Diagnostic Infrastructure

Alan Morris Alan.Morris at IMAIL.ORG
Sat Feb 6 16:47:48 UTC 2016


It is just these differences in approach that demand standardization for the sake of science in medical practice.  It is difficult to identify superior treatments, in general.  The unnecessary variation in practice makes it more difficult.

Protocols with enough detail to provide personalized care instructions can, and have, been developed with an interactive refinement process.  They required a consensus among experts.  This is achievable.  Once they were employed they produced clinical outcome data.  We have used such protocols and outcome data to distribute the protocols to other institutions successfully – and those institutional results were identical to the results from the development site.

This can be done, though the limits are not yet defined.
Alan H. Morris, M.D.

From: "Swerlick, Robert A" <rswerli at EMORY.EDU<mailto:rswerli at EMORY.EDU>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, "Swerlick, Robert A" <rswerli at EMORY.EDU<mailto:rswerli at EMORY.EDU>>
Date: Saturday, February 6, 2016 at 09:00
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: [IMPROVEDX] Diagnostic Infrastructure

Dr. Samuel points out an inherent weakness with deployment of decision support tools. All these tools rely on moving decision making from one at a time and individual context specific decisions made by a given decision maker, to a rules based  process which can hopefully become semi-automatic. However, someone needs to make the rules and once the rules are made, there must be a process whereby the rules can be tweaked on an ongoing basis.

While I can’t state this with complete certainty, my sense is that the vast majority of guidelines currently generated are not data driven but more consensus driven. I know that the process of guideline generation within specialty societies I am active has a large political element as well. Commenting on guidelines within the specialty is contentious and not a transparent process. Opening this up to comments from outside the given specialty is not likely to happen especially when payment is involved.

Even for rules which are based upon relatively hard data, the development of rules can be incredibly contentious. For rules based upon expert opinion, these discussions become more like forays into preferences and “Taste”.    Feelings regarding practice patterns tend to generate the most passions when there is little actual data to support any given preference.

I too am hopeful but tempered by experience.

Bob Swerlick

From: Samuel, Rana [mailto:Rana.Samuel at VA.GOV]
Sent: Friday, February 05, 2016 2:21 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Diagnostic Infrastructure

There are so many ‘guidelines’ ‘position statements’ and ‘practice papers’ put out by multiple professional medical societies and organizations. The very fact of having multiple, often contradictory or  conflicting guidelines on the same area of practice indicates a problem with their derivation.  Many of these are not evidence based and are perpetuating positions that may negatively affect patient safety as well as drive up the cost of care. What mechanism exists to correct such ‘institutionalized error”?

There are several examples, but the one I dealt with most recently concerned a patient with liver disease and portal hypertension being referred to interventional radiology for a TIPS procedure. His INR was 1.7 and the radiologist refused to do the procedure unless the INR was below 1.5. Can’t blame the radiologist because the ACR (American College of Radiology) has a practice guideline that states the same thing.  So this poor patient (and millions more like him all over the country who undergo an invasive procedure with a minimally elevated INR) was transfused with 2 FFP, and his INR dropped to 1.6 (essentially unchanged). There are several problems with this situation:

1.  The INR is being used as a surrogate measure of bleeding risk, a job that it is not designed to do. The INR is only validated as a measure of the anticoagulant effect of warfarin. Several studies have shown a very poor correlation between the INR and the risk of bleeding (A patient with an INR of 3.5 may bleed while many patients with INRs of 5, 7, 9 or even > 10 never bleed).

2.  The INR is a calculated value derived from the Prothrombin Time (PT) which measures the time it takes for a patient’s blood to clot and compares that to the time it takes for blood from a normal person to clot.  If coagulation factor levels in blood fall below the minimum needed for clot formation the blood takes a longer time to clot, and the PT and therefore the INR increase. The PT tests in use today are much more sensitive than the ones in use a decade or more ago. For the older PT tests to register a change, coagulation factor values had to fall considerably before the PT started to rise, so even a small elevation in PT (and therefore in INR) reflected a hemostatically significant decrease in coagulation factor levels. An INR of 1.5 with these older tests indicated factor levels at around 50% of normal, which is roughly the minimum concentration of factor levels needed for normal clotting. With the newer, more sensitive PT tests an INR of 2 reflects minimum coagulation factor levels needed for normal coagulation.  Just as was the case with H.Pylori, this change has not yet made its way into popular practice (? The result of still working in silos with radiologists not talking to pathologists or other specialists as needed when writing guidelines??).

3.  Several studies have shown that transfusion of FFP is usually ineffective in normalizing a minimally elevated INR (ie an INR < 2). Interestingly, the INR of FFP itself can be 1.3 to 1.7!

