Routine preoperative chest radiography in non-cardiopulmonary surgery.

Preoperative radiography was performed on 667 consecutive patients undergoing elective non-cardiopulmonary surgery in a large hospital in Wales. Of all significant findings reported 54% were due to cardiomegaly and 19% to chronic respiratory disease, and no appreciable abnormality was found in any patient under 30. Out of a subsample of 152 examined prospectively, 38% had received a chest radiograph within the last year, and the maximum marrow dose had been exceeded in 12-5%. It is concluded that the procedure, as presently practised, is not only being considerably overused but is also exposing many recipients to the potentially harmful effects of over-irradiation. The findings provide further evidence in support of the Royal College of Radiologists'' proposal that a national multicentre study of diagnostic radiology should be set up with some urgency.     

Preventive therapies: weighing the pros and cons.

The author comments on three issues raised by Dr. Kenneth G. Marshall in his series on the benefits and harms of preventive therapies, which begins in this issue on page 1493. First, because the method by which the results of clinical trials are presented markedly affects the perception of those results some measure of absolute benefit and harm must be used when the results of clinical trials are presented. Second, there is increasing interest in decision aids as a means of helping patients to understand evidence and make therapeutic choices. It is important that these aids undergo rigorous testing before they are adopted for common use. Third, evidence-based clinical practice guidelines are a welcome resource for busy clinicians. However, physicians and patients should bear in mind that interpretations of the available evidence can vary, leading to different conclusions about the appropriateness of preventive therapies.     

Routine smoking cessation intervention in health care systems.

Everyone agrees that insurance for long-term care is inadequate in the United States. Disagreement exists, however, on whether such insurance should be provided through the private or public sector. Private insurance generally uses the experience-rating principle that persons with higher risk of illness are charged higher premiums. For private insurance for long-term care, this principle creates a dilemma. Most policies will be purchased by the elderly; yet, because the elderly have a high risk of needing long-term care, only about 20% of them can afford the cost of premiums. A public-private partnership by which the government partially subsidizes private long-term-care insurance is unlikely to resolve this dilemma. Only a social insurance program for long-term care can provide universal, affordable, and equitable coverage.