Saturday, 21 January 2017

Dangerous charlatanry? Why not automate it…

Another interesting recent article on the BBC about thedangers of NHS trusts using referral services to review GP referrals with the intention of delaying or blocking treatment to save money. Although not this specific process, I do have painful first-hand experience of a GP referral being delayed without proper clinical evaluation.
About six years ago, during the events that led to my CKD diagnosis, I suffered a bout of severe back pain. I went to my GPs who prescribed medication, wrote me a referral to the local NHS back clinic and recommended I try their resident (private) osteopath. I took my medication, I saw the osteopath who provided a little relief but couldn’t work miracles, and I waited for the back clinic appointment.
A few weeks later I got a letter back from someone, their job title was something like ‘Senior Physical Therapist’, saying they’d reviewed the referral and decided I wasn’t worth an appointment at this time, but I’d be put on some kind of pre-waiting list for a place on the official waiting list (which I think was some sort of wheeze to game the genuine waiting list target). This ‘senior’ healthcare professional had basically read the referral from the GP and overrode his decision (which was based on clinical evidence) without examining me or even making any attempt to discuss my clinical symptoms.
During this time my back got much worse, Tramadol, Gabapentin and Diclofenac could only take the edge off. I was hunched over like an old man, I couldn’t walk properly, I couldn’t sit properly, I had to sleep on the floor. If it wasn’t for the fact that I was able to work from home I’d have been signed off sick for a prolonged period (I worked sprawled out on the lounge floor). Due to the lack of activity my weight ballooned by 15 kilos, the consequences of which are still with me today.
I went back to the GPs, I saw the other partner, who read the referral by his colleague, read the half-baked response and assessed the consequences to me which were now well past the point of medication or basic physical therapy. He asked me if I had medial insurance, I did, he wrote a referral to a private consultant, a couple of days later I had an appointment (handily he did a satellite clinic nearby), a couple of days after that I had an MRI which showed I had two bulging discs pressing on my sciatic nerve. About a week after the private referral I had a short procedure to inject cortico-steroid into my spine and the improvement was rapid.
A month or so later I did actually make it onto the waiting list for the NHS back clinic, but by this time the worst was over, my private health insurance had dealt with the acute problem. So instead of being an assessment to treat the acute problem I eventually ended up with a course of physical therapy designed to help me recover from it. Don’t get me wrong, I am grateful for that physical therapy, it taught me long-term techniques for strengthening and protecting my back which are very useful whenever I have any twinges. But the issue remains that without private healthcare I would have been left to rot in crippling agony due to a non-evidence based pseudo-scientific approach from a so-claimed health professional. So that’s how I know it’s dangerous to delay or veto referrals from without clinical assessment. It may save some money, if the patient is lucky enough to go private, or if more likely, they are unlucky and they simply die (being dead is a quick way of cutting healthcare costs).
Now I quite clearly believe the NHS shouldn’t be using dodgy processes like this, but if it’s going to use them in the name of efficiency, there are cheaper and more efficient ways. Working in Business Intelligence I know tools and techniques which could automate the assessment of referrals. These processes are not based on the first hand clinical evidence (that’s the GP consultation), they are based on textual analysis of what the GP wrote, which is something quite different.
With just a little up front involvement from the sort of healthcare ‘professionals’ currently reviewing referrals algorithms could be developed to recognise the patterns that delay treatment and the patterns that progress it. Plug those algorithms into a text mining data science tool like RapidMiner and you have a cheap way of assessing thousands of referrals an hour. Sure, from a clinical perspective it’s just as dangerous and pseudo-scientific as the current referral review process but it’s much cheaper, more consistent and also more objective as a computer doesn’t care for such things as ethnicity, religion or personal persuasions.
So my question is if the NHS is going to use dangerous processes to be ‘more efficient’ and to ‘save money’ why not race straight to the bottom and go with outright automation? With my kind of solution the NHS could do away with most of the costs of the healthcare 'professionals' currently rejecting referrals and instead spend that money on productive treatment. It won’t help the people who need treatment who get their referrals rejected on dodgy grounds, but at least the money currently siphoned off to these charlatans could be used so less referrals get rejected overall?

