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Am Fam Physician. 2004 Jan 15;69(2):440-441.

ACOG Opinion Paper on Elective Surgery

The Committee on Ethics of the American College of Obstetricians and Gynecologists (ACOG) has released a new opinion paper addressing the controversy of elective cesarean delivery. “Surgery and Patient Choice: The Ethics of Decision Making,” is available online at http://www.acog.org.

While the right of patients to refuse unwanted surgery is well known, less clear is the right of patients to have a surgical procedure done when the scientific evidence supporting it is incomplete, of poor quality, or completely lacking.

According to ACOG, when supporting evidence is limited, there is no single answer on the right ethical response by a physician considering a patient's request for surgery. Thus, the decision on whether to perform an elective cesarean delivery (also known as “patient choice cesarean” or “cesarean on demand”) will come down to a number of ethical factors, including the patient's concerns and the physician's understanding of the procedure's risks and benefits.

In the case of an elective cesarean delivery, if the physician believes that cesarean delivery promotes the overall health and welfare of the woman and her fetus more than does vaginal birth, then he or she is ethically justified in performing a cesarean delivery. Similarly, if the physician believes that performing a cesarean delivery would be detrimental to the overall health and welfare of the woman and her fetus, he or she is ethically obliged to refrain from performing the surgery. A referral to another physician would be appropriate if the patient and her physician cannot agree on a method of delivery.

With regard to changing the policy in support of elective cesarean delivery, ACOG states that the burden of proof should fall on those who advocate for the change. Therefore, physicians are under no obligation to initiate discussions about a procedure, such as elective cesarean, that is unproven scientifically or that the individual physician may not consider medically acceptable.

An increasing number of women are requesting elective cesarean instead of vaginal delivery in the belief that the surgery will prevent future pelvic support problems, or sexual dysfunction problems, or for other reasons. A number of physicians believe that such surgery should not be selected over a natural process without immediate and compelling medical need.

ACOG cautions that evidence to support the benefit of elective cesarean is still incomplete and that there are no extensive morbidity and mortality data to compare elective cesarean delivery with vaginal birth in healthy women. With better data, there could be a shift in clinical practice.

CDC Report on Physical Activity Among Children

Although the majority of children nine to 13 years of age engage in some level of free-time physical activity, increased rates of participation in both free-time and organized physical activities are needed, especially for non-Hispanic black and Hispanic children, according to a report by the Centers for Disease Control and Prevention (CDC). “Physical Activity Levels Among Children Aged 9–13 Years—United States, 2002” appears in the August 22, 2003, issue of Morbidity and Mortality Weekly Report and is available online at http://www.cdc.gov/mmwr/preview/mmrhtml/mm5233a1.htm.

To promote a healthy, more active lifestyle among U.S. youth, the CDC developed the Youth Media Campaign (YMC), a national initiative to encourage children nine to 13 years of age to engage in and maintain high levels of regular physical activity. The CDC conducted the YMC Longitudinal Survey (YMCLS) to provide a baseline assessment of physical activity levels among children in this age group.

According to the report, 61.5 percent of children nine to 13 years of age do not participate in any organized physical activity during their nonschool hours; 22.6 percent do not engage in any free-time physical activity. The CDC notes that improving levels of physical activity among this population will require innovative solutions that motivate children and that address parents' perceived barriers to their children engaging in physical activity.

Fewer children reported involvement in organized sports (38.5 percent) than in free-time physical activity (77.4 percent). Non-Hispanic black and Hispanic children were significantly less likely than non-Hispanic white children to report involvement in organized activities, as were children with parents who had lower incomes and education levels.

Although parents generally perceived the same barriers to participation in physical activities regardless of the child's sex and age, concerns about transportation, opportunities in their area, and expense were reported significantly more often by non-Hispanic black and Hispanic parents than by non-Hispanic white parents. Concerns about neighborhood safety were reported more frequently for girls (17.6 percent) than for boys (14.6 percent) and were reported more frequently by Hispanic parents (41.2 percent) than by non-Hispanic white (8.5 percent) and non-Hispanic black (13.3 percent) parents. Overall, parents with lower incomes and education levels reported more perceived barriers.

AHRQ Report on Spending for Prescribed Medicines

The Agency for Healthcare Research and Quality's Medical Expenditure Panel Survey (MEPS) has released a new report on prescription drug use and expenditures. “Statistical Brief Number 21: Trends in Outpatient Prescription Drug Utilization and Expenditures: 1997–2000” is available online at http://www.meps.ahrq.gov/papers/st21/stat21.htm.

The MEPS found a significant increase in total outpatient prescription expenditures between 1997 and 2000—from $72.3 to $103 billion. Outpatient prescription medications accounted for a greater proportion of total medical expenses, increasing from approximately 13 percent of total expenses in 1997 to more than 16 percent in 2000.

Average out-of-pocket expenses for people 65 years and older were more than three times higher than for people less than 65 years of age every year of the study period. Between 1997 and 2000, the average expense for people 65 years and older with any prescription medicine expense increased about 35 percent, from $819 to $1,102. For people younger than 65 years, the amount increased about 40 percent, from $347 to $485.

Finally, the average number of prescriptions for persons age 65 and older was more than twice the average number of prescriptions for persons under age 65 each year of the study period.


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