswill ensurethatactivityis recordedfor
Bewaremacularoedema administrative purposes inwhicheverlegitimate
De Vriesand Russell-Jones pointout thatthe mannerwill maximise income.
increasedriskofcardiacfailureinpatientstaking The side effectsofsuch a change inrecording
glitazonesmay resultfromfluidand sodium includeboostingmanyperceivedpositive
retention.1
Diabeticpatientstakingrosiglitazone ofgood orefficient
indicators care.The number
and pioglitazoneare also more likelytodevelop (and proportion)ofday case admissions
diabeticmacularoedema,which seems tobe increases. Ifother admissions are unchanged,
reversibleinmanycases on stoppingthedrug.2 thetotalnumberofadmissionsalso increases,
An associationofglitazoneswithdiabetic theadded day cases reducingtheaverage length
macular oedema has been reported in a large, ofstay.Since fewpatientsadmittedforday case
170000 strong,cohorteven afteradjustment endoscopydie, death ratesinhospitalalso fall.
fortheconfoundingfactorsofage, glycaemic Such changes inrecordingforendoscopy
control, and insulin use.3 and similarprocedurescouldaccountforan
Physiciansand ophthalmologistscaringfor important ofthebenefitofpayment
proportion
patientstakingglitazonesshouldbe awareofthis by results
withoutanychange inthetrueactivity,
visionthreateningcomplicationas well as the risk cost, or quality of patient care.
anti and stopglitazonetreatmentin
ofcardiacfailure, JohnPWatson consultantphysician,St James'sUniversity
Hospital, Leeds LS9 7TF john.watson@leedsth.nhs.uk
thosedevelopingdiabeticmacularoedema.
inophthalmology Competing interests:None declared.
Rosemary G Lambley registrar
1 FarrarS, Yi D, SuttonM, ChalkleyM, Sussex J,ScottA.
rosemarylambley@doctors.org.uk
Has paymentby resultsaffectedtheway thatEnglish
Kave Vahdani specialisttrainee inophthalmology
ArisKonstantinidisglaucoma fellow hospitals provide care? Difference-in-differences
analysis. BMJ2009;339:b3047. (27 August.)
Adam Booth consultantophthalmologist, RoyalEye Infirmary,
Cite thisas: BMJ2009;339:b3858
PlymouthPL46PL
Competing interests: None declared.
1 De VriesCS, Russell-JonesDL Rosiglitazoneor
pioglitazone intype2 diabetes?BMJ2009;209:b3076.
(18August.)
Market failure
2 RyanEH,Han DP,RamsayRC,CantrillHL,BennettSR, was intendedtoenable
Paymentby results
DevS, etal. Diabeticmacular oedema associated with
glitazoneuse: Retina2006;26:562-70.
commissionersand providersto focusand
3 FongDS, ContrerasR.Glitazoneuse associated compete on quality rather than costs. Farrarand
withdiabeticmacular oedema. Am JOphthalmol
2009;147:583-6. colleagues showed thatquality(asmeasured)
Cite thisas: BMJ2009;339:b3856 did notchange.1Perhaps the healthcaremarket
much more cannotbe used to improvequality,paymentby
BYRESULTS
PAYMENT resultsisthewrong tool to improvequality,or
theassessment ofqualitywas inadequate,or
Has paymentby resultsaffected all three.
Farrarand colleagues showed a small
howcare isrecorded? improvement inproductivity.Thismay be more
thanoffsetbytheadditionaladministrative
Paymentby resultshas changedthe recorded
inpatient ofhospitals,1butwhether
activity costs forbothcommissionersand providers.
thisrepresentsa genuinechange inactivityor Theyfoundno change incase mix. Indeed,
a change intheway activityis recordedisnot the increasednumberofday case procedures
clear. Take as an example upper gastrointestinal overall,thathealthierpatients
may reflect,
endoscopy?a common procedure performed receive treatment. Insexual health, for example,
on patientswho are nototherwisestayingin paymentby resultsrewardsprovidingminimal
hospital. servicesforthe
worriedwellwhile penalising
709
This content downloaded from 202.92.156.11 on Mon, 14 Sep 2015 07:01:57 UTC
All use subject to JSTOR Terms and Conditions
LETTERS_~_" _

