Wednesday, April 13, 2011


Numbers. Lots and lots of numbers.

Increasingly, we are seeing the way numbers are used to direct patient care:
  • Need a defibrillator? Check their ejection fraction.
  • Have diabetes? What's their glucose level?
  • Need a cholesterol-lowering medication? What's their LDL?
  • Are you a good doctor? What's your patient satisfaction score?
  • Are you using the computer in a meaningful way? Please, count the numbers.
Even some insurers have recently begun promoting "health in numbers" on big, splashy, television advertisements and on their self-promotional websites.
As if everything in medicine is linear, predictable, mathematical.

I recently saw a patient urgently because his ejection fraction number had declined and the patient who had a pacemaker implanted about 2 years ago felt fatigued. Sure enough, his number had declined from 0.56 on an echocardiogram to 0.40 on a nuclear scan. The referring doctor was concerned and thought he might benefit from upgrading his pacemaker to a more sophisticated biventricular pacemaker. Certainly, this might be a very appropriate referral. But the patient had a little caveat mentioned on the nuclear scan next to the 0.40 number and it said this: "This value might be an underestimation." Why? Because the patient was not in sinus rhythm at the time the study was performed. In fact, he's never been in sinus rhythm for years.

But the comment was not a number. Therefore, it never registered on a computer that tracks these numbers, nor entered the referring doctor's mind. Comments are like that - poorly quantifiable but remarkably important - numbers are not. Numbers are linear, predictable, unflinching, and some might say, wholey accurate.

Except when they're not.

All of us have seen numbers following blood tests that are "lab-omas" - lab values that make no sense when viewed with other numbers next to them and when related to clinical circumstances. Those labs are repeated and, more often than not, return very different than before. Or consider the automatic blood pressure cuffs and telemetry monitor that often give faulty "numbers."

So what gives? Shouldn't numbers be infallible and uniformly reliable?

Of course not.

Numbers are one piece of the grand puzzle called medicine. Numbers certainly can help us, spotting trends and quantifying, but they almost never conclude. For instance, a very high white count might be so for very different reasons: like pneumonia, leukemia, or steroids. Each of these medical problems demands a very different clinical approach irrespective of what might be the same elevated number.

But the message is everywhere. At home. In the hospitals. On Capitol Hill. Numbers are king. We're all about numbers. Especially in advertisements to doctors and patients via TV ads, drug reps, and hospital administrators. Numbers for cholesterol, one's prostate, ejection fraction, HbA1C, quality scores, numbers of procedures, duration of erections, and now, insurance 78,000 employees managing 70 million people. Numbers, you see, will help us save billions of other numbers, we are told.

Too bad no one talks about the numbers spent on the collection of all of these numbers that are used to justify the other numbers in health care.

That, you see, would be a VERY big number.


1 comment:

Anonymous said...

Nice post.
On another note, any comment about the recent NYT article with respect to Biotronik & Las Vegas.
Interesting news & reporting. Not defending reported allegations!, but this reporter seems to have an axe to grind in the ICD world