Sunday, 15 January 2017

Fitness trackers and DNA testing

I was intrigued by a recent article on the BBC website about the efficacy of fitness trackers. I’ve been wearing a fitness tracker for about six months now and I’m pretty convinced about its benefits, it’s not that I think it’s some sort of a miraculous panacea, but I find it very useful for encouraging me to keep active. I keep track of my step count each day and if I haven’t been active enough I make an effort to put in a bit extra, or if I fall short one day I try to catch up the next. I also use it to log changes in my weight each week and to keep an eye on how much sleep I’m getting.
It is true that the majority of my weight loss in the last twelve months came before I started wearing a fitbit, but it would be wrong to take that as evidence that not wearing one is more effective that wearing one. I lost more weight at the start because at my starting point I was heavier and my overall fitness was lower, by the time I started wearing one I’d already significantly improved my basic fitness (from a very poor base line) and incremental improvements where always going to be more challenging. To go from homeworking most days to commuting was a step change in activity, but I can only walk to the office once in a morning, and back to the station once in the afternoon and I only get one lunchbreak to take a walk. So there are practical, physical restrictions on the scope for exercise, if not the effectiveness. What the fitbit has done is supported my ongoing progress, helping me to avoid slipping backwards.
One thing in the BBC article that did get my attention is the idea of genetic testing to aid weight loss. I’ve long had a suspicion that there are insights into my diet that could unlock more effective weight loss strategies, at least beyond the usual boiler plate of eat more rabbit more and do more exercise (not that such generic prescriptions are worthless, they’re just very limited). I like the idea of customised dieting advice based on scientific evidence; it’s a bugbear of mine that the various NHS practitioners I regularly come into contact with hassle me to lose weight, but without ever offering any practical, customised support. I don’t hold it against them, I understand resources are tight, but the official Government driven approach appears to be all stick i.e. sugar taxes and treatment rationing (including rationing based on pseudoscience like BMI), and no carrot i.e. making customised nutritional advice more readily available to obese people like myself. I can’t help but feel that the official approach to obesity related health could be more cost effective long-term with a bit more investment and focus short-term.
I’m seriously considering paying for a service like the one offered by DNAFit, I just need to find the one that will offer me the most useful benefit for the fee. What I really want is some customised guidance around what food/nutrition I should avoid and what I should favour. I’m not really interested in the “value added” parts of the products (value added being business speak for boosting profit margins by selling lower value bolt-on products at a price that suggests they are actually high value products); I don’t want recipe books, eating plans or exercise plans, I can work things like that out based on my own preferences once I have the underlying nutritional insight. Nor do I want to be flogged ongoing fitness services or be benchmarked against Olympic athletes, or any of the stuff that probably delivers the most profitable customers.
I’m really just looking for a company that will offer basic but comprehensive diet testing. I’m sure all the “value added” stuff might be useful if I was a fitness nut, or even if I was still playing organised sport like I was ten years ago, but these days it’s simply about being healthy and getting my weight down to 100kg.  But most importantly I want anonymity, whatever my test results are they need to be completely confidential. I don’t want them shared without me choosing to do so proactively, nor do I want the risk of being required to disclose them to some third party (such as an insurance company) at a later date simply because they exist. I know there are pretty good data protection laws in the UK, but that doesn’t mean a company cannot be hacked, nor does it prevent a situation where one day I’m legally coerced into sharing them. Ideally, I’d like the process to be completely anonymous, with my sample and the records from it destroyed within a sensible time frame.
I think I have some research to do, but this blog post lookslike a useful start

Saturday, 14 January 2017

Target hit, well sort of…

I had my Consultant appointment on Tuesday, and by some strange fluke I managed to weigh in at 111.2kg, which was a bit of a surprise as I’ve been pretty consistently weighing in between 112kg and 113kg in recent weeks. I’m pretty certain that 112kg to 113kg is my current stable weight range, so I’ve created a bit of a rod for my own back, when I go back in four months I’m going to need to be under 110kg, which means a loss of at least 3kgs, and that’s not helped by me being a bit naughty ever since Tuesday!
On the positive side my Consultant is happy with my progress, she says my stats are strengthening and showing definite improvement with the weight loss and the medication regime. The closer I get to the ultimate target of 100kg the more time I’m giving myself before I end up on dialysis and the transplant list. I’ve also been free of gout attacks for a long time now, which is a very physical sign of improvement.