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At my annual physical exam last week, my primary care doctor employed a widely used web-based calculator to plug in cholesterol levels and other risk factors to estimate my likelihood of having a heart attack during the next ten years. I thought this was a neat idea until it produced an answer of 8%.
Wait, you mean I have a one in twelve risk of a heart attack over the next decade? That sounded really high. She calmly and thoughtfully explained that the main value of the algorithm was to help make a judgment about prescribing statins or other interventions that could lower risk. She also noted that anything under 10% at my age was a very good number.
So, I was going to write this post to tell this story and to make the point that these kinds of estimates can be shocking for the uninformed unless we have a context within which to interpret them.
I was also going to assert that the estimates give an impression of precision that may not be valid. What is the standard deviation around the estimate? How often is the actual estimate found to be true?
And, then, like a deus ex machina, the New York Times published this story about the very heart risk calculator that we had been using. The pertinent excerpt:
A new study finds that a widely used version of the ubiquitous heart attack risk calculator is flawed, misclassifying 15 percent of patients who would use it — almost six million Americans, of whom almost four million are inappropriately shifted into higher-risk groups that are more likely to be treated with medication.
Wow. So I revert to my doctor’s excellent advice about diet, exercise, and other life style factors as the main things on which to focus over the next ten years.
Paul Levy is the President and CEO of Beth Israel Deconess Medical Center in Boston. Paul recently became the focus of much media attention when he decided to publish infection rates at his hospital, despite the fact that under Massachusetts law he is not yet required to do so. For the past three years he has blogged about his experiences in an online journal, Running a Hospital, one of the few blogs we know of maintained by a senior hospital executive.
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We have got to get more efficient about this if we are going to reduce waste and error in our medical system This is likely going to require the establishment of incentives, both positive and negative, to meaningfully affect physician behavior. I really liked it and this information is worth remembering.
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A wonderful opportunity to challenge assumptions! The flawed calculator is disconcerting, but not unprecedented. Regulation is imperfect (hello, salmonella?!) and medical devices are created to make profit — this is more context for Mr Levy and any of us in his position.
Much as I appreciate the comments about the algorithm I especially appreciate the comments based in medicine. Why WOULDN’T the author’s rate of cardiac event be elevated? And why wouldn’t subsequent clinical decisions be made by both patient and doctor in collaboration?
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Much to do about nothing here. The thesis here is that some doc is going to use the simplified formula to decide whether or not you’re going to get a statin. But statins have not been shown to be useful in primary prevention. And the high risk patients ( diabetics, previous cardiovascular event ) are already taking a statin. So, really the worse result of a slightly higher percentage is that the doc might ask you to lose a little more weight, or be more aggressive in treating to target.
That is scary. Imagine how many uninformed people took the advice of their doctor and went on statins based on this flawed method! Thanks for sharing, everyone needs to hear this!
I am amazed by the manner in which unvalidated diagnostics become relied-upon physicians tools. The only thing more frustrating is that physicians, on average, so slowly move to discard these tools when they are proven inaccurate/unhelpful. It is estimated that newly documented best practices take somewhere between 7-15 years from the time they are first published in a reputable journal such as NEJM to the time they trickle down broadly throughout American physician practices. We have got to get more efficient about this if we are going to reduce waste and error in our medical system This is likely going to require the establishment of incentives, both positive and negative, to meaningfully affect physician behavior.
It just goes to show. Illusion is not reality. If they tested HIT devices and CPOE devices and accurately recorded all adverse events from the attendant delays in care and “lost and hidden” data, and the intrinsic flaws and defects of the devices, similar “shocking” results are likely.
I can not believe that the leadership of this country, partnering with HIT vendors and hospital executives, are spending $ billions on devices that have no methodological proof of safety and efficacy on overall care of the patients, aka government guinea pigs. If you take away the work arounds, unexpected death will be widespread. Go test it and prove this wrong.
Just dashed the plans of a number of PMR developers who were using the web app to factor lab results and history into generating a product which would report with micrometer precision whether you were going to die today.