thosewho havemost togain fromusing

targeting Whereas perfect use failure rates are
the services?the most expensive patients. thetheoreticalminimumriskofpregnancy
Rudiger Pittrofconsultant in integratedsexual healthand associatedwitha method,typicaluse figures
HIV,EnfieldCommunityServices, EnfieldEN11NJ
providepatientswitha more accuratepicture
Rudiger.Pittrof@enfield.nhs.uk of theirriskofpregnancy.
Researchshows that,
Competing interests:None declared.
forwomen, the most important characteristic of
1 FarrarS, Yi D, SuttonM, ChalkleyM, Sussex J,ScottA.
Has paymentby resultsaffectedtheway thatEnglish a contraceptive
method is itseffectivenessin
hospitals providecare? Difference-in-differences
4
preventingpregnancy,2and theWorldHealth
analysis. BMJ2009;339:b3047. (27 August.)
Cite thisas: BMJ2009;339:b3859 Organizationhas developed a chartto help to
communicate this information. The hormonal

contraceptive pill remainsthemostwidely

SOCIALMOBILITY
PROMOTING used method intheUnitedKingdom,but itis
associatedwitha significantly highertypical The reason forthis isthat intrauterine
devices
Not justdown to individuals use failurerate(8% inthe firstyearofuse) than are farless effectiveinpreventingectopic
Some important misunderstandings about more effective methods (wellunder1%).5More pregnancies than intrauterine pregnancies.
socialmobilityriskdefeatingtheobjectof effectivemethodsalso have equal or better Failuretoappreciate thisfactcould have
Themost important
policies topromoteit.1 acceptabilityratings and continuationrates disastrous consequences under some

misunderstandingisthatsocialmobilitydepends (proxy measures ofhow tolerableanyside effects circumstances.