All professional society guidelines should be posted on a website with a link via which any interested person can share updated knowledge that may require a revision or retraction of parts of the guideline, with all comments publically visible and open to rebuttal. We should not continue to select patients who will not benefit from FFP transfusion and then expose them to all the risks of FFP by transfusing them!

Can SIDM become the force that recommends and facilitates the above change?

Always hopeful,

Rana

Rana Samuel, MD, FCAP
Chief, Pathology and Laboratory Medicine Service (PALMS, 113)
Lead pathologist – VISN 2
VA western New York Healthcare System (VAWNYHS)
3495 Bailey Avenue, Buffalo, NY 14215
Ph:    716-862-8701
Fax:  716-862-7824
Rana.samuel at va.gov<mailto:Rana.samuel at va.gov>



From: Alan Morris [mailto:Alan.Morris at IMAIL.ORG]
Sent: Friday, February 05, 2016 10:54 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [EXTERNAL] Re: [IMPROVEDX] Diagnostic Infrastructure

Rob:
If by infrastructure you mean decision-support, then I agree.  If you mean education and the usual traditional means we have used, I think this will have little effect.  We just discussed a fatal case of plague in Medial grand Round.  There is no way to help clinicians, in the absence of an epidemic, to quickly diagnose plague.  It is too infrequent.  We could, however, introduce a rapid diagnostic test that might become routine, if it had a low enough false positive rate.

Decision support is the key to helping humans because of their limited cognitive ability.

Alan
Alan H. Morris, M.D.
Professor of Medicine
Adjunct Prof. of Medical Informatics
University of Utah

Medical Director, Urban Central Region Pulmonary Function Laboratories
Pulmonary/Critical Care Division
Sorenson Heart & Lung Center - 6th Floor
Intermountain Medical Center
5121 South Cottonwood Street
Murray, Utah  84157-7000, USA

Office Phone: 801-507-4603<tel:801-507-4603>
Mobile Phone: 801-718-1283<tel:801-718-1283>


From: Robert Bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Robert Bell <rmsbell200 at YAHOO.COM<mailto:rmsbell200 at YAHOO.COM>>
Date: Thursday, February 4, 2016 at 23:02
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: [IMPROVEDX] Diagnostic Infrastructure

Thanks Helene,

I had not thought of journalists. but they are so important. The AMA quotes each day in their daily sendings many newspapers. It seems as this is one of the main ways that medical information is spread.

Rob Bell



Sent from my iPad

On Feb 4, 2016, at 2:13 PM, HM Epstein <hmepstein at GMAIL.COM<mailto:hmepstein at GMAIL.COM>> wrote:
Robert:
Thank you for posting that link. It brings up an excellent point as well for freelance journalist like me. I often have to go to extreme measures to get copies of full studies. Most journalists don't bother which is why consumer press coverage of medical news is often limited to what the press release says. Those of us who like to dig a little deeper lose the ability to do so in a timely fashion in contrast to the echo chamber of most press outlets.

Now I'm going to check out #ICanHazPDF which the article refers to as an end run around pay walls.

Best,
Helene
--
hmepstein.com<http://hmepstein.com>
@hmepstein
Mobile: 914-522-2116

Sent from my iPhone



On Feb 4, 2016, at 3:36 PM, robert bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>> wrote:
To all on the list.

A friend kindly sent me this:  http://www.brookings.edu/blogs/techtank/posts/2016/01/11-open-access-scientific-knowledge

It seems that much of the information that we see is obtained from Open Access information not from closed source Scientific Journals. Wikipedia editors are 47 percent more likely to use Open Source Journals for their information.

Consequently, the the public and probably also physicians are not getting the very best scientific information in a timely way.

This brings up the issue of what I will call the Diagnostic Medical Infrastructure.

If the infrastructure is not sound, information is not being distributed in the best way to physicians and the public to focus on evidence based medicine, physicians are missing a “raised" PSA test when someone has had a prostatectomy, and a large percentage of radiologists are missing an image of a "Gorilla” on an X-ray, and also a thousand and one other problems, particularly in the communication area, that in turn all lead to error, how can we hope to successfully first tackle diagnostic errors?

If the current diagnostic error rate on all patients is say 30% would it not be better to get this figure down before focussing on improving diagnoses as a whole? It may be possible to tackle the standard errors and diagnostic errors together in some way but surely some of the standard errors have to be dealt with first to save lives and injury.

Triaging some of these problems, correcting/improving them, could quickly start reducing the current diagnostic errors.

Should we first be focussing on the Diagnostic Medical Infrastructure?

Should our focus first be on the best ways to save lives and stop patient injury?

Robert M. Bell, M.D.




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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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