Remote Exercise Partners

The most recent article that I found in the Wall Street Journal focusing on exericse talks about two individuals in Tennessee and New York City who take a spin class together.  Why do I find this interesting?

First, it is another example of the value of having someone with whom to undertake an activity.   The old expression is "two heads are better than one."  This is not so much a matter of two heads in the classic sense in which the expression was originally used.  This has nothing to do with getting ideas from two people.  This is almost "two hearts are better than one".  Not in the sense of love as we would use for Valentine's Day.  But rather love of something.  Almost anything.  Having two people together who love to do something can make it much easier to do.  Each can hold the other accountable.  Each can help to encourage the other.  The process of checking on each other can be one of peer mentoring.  Or it could simple be peer pressure.  But the key is that to have someone to engage in an activity and to engage in checking up on progress with the other person can be very helpful to sticking to an activity and working to continue to improve performing an activity.

Second, it is a great way to re-imagine a use of a technology.  Live streaming can be used for so many things.  So, why not use it for doing workouts together.  So far, it seems like it would work best for activities that don't require a person to get up and move around very much.  But it would be very interesting to imagine some type of "visor-cam" that could help individuals to run together whether they are in the same place or not.

So, in exercise, it is wonderful to re-imagine a use of technology to increase interpersonal accountability.  There are many other parts of life in which re-imaginging technologies to help individuals to connect and to grow better in their performance of activities could also arise.  Leadership skills.  Really any skill at work.  Parenting.  Musical instruments.  And any type of concentrated effort will support concentration in general and have spillover into other parts of life as a person chooses to direct efforts that start in one area of life to other areas that need improvement.  People are likely to find useful the opportunity to connect.  Those can find ways to help individuals connect are likely to be the economic and thought leaders of the future.  

New Technology in Prostate Biopsies

On the professinal side, I am often looking at new opportunities to screen, diagnose, or treat and asking the economic question--what makes this a good buy?  Some, of course, migth simply say, "It is more effective so why would we not want to use resources for it?"  And given the value that is assigned to life, that is often a reasonable supposition.  However, given the limited resources that are available for medical care and public health efforts, it is also often worth while to ask a few deeper questions and determine whether a use of resources is the best use of resources or not.  

On the personal side, my blogging began with a memorial service for a fellow parent at my kids' elementary/middle school who lost a battle with prostate cancer.  So, when there are new ways to guide screening, biopsies, and making a progosis, they almost always catch my interest.

An article in today's Wall Street Journal focused on the potential use of MRI's to guide biopsies to determine whether prostate cancer is agressive and should be treated agressively or whether it is more likely that the tumor, despite its presence, is clinically insignificant.

The article does a good job of describing everything that would go into an economic, cost-effectiveness evaluation without doing one and without, it appears, one having been completed so far.  Specifically, there is a higher cost to have the MRI prior to the biopsy--but from the patient's point of view some of that is paid by the insurer.  There are some aggressive cancers that are detected by the MRI technique and, as importantly, some cases that are rules as "not signficant" after which a patient can avoid being over treated.  Then, to make matters more complicated, there are also a fair number of cases missed despite the MRI.

Thus, an economic evaluation would have to compare the clear and readily identified cost of the procedure (potentially from different perspectives) with the value of more appropriate identification of aggressive cancers and the value of avoiding over-treatment (not just lower costs but potentially better quality of life that results from avoiding the side effects of surger to remove the prostate like incontinence and sexual dysfunction, and then account for the costs associated with still missed cases.

This would not be a simple analysis.  And while we may have quality of life and life expectancy measures for each of the resulting outcomes, this is a complicated situation in which the fear of a missed case or the disappointment with finding out that the cancer was not as bad as expected should be taken into account.  These types of quality of life issues are dynamic and complex.  

How should a decision be made?  The technology has some distinct advantages.  These should be presented to patients.  However, this does seem to call for shared decision making between the patient and urologist with as much information as possible shared in a way that is comprehensible until there is clear data to suggest whether the MRI is truly economically preferred.   

Response Rates of Emergency Medical Services and Mortality

A recently published article looks at the association between reduced emergency medical system (EMS) response time and the mortality outcomes of patients.  You may be asking, "Well, why does it take a study to show that?"  It would seem logical and intuitive that faster response times are associated with better outcomes.  Many municipalities and others responsible for local EMS units have spent quite a bit of time and money trying to minimize response times.  If they did not lead to better outcomes why would we be doing such a thing?

In fact, there are many things in medical care where what is intuitive is what is done and there is not a strong evidence base to support the action.  There are many in the system who are trying to change this and move us to a more "evidence-based" medicine approach, but it takes a while.

How did this study address the question in a novel manner?  Sometimes, randomized trials are appropriate.  In this case it would be completely unethical to make it take longer to respond to some people at random.  The approach used is describe in the study's abstract which can be found here.  The author, Dr. Elizabeth Wilde, points out that some studies focusing on cardiac events have shown the expected relationship but that there was little evidence outside cardiac events and what evidence there was outside cardiac events suggested no relationship.  Why might there be no relationship when the data are analyzed?  That requires us to think about incentives and to think about who knows what.  If the caller indicates a dire emergency the dispatcher can (and has an incentive to) communicate this to the EMS unit.  This is a form of triage.  The researcher working with the data later has not idea how the dispatcher communicated with the EMS unit.  So, if the dispatcher consistently triages cases in ways that make the response times for more dire cases shorter, then those cases may do better than they would otherwise.  But if the original mortality rate for those cases was high, making it a little lower will just make it similar to the mortality rate for the ess severe cases that take longer.  Then, there will be no apparent relationship between the  time of response and the morality outcomes.

Dr. Wilde found a way to use some other data--the distance from the location of the person who called for EMS services to the nearest EMS unit--as a proxy for the response time.  People have used this type of proxy (or to use the technical term, instrumental) variable before--to show things like the effectiveness of more intense treatment for heart attacks. In that case, there was a similar concern about the severity of the condition being observable to the medical care provider but not the researcher.

In the end, Dr. Wilde found that a one minute increase in response time was associated with an 8% mortality increase one day after the incident and a 17% mortality increase 90 days after the incident.

So, now we have an evidence base for efforts to improve response time.  What is the most appropriate way to do that?  That is a separate economic, political, and normative question.  It could involve technology of locating individuals.  It could involve technology for traffic control?  It could involve enforcement of traffic rules.  Or it could involve a change in norms where people are more aware of the true costs of not moving out of the way of EMS vehicles as quickly as possible.

Regardless, the study by Dr. Wilde shows that every minute can be associated with increasing the potential to save more lives.