on the person. But for someone to move into a are) comparedwiththepill.5Forcontraception Martin P Vessey emeritusprofessorof publichealth,Unitof
HealthCare Epidemiology,Rosemary Rue Building,Old Road
more advantaged social situation, there must counsellingtobe evidencebased clinicians Oxford0X3 7LF
Campus, OxfordUniversity,
be a place forheror himtomove to.When the shouldensurethatwomen understandthe lower martin.vessey@dphpc.ox.ac.uk
no
numberofwell paid, skilledjobs is limited pregnancyriskand highacceptability ofthemost Competing interests:None declared.
amountof intelligence ordeterminationwill be effectivemethods.Then theirchoiceofmethod 1 AmyJ-J, women: an evidence
TripathiV. Contraceptionfor
based overview.BMJ2O09;339:b2895. (7August.)
sufficient to guarantee a position. will be fullyinformed. 2 Vessey MP, JohnsonB, Doll R,Peto R.Outcome of
A secondmisapprehensionisthatpeople uponAvonCV37 9BF rich.
RichardLyusdoctor,bpas, Stratford pregnancy inwomen using an intrauterine device. Lancet
1974;i:495-8.
educated tomove into
must be highly more tyus@bpas.org
3 XiongX,Buekens P,Wollast E. IUDuse and the riskof
favourableoccupations.Afterthesecondworld Competing interests:
None declared.
ectopic pregnancy:a meta-analysis of case-control
1 Amy J-J, V. Contraceptionfor
Tripathi women: an evidence studies. Contraception1995;52:23-34.
warthe number of new professional, managerial, based overview.BMJ2009;339:b2895. (7August.)
Cite thisas: BMj 2009;339:b3864
2
and technicaljobs (manyinthenewwelfare Grady WR, KlepingerDH,Nelson-WallyA.Contraceptive
characteristics:theperceptionsand prioritiesofmen and
state)exploded.These jobswere quicklyfilled women. FamPlannPerspect 1999;31:168-75.
OTTAWA
RULES,OK?
byan age cohort
and adequatelyperformed 3 SteinerMJ,Dalebout S, Condon S, DominikR,Trussed
J.Understandingrisk:a randomizedcontrolledtrialof
inwhichonlya verysmallproportion stayed communicatingcontraceptiveeffectiveness.Obstet
at schoolbeyondtheminimumage. Currently, Gynecol2003;102:709-17. Noctors,doctors,and rules
4 SteinerMJ,TrussellJ,Mehta N,Condon S, Subramaniam
however, for some to move "upwards" into highly
S, BourneD<Communicatingcontraceptiveeffectiveness:
The example of6 yearold Tarquinfallingoff
paid jobs others must move "downwards," a fate a randomizedcontrolledtrialto informaWorld Health his swingand being referred forreassurance
Organizationfamily planninghandbook.AmJObstet
strenuouslyavoided bymiddle class parentsfor radiography of theankle bya nurse inaccident
Gynecol2006;195:85-91.
theirchildren. 5 HatcherRA,TrussellJ, NelsonAL,CatesW,Jr, StewartFH, and emergencyisa bad exampleof showing
KowalD. Contraceptivetechnology.19thed. NewYork,NY:
Whatmightbemoreeffective would be to ArdentMedia, 2007.
thedifficultiesin implementing theevidence
combine improved educationforlessadvantaged Cite thisas: BMf2009;339:b3869 based Ottawa ankle rules.1Ifthenurse
withsupportforselfemploymentinthe
children practitioner(ornoctor,fromthephrase "not
creativearts,forexample.Peoplewitha degree a doctor") isunable todeal with the family's
on around
and no jobare stillgoingtobe living Intrauterine
devicesand concernaccordingto theprotocol,she should
10% oftheaveragewage intheUnitedKingdom notsolve theproblemby irradiating thechild
(oneofthe lowestratiosinanydeveloped ectopicpregnancy unnecessarily.
nation)?justas iftheyhad notbothered. devices and
The relationbetween intrauterine Ifthefamilyconcerncontinuesdespite the
Mel Bartleyprofessor,
Departmentof Epidemiologyand Public ectopic pregnancy continues to cause confusion, protocolhavingbeen followedand radiography
Health,UCL, LondonWC1E 6BTm.bartley@ucLacuk
justas itdidwhenmy colleaguesand Ireported notbeingwarranted,thepatientshould be
Competing interests:
None declared.
the relevantfindingsinour cohortstudyin referredtoa doctorwho isable toallay the
1 Forde I,ZeunerD. Financialincentivestopromotesocial
mobility.BMJ2009;339:b3219. (25August.)
1974.12 parentalfearsbyexplainingthe situationwith
Cite thisas: BMJ2009;339:b3857 Amyand Tripathi state that"a meta-analysis the risksand benefitsof radiography.
ofcase-controlstudiesshowed thatectopic Allowingnursingstafftoover-rideset
pregnancy is not more common inwomen who protocolswill lead tooverinvestigation
with its
CONTRACEPTION
FORWOMEN conceive with an intrauterine device in place."1 knownpotentialrisks.Ifthepoliticalwill isto
Themeaningof thisstatementisnotcleartome, replacedoctorswith noctors,Hippocrates is
Evidencebased counselling but theclinicallyimportantfactisthatifa woman still relevant?"first do no harm"?even ifthe
Intheirreviewof contraception
for
women,Amy withan intrauterinedevice insitupresents see yourpointofview.
parentsdo not initially
and Tripathiemphasise the importance ofpatient withan accidentalpregnancyshe isfarmore TreforJRoscoe GP principal
choiceand discussionof typicaluse failure Sarah JRoscoe, SothallMedical Centre,SheffieldS201HQ
thana womanwho has become pregnant
likely
Competing interests:
None declared.
rates.1 However, they focus on the hormonal under other circumstances to have an ectopic
1 Weaver TD, PattersonS. Themythof complexity.
BMJ
pill,withonlybriefanalysisofmore
contraceptive pregnancy.Indeed,the reviewcitedbyAmyand 2009;339:b3505. (1 September.)
effective methods such as intrauterine devices. gives the increaseinriskas 10.6-fold.3
Tripathi Cite thisas: BMJ2009;339:b3872

710 BMj 126SEPTEMBER 20091 VOLUME 339

This content downloaded from 202.92.156.11 on Mon, 14 Sep 2015 07:01:57 UTC
All use subject to JSTOR Terms and Conditions