Can Critical Care Analytics Overcome Ethics Concerns?


In the 1990s, I worked for a company named APACHE Medical Systems. (It is now named APACHE Outcomes.) APACHE was an acronym for Acute Physiology and Chronic Health Evaluation. This tool was designed to measure the severity of disease for adult patients admitted to intensive care units. In effect, we developed systems designed to predict the clinical outcomes for ICU patients. The software was a decision support package that gave health care providers and financers risk-adjusted predictive analytics on mortality, length of stay, the amount of resources needed to sustain life, etc. The premise was that by using patient data based on ICU health status, then families, physicians and insurers would have an idea of whether continuing treatment of the ICU patient would result in a viable-life outcome.

(Image: ESB Professional/Shutterstock)

(Image: ESB Professional/Shutterstock)

The unique thing about this system was that it was like a prism; what you thought of it depended on the angle from which you examined it. From the perspective of a developer, this was a great piece of software. You input patient demographic information, severity of injury and physiological measurements and you get a pretty reliable statistical result of what the clinical outcome would be. From the perspective of a shock trauma nurse or surgeon, the software helped you to design the best treatment of care with a minimum amount of information needed, in the shortest period of time. From the perspective of the insurers, it allowed one to know the whether the costs of sustaining the patient would result in the benefit of recovery. Without a question, this was a great piece of critical care software; this was applied analytics at its best.

But let's think about this from another perspective -- it is your loved one that is the object of critical care analysis. There is an algorithm in the background informing opinions on whether efforts should be exerted to save your loved one's life. Let's consider the following scenario:

Your 84-year-old diabetic mother was driving when her glucose level dropped. She passed out and drove into a tree. You arrive at the hospital, contact her primary physician and give the attending physician her background information. Your family history detail states late-onset diabetes in prior generations with an average life expectancy of 86 years. Her blood test shows a low white blood cell count, which might be a viral infection or acute leukemia. The nurse has entered all of the information into the critical care analytics system so that the attending physician can recommend recovery, palliative or hospice care. The question in your mind is "Will they do enough?"

The question in the mind of the health care providers is "Are we doing what is right?"

The questions in the mind of the insurer are "Are they doing more than what is necessary? Will the patient have an unreasonable length of stay? Do we have to reimburse every line item used in this episode of care?"

With this being your personal scenario, the 'cool factor' of the software is overshadowed by the fact that a human life depends on the precision of the calculations and the accurate interpretation of the results. The public popularity of the software is dwarfed by the fact that the work for which someone received a 'Good Job Award' may lead to a decision to end the life of your mom. Your impartial and dispassionate use of analytics will be forgotten when you are told that choices about your mom's care will be based on a regression model that you neither designed nor tested. In that moment, your profession just got real.

So in that light:

  • Are you willing to trust software developed by an analytics peer unknown to you?
  • Does having a personal stake in a patient's outcome make it easier or harder for you to be an advocate for critical care analytics?
  • Should software be used as a decision support tool in matters of life and death?

Please share your thoughts.

Bryan Beverly, Statistician, Bureau of Labor Statistics

Bryan K. Beverly is from Baltimore. He has a BA in sociology from Morgan State University and an MAS degree in IT management from Johns Hopkins University. His continuing education consists of project management training through the ESI International/George Washington University programs. He began his career in 1984, the same year he was introduced to SAS software. Over the course of nearly 30 years, he has used SAS for data processing, analytics, report generation, and application development on mainframes, mini-computers, and PCs. Bryan has worked in the private sector, public sector, and academia in the Baltimore/Washington region. His work initially focused on programming, but over the years has expanded into project management and business development. Bryan has participated in in-house SAS user groups and SAS user group conferences, and has published in SAS newsletters, as well as company-based newsletters. Over time, his publications have expanded from providing SAS technical tips to examining the sociological, philosophical, financial, and political contexts in which IT is deployed. He believes that the key to a successful IT career is to maintain your skills and think like the person who signs your paycheck.

