Saturday, January 2, 2016

Compassionate End of Life Care and Evidence-Based Medicine: Treatment Scores

My father-in-law was 87-years-old when we got the call. It was a Saturday night. He’d set off the alarm in his house and his alarm company was calling us since he was not answering his cell phone.

He lived about 10 miles away so my wife jumped in the car and arrived at his house to find him febrile, confused, and complaining of some vague abdominal pain.  After the ambulance arrived, the driver insisted on taking him to the closest hospital which was about 2 miles closer to his house than the hospital where I worked.

After the CAT scan and lab tests, it became apparent that he had a stone obstructing his common bile duct. The next day was Sunday and after being NPO and getting some fluids, his symptoms were much better and he was beginning to look like his old self.

Monday came next. Since my father-in-law had a Bilroth II procedure in the 1960’s, the usual treatment for a bile duct stone, which is an ERCP (endoscopic retrograde cholangiopancreatography), became problematic due to the changed anatomy. That morning the internal medicine doctor told my wife that since an ERCP was not an option, he needed a percutaneous bile duct stent, and the radiologist would be able to do it in the afternoon. The gastroenterologist came by in the late morning and said he would need surgery, but we might consider sending him home in a day or two in order for things cool down. He mentioned some drugs and said they should do an intraoperative cholangiogram when they took out his gallbladder. About an hour later, the surgeon called and said he was on the schedule for a laparoscopic cholecystectomy in the morning and we needed to cancel the bile duct stent.

My wife called me confused and overwhelmed and had no idea what to do. I am a physician and I felt exactly the same way. We decided that we needed to transfer him to the hospital where I worked where at least we knew the physicians and could sort things out.

Being a physician, I wanted to know, “What is the literature on the treatment of a common bile duct stone in a patient with a previous Bilroth II?”  It doesn’t seem like an extremely hard question. Let’s start with WebMD. There were a couple of things about ERCP’s and Gallbladder surgery in general neither of which was helpful in this case. So I went on to PubMed. Some case series studies came up about a double balloon enteroscopy for ERCP and there was a case series report on laparoscopic bile duct exploration. Okay; this is a start.

How about the Cochrane Reviews? There seemed to be one pertinent article, but it didn't specifically talk about patients who have had a Bilroth II. It seemed to be saying that open cholecystectomy and bile duct exploration may be just as good as endoscopic procedures. My father-in-law was 87. If you've ever seen an open cholecystectomy, this is not a procedure an 87-year-old would recover from easily. There was one study of laparoscopic bile duct exploration, but this was only done in specialized centers. After a couple of hours of frustrating searches, it was apparent there is no one place where the medical literature is organized so that a list of treatments and the studies behind them was available in the way I needed them.

This is where Treatment Scores comes to the rescue. Going to the website and the Treatment Organizer™ I put in a level 1 diagnosis of a common bile duct obstruction with a secondary diagnosis of history of Bilroth II. Our Main Statistic is the chance of reobstruction and we put a follow up of 1 year to start. Now I am able to list the treatments I've found so far in the Treatment Organizer™.  Moving into the STAR™ Blocks I am able to input the studies I've already looked at and eventually give my own Treatment Score using the Treatment Score Calculator™.  As shown in the Treatment Organizer™ below, most of the studies for these treatments are case series so none of them will have high Treatment Scores™ on a scale of 100, but at least now I know what the treatments are and what the evidence or in some cases lack of evidence is for each of them. Someday I will be able to build on the work of others. For now it’s just the studies I've entered, but at least they are organized in one place.





It was now 4 days since my father-in-law’s initial obstruction and his symptoms and lab tests had improved significantly. He had multiple stones in his gallbladder and it was clear it needed to come out. Here we go again. Is a robotic assisted laparoscopic cholecystectomy better than a laparoscopic cholecystectomy without the robot? What is the evidence behind each? Again after a significant amount of time searching the usual places, I listed the relevant studies in my STAR™ Blocks.  It’s apparent there are not many studies out there and none showing a significant difference as shown in the STAR™ Block below.



The laparoscopic cholecystectomy without the robot is a shorter procedure so it appeared to be the better option. When he had this done, there was clear evidence of metastatic cancer which was confirmed later by the peritoneal biopsy taken at the time of surgery. Once again, this led to many more hours of figuring out what were the treatments for his cancer, what were the benefits and what were the side effects? It consisted of going through multiple review articles, (most of which were not quite pertinent and presented with the biases of the writers), sorting through numerous articles on Medline to find the relevant ones and then figuring out which ones were well done and useful.

It was apparent that for his age and co-morbidities, the side effects and risks of chemotherapy were not worth any potential benefit. My father-in-law passed away a few months later with his family around him. He never had another bile duct obstruction. I’m confident we did everything right, but having Treatment Scores before all this started could have made things so much easier.

There is an old adage: “Know what you know and know what you don’t know.” In medicine today we haven’t yet got the “know what you know part.” Textbooks become outdated quickly. If you’re lucky there is a great review article, but it may not pertain to your situation and is written with the biases of the reviewers. We need access to the sources. Here is the literature and this is how good or bad it is. Treatment Scores answers this need.  It’s time to fill in the “know what you know part.”  It will be exciting to get Treatmentscores.com beyond the alpha web site it is today, so we can do just that with a future beta website. (See the disclaimers below.)

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