THE LANCET • Vol 352 • August 29, 1998 743

CORRESPONDENCE

Drug treatment for Crohn’sdiseaseSir—In her June 6 feature (p 1710),Dorothy Bonn’s1 quotation “so far nodrugs have been shown to effect animprovement that persists afterwithdrawal of treatment” does not takefully into account our data.2 Theclinical improvement shown in thispilot study of ISIS 2302 extended wellbeyond the treatment period. In ourstudy, 15 patients received 13 infusionsof ISIS 2302 over 26 days, and fivepatients received placebo. Patientswere then followed for an additional5 months. At the end of the treatmentperiod, seven of the ISIS 2302-treatedpatients were in remission by Crohn’sdisease activity index measurements,and at the end of the 180 day trial, fiveof these seven remitters were still inremission. In addition, significantdifferences in mean corticosteroiddoses were recorded between patientstreated with ISIS 2302 and placebo forthe entire 5-month follow-up. Meancorticosteroid doses were similar in thetreatment groups at baseline. Steroiddoses were kept constant during thetreatment period, after which timedoses in individual patients were adjustedaccording to blinded clinical judgment.

These data point to the importanceof targeting specific inflammatorymolecules, especially those far enoughdown the inflammatory cascade to keepside-effects to a minimum, yet enhancefully activity in terms of efficacy anddurability.

Bruce R YacyshynDivision of Gastroenterology, WalterMackenzie Health Sciences Centre, Universityof Alberta, Edmonton, Canada T6G 2R7

1 Bonn D. Tackling the real culprits inCrohn’s disease. Lancet 1998; 351: 1710.

2 Yacyshyn BR, Bowen-Yacyshyn MB,Jewell L, et al. A placebo-controlled trial ofICAM-1 antisense oligonucleotide in thetreatment of Crohn’s disease.Gastroenterology 1998; 114: 1133–42.

However, a charity for the homeless,Crisis, has published details of deathsamong Londoners who were classifiedas being of no fixed abode on theirdeath certificates,3 with information onage and sex. From these data it ispossible to calculate SMRs for malerough sleepers in London. The numberof rough sleepers is taken from the 1991Census.4

There are undoubtedly manydifficulties with the reliability of thesedata; it is impossible to calculate withgreat accuracy death rates for thisindeterminate and mobile population.The results in the table are, however,the first to be calculated for a UKsample, and suggest that the death ratesof male rough sleepers aged 16–29 yearsare almost 40 times those of the generalpopulation. For all men aged 16–64years, this number is about 25 timesgreater (SMR=2587).

Although it is not surprising thatrough sleepers have higher death ratesthan the general housed population, themagnitude of the difference noted hereis startling. In the light of the fact thathomelessness seems to be becoming apermanent feature of society, this highrate is cause for grave concern.

*Mary Shaw, Danny DorlingSchool of Geographical Sciences, University ofBristol, Bristol BS8 1SS, UK

1 Roy E, Boivin J-F, Haley N, Lemire N.Mortality among street youth. Lancet 1998;352: 32.

2 Bines W. The health of single homelesspeople. York: Centre for Housing Policy,University of York, 1994.

3 Grenier P. Still dying for a home. London:Crisis, 1996.

4 Shaw M. A place apart: the spatialpolarisation of mortality in Brighton. Bristol:University of Bristol, 1998.

They are also critical to administrativedata as a measure of quality. We feelthat they simplify matters and that thetwo approaches cover different features.These differences are context-specific(eg, care as commodity vs part of thewelfare system) rather than because oftime or development.

Integrated clinical and administrativedata are used in Sweden, where healthcare is similar to the UK, based ontaxes, rationing, central priorities, andequality, irrespective of insurance andincome. Regional and local authoritieshave responsibility for all kinds of healthcare, in a similar way to managed care.Statistics from private providers areavailable, since they are the basis forreimbursement. The legal basis is tosupply citizens with “good care”, and allproviders are by law obliged to dosystematic quality assurance.

Quality development in Sweden isbased on local total quality managementor similar principles, medical audit, anduse of nationwide databases developedby cooperation between hospitals,counties, and the National Board ofHealth and Welfare (NBHW), agovernmental agency. An administrativedataset is common to many countries,including lists such as the hospitaldischarge registry, indicating localdifferences in practice and use of care,the cancer registry, and the cause ofdeath registry. The other dataset isclinical and includes 40 (1998) registrieson specific procedures or diseases suchas surgery for hip replacement,coronary-artery bypass grafting andpercutaneous transluminal coronaryangiography, cataract surgery, renalreplacement therapy or diabetes.2 Bystatistical procedures, updatedstandards of indications, use, andperformance are developed. Primarydata are available to participatinghospitals as bench-markers, on anaggregate level available to counties, theNBHW, and the public. These data-bases of comparable numbers arepowerful tools for long-term systematicquality development in health care.Similar development is currently hap-pening in other Scandinavian countries.

The definition of quality in healthcare varies with the perspective. Accessto care, the balance between suppliers,and efficient use of resources based onthe correct implementation of medical

Age Male rough sleepers in London (1995/96) Total male population of England and (years)

Rough Rough Death rate SMR (95% CI)Wales (1995)

sleeper sleepers per 1000 Deaths Population Death ratedeaths people per 1000

people

16–29 14 341 41·1 3732 (2038–6263) 5759 5 101 800 1·130–44 21 292 71·9 3127 (1935–4780) 12 826 5 682 900 2·345–64 32 203 157·6 2074 (1418–2928) 44 460 5 830 200 7·6

Mortality among rough sleepers in London and among the general population

Mortality among streetyouth in the UKSir—Elise Roy and colleagues (July 4, p 32)1 report on mortality among streetyouth in Montreal, Canada. Theyfound standardised mortality ratios(SMRs) among street youth aged 14–25years (n=10) were almost 12 times thatof the general population (11·67/1).

As is the case in North America,while there is some evidence of themorbidity of the homeless in Britain,2

little is known about their death rates ascompared with the general population.

Measuring quality in theNHSSir—Paul Shekelle and Martin Roland(July 18, p 163)1 imply that in the US,quality is an integrated part of healthcare, based on clinical data, whereas inthe UK, administrative data do notsupport improvement of clinicalperformance. This difference is due toslow development: “what physicians inthe UK are facing now resembles whatUS physicians faced 30 years ago”.