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Re: Sickening future
  • 1/4/2017 12:15:04 PM
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@Ariella, so it sounds like for that family, money was not an object. In that case, love is all that matters. That family is very fortunate. However, in most other cases, there are financial caps. Hence you have to use quality of life to justify spending. Hence when you have unlimited love but limited health care financing, that's when the heart breaking decisions have to be made.

Re: Sickening future
  • 1/4/2017 11:03:51 AM
NO RATINGS

@bkbeverly I recall that over 25 years ago when a friend of mine was training to become a nurse, she said that the official direction was to push people to consider "quality of life" and not request extended life support. In that case, they really seemed to believe that it was not just a drain of resources but that life like that is not worth sustaining. It's a tough question, really.

A woman in my neighborhood developed something like ALS, though doctors didn't diagnose it as such exactly. She had been an energetic person, attending the gym regularly and entertaining regularly. She first became ill about 4 or 5 years ago. Then she became weaker and weaker. For the past couple of years, she has been unable to walk. It also takes a great effort to transport her, as she needs to be connected to oxygen. The costs must be very high as the she has two nurses for round-the-clock care, and at least one of them is not covered by insurance at all. Yet her family considers her life worthwhile, and her children and grandchildren (most are not that far away) visit her all the time.

Re: Sickening future
  • 1/4/2017 10:57:11 AM
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@bkbeverly theere are even more questions when you have taxpayers footing the bill for everyone's healthcare, as in the case of the NHS in the UK and socialized medicine in Canada. In the former, there tends to be shortage of hospital beds and major waits for just about all surgical procedures. As for Canada, I have no doubt that the economics of the situation is behind the legalization of assisted suicide. Terminally ill patients would be a major drain on the halthcare system.

Re: Sickening future
  • 1/4/2017 7:22:01 AM
NO RATINGS

@TS - I agree with you. However in the interests of 'stirring the idea pot' a little, please consider this. If you look through my posts, you will see a piece on The Value of a Statistical Life. The VSL methodology is often used to determine how much a community is willing to spend in new taxes to prevent or eliminate a problem. For example, if tax payers are willing to pay $200 more per person in taxes for abestos removal in a building they want the mayor to sell, in the hope that the additional taxes will reduce the number of deaths by one person, then that puts a dollar figure on how much that community believes each person is worth statistically. While I fully agree with you about the morals of the insurers, I wonder in a broader sense, don't we make the same judgments as tax payers when we say that we will give $200 more per year to reduce cancer deaths attributed to abestos, but not $300? If we ask our municipal executives to settle wrongful death suits because it is less of a tax burden to do that than to spend ten times as much to eliminate the problem, then in that sense, don't we share he same value system as the insurers? If an insurance company says that it will lose money to sustain the life of an elderly person in an ICU, who has a 10% chance of survival - and if we say that we don't want to increase our tax burden more than $200 this year to keep one less person from getting cancer from asbestos in an old building that we want to sell to a company that will bring new jobs to our community, then aren't the value systems/moral foundations/ethical frameworks the same?

Re: Sickening future
  • 1/4/2017 5:55:19 AM
NO RATINGS

You bet, Bryan... it's the insurers, who want to quantify and cost out everything from an aspirin to a CAT scan. We were reminded with the healthcare overhaul how many parts of the system are broken and craven, but these folks lead the pack, in my opinion.

Re: Sickening future
  • 1/4/2017 3:57:01 AM
NO RATINGS

..

Especially when issues of life or death, life quality, and the well-being or even survival of loved ones are involved, the separate motivations and interests of medical practitioners and those close to the patient are complicated enough. Adding the interests of profit-oriented private insurance companies into this mix would seem to make the situation even more difficult. 

That said, the analytics approach Brian describes would appear to be helpful, at least for rational medical decisionmaking.

..

Re: Sickening future
  • 1/4/2017 2:08:13 AM
NO RATINGS

@TS, Would you mind elaborating a little please? Whose morals would you deem as suspect - the physicians or the insurers?

Sickening future
  • 1/3/2017 11:21:05 PM
NO RATINGS

It's all elegance and efficiency and savings galore til we insert personal details into the equation -- living, breathing humans, not pallets of merchandise or commodities being shipped around. The calculations at work in this equation may be statstically sound; they are also morally suspect.

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