Part VIII: Scoring PDMP Data
BY JIM HUIZENGA, M.D. AND CHIEF CLINICAL OFFICER OF APPRISS HEALTH
Series Introduction – Appriss Health has long held that chronic pain and addiction (substance use disorder) are separate medical conditions and that each deserve a unique clinical approach. We have spent years developing clinical decision support tools and in doing so have obtained the feedback from countless medical professionals, including many pain providers. Through those providers we have also heard (directly and indirectly) from many chronic pain patients as well.
To continue this conversation, over a long series of blog posts, we will explore our approach to benefit/risk assessment, data presentation, and clinical support…and how they relate to our goal of creating a usable and balanced, clinical viewpoint that protects access to care while highlighting areas of risk that clinicians and patients should be aware of.
Never treat a number.
I saw my own doctor for a physical recently. It was at 11:00 am EST on the 28th of August. He was a new doctor for me (I recently moved) so I put his office in my map program when I left and saw he was 11.2 miles and 18 minutes away. On the way there my truck told me I was doing 70 mph at an average of 16.8 mpg. My physical started with a height and weight measurement (6’1” and ahem…200lbs), followed by blood pressure and heart rate and respiratory rate (130/82, 60, 14). I was scheduled for what’s called a comprehensive metabolic panel, which is sometimes called a chem-14, that measures a bunch of levels in my blood. If they’re all normal (and I hope they are) they could be reported as follows:
My doctor told me that at my age (52) it was time to talk about preventative health screenings…and well, you get the picture. Much of my morning, and my physical exam came down to a series of measurements that were reported with numbers.
Having made this point, I can vividly recall one of my many pivotal or “ah ha” moments in medical school that came during rounds on a critical care rotation when one of my attendings made the point of saying…”Never treat a number.”
Wait a minute.
If you’re never supposed to treat a number then why the heck are there numbers everywhere in a patient’s chart!
My illustrious attending (she really was great) was making the point that a number, whether it was a blood pressure, or heart rate, or temperature, etc. etc. should serve to raise your awareness to a potential problem. In other words, an unexpected number should result in a search for a problem, and if a problem is found…THAT is what should be treated.
Her point was well received and I have subsequently used that exact line with my own students many times, but the fact is that numbers are a routine part of medical care. Numbers are a form of universal languages (I practiced in Korea for a year while in the military and found medical “numbers” were still the same over there!) and they are easily incorporated into medical records, easy to display, useful for trend analysis, and more, but in the end…the important point I’m trying to make is that numbers in medicine generally serve to reassure, OR raise concern. Numbers are not end points*.
For all of the reasons above, we score PDMP data. We use numerical ranges from 000 to 999 to represent the relative amount of use (and risk) within a PDMP report and we calculate four different scores that correspond to:
- The amount of use and risk associated with the use of opioids (or narcotics)
- The amount of use and risk associated with the use of sedatives
- The amount of use and risk associated with the use of stimulants
- The overall risk of an unintentional overdose
In a PDMP report our scores look like this, and we display them above the Rx Graph.
We use many inputs (or measurements) to create these scores. For instance, there are 20 different time-based measurements used to create a Narcotic Score (which again ranges from 000-999). The higher the score the more “risky” each one of those 20 measurements is within the PDMP report.
One effect of using a large number of different measurements is that one aspect of use or risk will not skew the score to an overly high range. For instance, if we calculated a Narcotic Score for a patient who was taking opioids at the CDC guideline maximum of 90 morphine milligram equivalent (MME) while seeing one doctor, one pharmacy, and not taking any sedatives that patient’s score would be 390 (on a 000 to 999 point scale).
To emphasize that using many variables helps to minimize the impact of any one element of risk (like MME), if we calculated the Narcotic Score for a patient who was on 900 MME a day, or even 9,000 MME a day…or why don’t we just pick an infinitely high value. The maximum Narcotic Score for a patient who uses an unlimited amount of MME, but who also sees one doctor, goes to one pharmacy, and doesn’t take any sedatives is 410.
Of course, some patients have three or four doctors, and some patients find it convenient to use multiple pharmacies, and some take 20 MME a day, and some take 200 MME a day. And many patients are also on sedatives for other health reasons. Every patient is unique and the range of “numbers” that could be associated with their PDMP reports is very large. That’s one of the reasons why we have such a broad range for our scores.
In our next post we’ll look more concretely at how we calculate scores and how they’re supposed to be used in practice. We’ll see that there are a number of different paths that can lead to a similar score and if a score is unexpectedly high for a patient, then the right course of action is typically a discussion…not a decision. More on all of that next.
*As a doc I always feel the need to be complete and accurate so I want to acknowledge that in the last decade (or two) or so there has been a lot of emphasis in certain types of situations on what is called “goal directed therapy” or “early goal directed therapy.” This is most pronounced in sepsis and does come very close to “treating a number.” For instance, a patient may be infected and have low blood pressure and a high lactate level, and in that instance an automatic amount of fluid may be given intravenously. In the end…even with goal directed therapy, the numbers are still indicative of a problem and the treatment of that problem is the real medicine being applied to the patient.
To read more on this series:
- Part I – Benefit and Risk
- Part II – Risk Defined
- Part III – Dependence and Addiction
- Part IV – PDMPs
- Part V – Multiple Provider Episodes
- Part VI – PDMP Visualization
- Part VII – Interpreting PDMP Visualizations
- Part VIII – Scoring PDMP Data
- Part IX – Understanding How PDMP Data is Scored
- Part X – Machine Learning
- Part XI – Epilogue