What Diagnosis?

Share | In the early nineteen sixties Larry Weed promoted the problem oriented medical record (POMR) in order to focus physicians on all of a patient's problems rather than focusing mainly on the chief complaint. No doubt the problem oriented approach was a systems improvement resulting in an improvement in medical care. Indexing all of the problems on a list with dates and resolutions made better sense of the patient record. The POMR was widely accepted but usually implemented in a mixture of the traditional source oriented medical record and the system promoted by Larry Weed. A medical school may title the teaching as POMR and then proceed to teach source oriented history taking with a chief complaint and a problem list.

Some complain that the POMR tends to focus on treating problems whilst ignoring diagnosis. Indeed, medical records and reimbursement documents force a qualifying diagnosis, but anyone wrestling with the ICDA diagnostic codes knows that a diagnosis can be written at various levels, four digits or five digits. For example are we treating cough, community acquired pneumonia or pneumonia due to a specific organism? The list is  long and reflects historical diagnoses based on gross findings. A physical diagnosis without regard to the bio-molecular underpinnings may be based on the problem list. For example: gastritis, hypertension, pneumonia, colitis, arthritis, arrhythmia, etc. 

The qualifying diagnosis for the guidelines may not accurately reflect the true underlying condition.

GBD omissions

Share | What about TB and Malaria? Christopher Dye and Mario Raviglione point out that GBD did not include TB. They call for a broader range of disease determinants for future studies.[1] One might also point out the omission of Malaria. TB and Malaria are the two most widespread and lethal diseases. TB especially could once again take hold in the US due to the concurrence of HIV and the emergence of TDR-TB, totally drug resistant organisms.

"This proposal goes beyond TB: for many causes of ill health, an unidentified risk is a missed opportunity."
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Nature 502, 10 Oct 2013 Perspective, Weigh all TB Risks, Tuberculosis Outlook, S 13

Lim, s. s. et al Lancet 380, 2224-2260 (2012)

Global Burden of Disease (GBD) ranking

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JAMA published a seminal investigation documenting the Health of America compared to other developed countries broken down by disease, risk factors, morbidity and mortality. The massive undertaking involved hundreds of collaborators in thirty-four countries and some highly sophisticated statistics comparing the burden of disease. The report here includes the developed countries participating in the Organization for Economic Co-operation and Development.  The State of US Health, 1990-2010, Burden of Disease, Injuries and Risk Factors appears in the August 14 issue of JAMA.[1] If you have any interest in the shortcomings of our health care system or the health of our own human resource, you should read this landmark study.

Harvey Fienberg’s editorial on page 585 observes the decline in the US standing among developed nations.  Herein, “results for the United States are presented in detail for the first time.”  The statistics utilized in the study were extremely complex and all inclusive. However, Fienberg points out the fact that socioeconomic s was not included as a risk factor in this study.  The collaborators agree. The difficulty was in equating socioeconomics across the many cultures in the thirty-four nations that took part in this study. The editorial further reminds us of the well-established fact that socioeconomic status relates strongly with mortality[2] Fienberg further observes that the assessment for the US as a whole does not account for significant regional differences. On the plus side, the editorial suggests that the framework for assessing the burden of disease is scalable and applicable to states, counties and municipalities.[3]
The statistical terms used in this study include:  Years of Life Lost due to premature mortality (YLL), Years Lived with Disability (YLD), Disability Adjusted Life Years (DALY), which combines YLL and YLD and, Healthy Life Expectancy (HALE). The article compares these attributes in the thirty-four countries between 1990 and 2010. This monumental study goes beyond all previous reports by including risk factors for disease. In 2010 in the US the big eight YLL were in order: Ischemic heart disease, lung cancer, stroke, COPD, road injury, self-harm, diabetes and cirrhosis. The first eight YLD, however, were:  Low back pain, major depression, other musculo-skeletal, neck pain, anxiety disorder, COPD, disorders resulting from drug use, and diabetes.

The diseases causing premature mortality, YLL, differed dramatically from those causing morbidity and disability, YLD. However, the risk factors underlying the leading causes for both YLL and YLD diseases were almost the same. The list of risk factors included: Dietary, tobacco, HBP, high BMI, physical inactivity, high serum glucose, ambient particulate pollution, alcohol, drug use and high cholesterol.

The figure 4 illustration on page 604 reflects the US’s low YLL ranking compared with the thirty three other countries. The US is 7th from the bottom following the Check Republic and Chile in overall ranking. Our ranking by the raw longevity score, infant mortality and perinatal mortality reported elsewhere[4] are even worse.[5] The US comes in 38th in both longevity and infant mortality. The perinatal mortality rates are even worse.[6]

Figure 4.

Rank of Age-Standardized YLL Rates Relative to the 34 OECD Countries in 2010
Numbers in cells indicate the ranks of each country for each cause, with 1 representing the best-performing country. Countries are sorted on the basis of age-standardized all-cause years of life lost (YLLs) for 2010. Diseases and injuries contributing to YLLs are ordered by the difference between the US rate and the lowest rate in the Organization for Economic Co-operation and Development (OECD) countries for each cause. Colors indicate whether the age-standardized YLL rate for the country is significantly lower (green), indistinguishable (yellow), or higher (red) from the mean age-standardized YLL rate across the OECD countries. HIV indicates human immunodeficiency virus.[7]

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[1] JAMA,2013;310(6):591-608. Doi:10.1001/jama.2013.13805
     Lim, S. S. et al Lancet 380, 2224-2260 (2012)
[2] National Research Council; Institute of Medicine. US Health in International Perspective: Shorter Lives Poorer Health. National Academies Press; 2013
[3] Katz B. Bradley J. the Metropolitan Revolution. Brookings Institution; 2013
[4]  http://www.enagic.com/enagic_life.php
[5] http://data.worldbank.org/indicator/SP.DYN.IMRT.IN
[6] http://whqlibdoc.who.int/publications/2006/9241563206_eng.pdf
[7] Figure 4 reproduced with permission JAMA RightsLink and Copyright Clearance Center Aug 14 JAMA, Christopher Murray et al; Copyright © 2013, American Medical Association

 

Virus vs Bacterial Respiratory Infection

Share |Science Translational Medicine reports an RT-PCR that can distinguish a viral pneumonia from a bacterial pneumonia. Christopher Woods and Geoffrey Ginsburg at Duke claim that the assay monitors  human genes that react differently to viral disease than to a bacterial infection. 
Based on a trial of 102 patients with fever and respiratory symptoms, the test showed 94 percent sensitivity and 89 percent specificity.
PCR might be an expensive test at the clinical level. It would be nice to run such tests as a routine if the small clinical lab can have the technology without involving big pharma patents.
With the new terminology for basilar rales, namely "crackles," one might expect the new physician to be confused over the identification of the subtle left lower lobe sounds which sound nothing like crackles. The PCR might help and more so for upper respiratory infections. Professor Kemp once told me as a resident on pediatric rotation that I was treating an upper lobe pneumonia with a lower lobe antibiotic. It won't hurt to look at the gram stain either.
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Sci. Transl. Med. 5 203ra126 (2013)