MIND STRETCHER ONE – QUALITY AND SIZE

I enjoyed this article, more for tangential reflection than for its obvious good sense in its immediate application.  I certainly do not have a pointy head!  Within the comment, and in reference to trials, you state that small might be wrong, that we need large data sets of high quality and that small amounts of information, or poor quality information, increase the risk of results being incorrect.

My reflection translates these statements to the individual.  What is true for populations is surely true for the individual.  We make interventions in chronic disease management (blood pressure, diabetes, asthma) on appallingly inadequate data.  I change blood pressure treatment on the basis of one or two opportunistic surgery visits.  We have no idea whether these levels represent deterioration or improvement because we have made no measurement of chance.  I have become committed to patients’ self measurement and the luxury of multiple data points to review at our annual or biannual consultation.  I observe variation and identify common cause and special cause to help make appropriate intervention in the hope of minimising “chaos”.  These smarter patients call for much smarter process and smarter doctors.  I have spent 28 years dreading patient generated data.  I now welcome it, but it raises many handling issues, not least the simple transference onto a medical computer system.  The whole programme has been embraced by the patients to the embarrassment of their doctor, particularly when they arrive with Excel spreadsheets on disc, some with process control charts already mapped and many providing me with the calculations for their mean arterial pressure!

I hope I have illustrated the opportunities for reducing inappropriate medical intervention.  Donald Berwick quotes David, a 12 year old, in renal failure as a result of post streptococcal glomerulonephritis. During his nine days hospitalisation his blood pressure was measured 216 times, his doctors used four different medications and his anti-hypertensive treatment was adjusted 54 times by 11 people.  Following his discharge a simple blood pressure graph demonstrated his blood pressure variation had been statistically random, showing no perceptible relationship between treatment and level.  Very dedicated doctors, attentive nurses and wonderful care, but the result of their striving for excellence was chaos.  They were treating common cause variation in  David’s blood pressure.

Is this an avenue you wish to explore?

Michael Ellis-Jones (D83043) The Health Centre IP23 7DD"

Michael.Ellis-Jones@gp-d83043.nhs.uk