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
  • 1/5/2017 8:21:01 AM
NO RATINGS

I'm not arguing for assisted suicide here but I don't think treatment is always about money.  I know people who could afford the treatment but didn't have the appetite for months of pain and sickness through a treatment that might not extend their lifespan at all.  Quality of life comes into play and what is an acceptable level of quality will vary from person to person.  I would prefer that we let individuals determine what they think they can handle and if they think treatment is going to worth it but I'm sure self preservation really kicks in for some people and they would insist on every treatment available even though chances of survival are statically zero.

 

 

Re: Sickening future
  • 1/4/2017 6:46:15 PM
NO RATINGS

@PC Indeed, I know of people who would even do that for their pets. Consider, you have a mutt for 6 years that you've come to love, and he needs an operation that will cost you $2,500. If it were purely a question of economics, you could say, I an buy a new mutt for less than $500, so it's more economical to let him die or have him euthanized. But most pet owners would shell out for the operation (unless they are told it will cause the dog undue suffering). Now with people, it would be completely callous to say, save your money, and let your kid die because you always have or adopt another one for far less money. 

One of my cousins had a baby born at about 25 weeks. She was in the NICU for many months, and I have no doubt that the bill topped 6 figures. But what kind of society woudl demand that the baby not receive care and just be allowed to die? She has now been released and is doing well, from what I've been told. I know of another family who had a child born that prematurely. He had to be in special ed classes his whole life, though he is pretty high function. So would we say, he should have been allowed to die to save on costs all around? That is the beginning of the path toward fostering a superior race and weeding out those whose lives we value less -- shade of Nazi ideology there.

Re: Need a human
  • 1/4/2017 6:22:29 PM
NO RATINGS

@tomsg - Agreed. The question is who has the dominant voice - the family, the physicians or the medical/health insurers (who control claim reimbursements and payments for medicines and surgery)? In most cases, I am guessing the family has the dominant voice, but I am also assuming that the physicians and providers are totally transparent regarding the options available. In total agreement that the software should only point but not decide.

Need a human
  • 1/4/2017 5:55:03 PM
NO RATINGS

I think that while the software provides valuable input, you still need a human in the equation. Matters like these will vary person by person, so the averages may not be the est guide.

Re: Sickening future
  • 1/4/2017 4:45:09 PM
NO RATINGS

@SaneIT, so noted! What has pleasantly surprised me thus far has been the responses posted. Analytics professionals who typically are dispassionate on most topics are expressing the conflict between the human aspect and the need for making valid and reliable decision support tools.

Re: Sickening future
  • 1/4/2017 3:46:12 PM
NO RATINGS

@SaneIT

Some medical treatments are so expensive, and so fruitless; that if I were a candidate for one myself I would pass.

My Aunt was offered some of these treatments. After careful consideration, she declined and went home to spend her last months peacefully with her family. She might have lived a bit longer with more treatment, but it would have basically taken the life she had. She didn't think it was worth it.

Re: Sickening future
  • 1/4/2017 3:40:07 PM
NO RATINGS

@Ariella

If one owns a car that requires an expensive repair, it's only natural to think of the car's remaining useful life. Is it worth $2500 to fix the air conditioning in a old car that's only worth $2000 after it's fully working? Probably not. But the same repair for a relatively young $40,000 sports car, is well worth doing.

We generally don't think of people in this way. With people that we know and love, it is not difficult to avoid thinking this way.

 

Re: Sickening future
  • 1/4/2017 2:11:51 PM
NO RATINGS

@bkbeverly, this is a very deep issue and I think a lot of us have trouble removing emotional responses from those business decisions.  In a perfect post scarcity world where we would save everyone that we could possibly save from every disease/injury.  The line drawn to determine the ethical duty to save an individual is not only grey it will shift greatly due to more than just the dollars required for treatment.  $200 in NYC versus $200 in rural Kentucky will mean different things as well. 

 

Re: Sickening future
  • 1/4/2017 2:05:19 PM
NO RATINGS

..

Ariella writes that


... there 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.


 

It's important to understand that Britain's National Health Service once represented perhaps the world's best public health system among countries with capitalist economies. In his documentary film Sicko Michael Moore even focused on it as an example of what a good national health service could offer.

But rising conservative political forces, including within the leftist Labour Party, have systematically underfunded the NHS and slashed services and quality. This process has accelerated with the Conservative Cameron (and now May) regime. Some measure of public concern can be gauged from the fact that a de facto protest against the cutbacks, and in celebration of the NHS, was staged as one of the main performances in the 2012 Olympics in London.

..

Re: Sickening future
  • 1/4/2017 12:23:00 PM
NO RATINGS

@bkbeverly they're not rich. The only breadwinner now works as an administrator in a university. I'm sure that this is eating up all that they may have saved for retirement. But some people think that you just can't put a price tag on certain things -- and keeping a family member alive and as comfortable as possible woudl be one of them. When people make the decision to let someone die, I doubt they admit that money enters into it. That was the point I was making when I referenced my friend's nurse's training. The medical professionals there really believe it's not worth keeping a person alive in that state. This seeps into different atttitudes you also encounter in hospitals when the patient is young versus when the patient is old. When my son had surgery a few years ago, they kept referencing, "for a young person..." While that was meant to be reassuring, I couldn't help thinking of the flip side: for an older person they would see less of a payoff because the person would naturally have fewer years to live. My husband who enjoys reading books by doctors says that is indeed the case: they are far more motivated for a person who has a natural lifespan of another 50 plus years than for someone who is already past 70.

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