[EXTERNAL] Re: [IMPROVEDX] Diagnosis gone awry: A flawed drug test could be sending thousands of innocent people to jail each year

Samuel, Rana Rana.Samuel at VA.GOV
Wed Jul 13 14:43:23 UTC 2016


Very well stated Liz! This is an issue I deal with multiple times each day, and is a major contributor to medical error and wasteful consumption of scarce healthcare resources (chasing down false positive results, or dealing with delays in diagnosis due to false negative results).

Can this society effectively interface with the Medical education system to ensure it leads to the development of an appropriate skill set in future doctors? Unfortunately Medical school training in Pathology often consists of hours of looking through a microscope at tissues but negligible, if any, time spent understanding how to evaluate lab tests for clinical validity and utility. While looking at a section of a heart that has undergone myocardial infarction may be interesting, that time could be better spent understanding the uses and limitations of Troponin tests for the diagnosis of MI.

I would be willing to bet that in this audience alone about half use Troponin but no longer use CK-MB for the diagnosis of MI, while the other half continue to use both.  The latter strategy adds cost with no added value, and may even have a net negative value as it will inevitably identify some patients who have normal levels of Troponin with elevated levels of  CK-MB, leading to a false positive rabbit chase!

While it is heartening that the latest IOM document on error recommends the use of multidisciplinary diagnostic teams, it would be great if this society could set up a workgroup to develop a practical curriculum on error prevention. Informed, evidence-based use of lab tests should be one of the modules in that curriculum.

Rana

From: Regan, Elizabeth [mailto:ReganE at NJHEALTH.ORG]
Sent: Tuesday, July 12, 2016 6:33 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: [EXTERNAL] Re: [IMPROVEDX] Diagnosis gone awry: A flawed drug test could be sending thousands of innocent people to jail each year

I agree that this story is not about medical diagnosis per se, but does raise some important issue around medical diagnosis.

With the trend to algorithms driving medical decision making – especially with mid-level providers, I believe that there is an inappropriate assumption that a test result is “positive” or “negative” and that this in turn drives a message to the patient that they do or do not have “disease X”.  This is fostered by specialists talking to primary care physicians and giving them shortcuts and diagnostic absolutes.

As discussed already, every test has a finite error rate at the level of performance (that we try to manage with QA procedures) and also has some reported association to the disease state – positive and negative predictive values.  The predictive power is derived from the sensitivity and specificity of the test in one or more populations.  (and it changes depending on the prevalence of disease in the population).  Bottom line – no test is perfect and every test results should be considered carefully in light of the situation and reliability of the test itself.  Some (actually most) tests cannot be used to “rule out” a diagnosis because few have perfect sensitivity.

I frequently hear patients and family members (and have been told myself) that because test A is negative – you do not have disease X.  If test A is positive in 70% of subject with disease X, a negative test is really not helpful for an individual patient.  The correct message is that we cannot be sure about whether the patient has Disease X based on that test – we only know that the test is negative and 30% of patients who truly had Disease X had a negative test.

It is really a problem for diagnostic error to not take those basic epidemiology facts into account when assessing test results.  In the NY Times article the consequences were wrongful imprisonment and major losses of life stability.  In our patients it may mean that they are sent out of the ER – told that they didn’t have a heart attack/strept infection/fracture – and may have a bad outcome, because the judgement was made on the negative test result – not the whole picture.  The doctor who doesn’t see the potential for a test to be wrong – doesn’t hedge his/her discussion with the patient and emphasize the need to watch for symptoms and return.

I would argue that there is far too much reliance on test results as an absolute.  I think it is done in part because providers don’t understand the science of testing and partly to fit into algorithms.  I also think that just like for the police – it meets a need.   That need is to move patients through the system at the cost of diagnostic accuracy.

Liz

From: HM Epstein <hmepstein at GMAIL.COM<mailto:hmepstein at GMAIL.COM>>
Reply-To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, HM Epstein <hmepstein at GMAIL.COM<mailto:hmepstein at GMAIL.COM>>
Date: Tuesday, July 12, 2016 at 1:53 PM
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] Diagnosis gone awry: A flawed drug test could be sending thousands of innocent people to jail each year

Thanks for sharing that, Mark.

This is a hot button for me, since before I focused on diagnostic error, I wrote about the issues and risks families face when children are accused of breaking alcohol consumption laws.

These often faulty field tests go hand in glove with the tests done on potentially impaired drivers which don't test for current intoxication but test instead for signs of drug use that could be as old as two weeks or more. The statistics around alcohol and drug use and driving are often based on outmoded and coerced urine and blood tests.

Once in the system, the arrested person rarely has access to knowledgeable counsel, just like the woman in the article. Pro-publica also did an exhaustive investigative review of how often people are arrested and falsely accused who then lose their automobiles - even if they are found not guilty - which are sold by the arresting police precinct or its municipality. Those proceeds go for new gear for the precinct or for overtime pay so the police officers can then stop more drivers and accuse them of driving under the influence. There's a lot more but it is off topic for this thread.

Best,
Helene


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

Sent from my iPhone



On Jul 12, 2016, at 2:09 PM, Mark Graber <graber.mark at GMAIL.COM<mailto:graber.mark at gmail.com>> wrote:
This is a disturbing article in this week’s NY Times magazine on the roadside tests police use to detect narcotics.  People are being jailed for narcotics possession based on tests that have high, and unknown, rates of false positive results.

http://tinyurl.com/zhqm44o

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