1/Listening to @1a "Against the Pain" - @1a is to be commented for covering this issue Hats off.
I wish to share a thought on a form of bias built into NARXCare as it is obvious, correctable, and harms patients. wamu.org/story/21/11/11…
2/Dr. Nishi Rawat of Bamboo Health (provider of the NARXCare algorithm to assess overdose risk) describes the NARXCare product they put onto the screens of doctors (via Prescription Drug Monitoring Programs) as an "objective summary". About that...
3/Dr. Rawat's definition of NARXCare covers 2 distinct function. One is a graphic summary of the Rx's received by a patient (if the data are accurate, this is helpful).
But the concerning one is an "Overdose Risk Score"
4/The NARXCare score asserts that it communicate risk of overdose. Sadly it is subject to a built-in form of bias against
*patients who use teaching hospitals,
*against Veterans, and
*against persons of color.
It could have been corrected by the way.
5/The bias I get to see daily is NARXCare counts the "# of prescribers" toward OD risk. All things equal, there is an actual association. But the # of prescribers is often high for patients getting care in teaching hospitals (including Veterans hospitals)
6/In a clinical system where academic or non-academic providers cover each others' patients prescriptions, under strict protocol, that counts the patient as having "more prescribers". But that "more" is very different from "more" due to doctor-shopping, for example.
7/NARXCare will designate all such patients as higher risk even when, they may well be uniquely protected from OD. This misclassification is not 'random' but systematic.
It will declare higher risk for patients in these institutions, just because they sought care there.
8/What kinds of patients differentially go to teaching institutions?
People with more severe illness:
Veterans (*Happy Veterans Day*)
To a degree, African-Americans
All these people will be misclassified systematically in ways prejudicial to their care, by NARXCare
9/I want to underscore that this misclassification problem could be addressed by careful analytic and database improvement by the people who developed NARXCare, at any time.
Often the prescribers in one teaching institution share an address, which is known and on screen.
10/To my knowledge, as a regular user of our state's PDMP with NarxCare, I do not see evidence of programming, to date, to address such a problem. If Bamboo wishes to clarify, of course, I will post the clarification their behalf.
11/Based on what I see, I don't think "objective" fairly classifies algorithms that seem to systematically mis-classify risk of overdose based on disability, Veteran status, residence in an urban area, or being African-American. Again, I invite Bamboo to clarify, and I'll post it
12/None of this is to discourage active inclusion of all voices in discussion of what is happening for patients with long-term pain right now. I think it is simply amazing that this episode happened and I thank @1a@ibdgirl76@maiasz and even Bamboo./fin
13:/PS - I have listened to the account by Dr R that the algorithm can avoid penalizing patients for team based care. I re-reviewed my patients improperly designated as “multiple prescribers”. — continue-
14/I can’t reconcile her statements with each other, with standard analytic approaches to large pharmacy databases, or with the operational definition of multiple prescribers declared explicitly on the Bamboo/Appriss screen I see in our PDMP. That said
15/If there is an unspecified method used to achieve the objective claimed on @1a , it would be a unique accomplishment, but it would also be one that is not consistent with the account of methodology provided on the Narxcare screen
16/I want to vouch that further review or our care panel, and hearing from individual patients I know continues to suggest that the “multiple prescriber designation” without reference to collaborative or team-based care by Narxcare, contrary to what was said on @1a yesterday
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1/It is bad that clinician performance on matters related to the opioid crisis is *still* being measured in terms of # of opioid prescriptions.
These metrics, which ape prior metrics that drove the original⬆️ reject the approach we normally require for measuring quality of care
2. To be clear. Optimal health care metrics require
a) clear denominator of eligible patients with the condition
b) clear evidence that the treatment's provision is wholly good or its nonprovision wholly bad
c)evidence that imposing the metric leads to improvements in health
3. For example, a metric such as "provision of cervical cancer screening" would be BAD if it includes persons with no cervix either because of hysterectomy, or because they are cis-male.
1/This report on the homeless “sweep” at Boston’s Mass & Cass highlights a tragedy to which the city contributes, and some helpful points for people thinking about unsheltered homelessness wgbh.org/news/local-new…
2/The City’s accumulation of persons who are unsheltered partly results from the City’s closure of its Long Island Shelter, which was often used by people with drug use disorder - I used to work there
3/But it is also true many people really do not tolerate congregate shelters at all. Close quarters with people who might be intoxicated or paranoid is actually not an easy thing.
1/For any discussion of homelessness - please remember: the key driver of *total number of people homeless* in any area of the US is the number of units that are affordable to poor renters
2/Efforts to blame homeless numbers in West Coast cities to "fentanyl" are not based in evidence. Here's an opioid overdose per capita map. States with horrific overdose crises often have lower homeless counts per capita than ones like California, where the OD rate is lower
3/Still not convinced? San Francisco's homelessness is high per capita. It's fair market rent for a 2-bedroom apartment is $3500!!! That translates downhill to poorer folks not being able to afford an extra bedroom or accommodate family members with problems of any kind
1/Prescription opioid counts have fallen to levels last seen in 1992,reports @US_FDA Corinne Woods, PharmD for workshop at Duke Margolis today
2/Prescription #opioid milligrams are at levels of early 2000s. That number is higher (relative to prescription count) according to @US_FDA Corinne Woods, PharmD at Duke-Margolis today - I think this difference reflects the patients with long term receipt.
3/Total milligrams and total count of oral tablets in an “initial prescription” have declined, reports @US_FDA Corinne Woods, PharmD to today’s session for Duke-Margolis and FDA (2 images here)
1/An excellent new article reviews this summer’s controversial pushback against efforts to remediate the antisemitic mistreatment of Mountain Brook Jewish youth, by other youth. I will share some comments as a regional resident too atlantajewishtimes.com/adl-embroiled-…
2/First, antisemitic comments or mistreatment of Jewish students in suburbs south of Birmingham is the “modal experience”, ie most Jewish students hear comments denigrating their religion, from peers. This doesn’t mean most non-Jewish students say such things or harbor such views
3/I base my statement that it is the “modal” experience from talking with Jewish youth who grew up here and with their parents and confirming with multiple Rabbis. And *none of this is unique to Mountain Brook* - it typifies *all the bourgeois suburbs south of Birmingham*