The KHIT Blog: The dx from Hell: ICD-10 code C25.9

Monday, May 15, 2017

The dx from Hell: ICD-10 code C25.9

Pancreatic Cancer
Pancreatic cancer (PC) has the highest case-fatality rate of any of the major cancers, both in the US and worldwide. The disease is difficult to detect, rapidly metastatic, resistant to treatment, and often results in death. Pancreatic adenocarcinoma is also one of the most difficult cancers to study. Case-control studies may be inaccurate because patients with PC often die within weeks of their diagnosis. At the same time, prospective studies of PC are challenging due to the relative rarity of this type of cancer (~ 1% lifetime risk) and low prevalence due to short life expectancy. Consequently, PC etiology is often investigated by analyzing data from large-scale prospective studies or clinical trials for diseases other than PC, but limited numbers of cases and methodological heterogeneity (e.g., no or incomplete histological verification) affect the validity of these results.

The etiology of PC is widely acknowledged to be multi-factorial. The incidence of PC is greater in males than in females, and higher in Blacks than Whites. According to SEER 17 areas data, the age-adjusted incidence of PC in 2006 per 100,000 individuals was 11.61 (95%CI 11.34-11.88) for Whites and 15.57 (95%CI 14.57-16.62) for Blacks, with 16.56 for Black men (95% CI 15.08-18.61). Environmental or host risk factors shown to be associated with PC include cigarette smoking, obesity, type II diabetes mellitus, chronic pancreatitis, physical inactivity and blood groups A or B. Dietary risks may be related to low fruit and vegetable intake and increased intake of high-heat cooked meats (i.e., grilled/fried animal protein sources). Two separate, recent studies linked pancreatic cancer to high consumption of carbohydrates and alcohol. Unfortunately, these common risk factors have small effect sizes, so it is difficult to produce highly accurate risk models. For example, smoking yields a risk ratio of approximately 2. The risk of developing PC is recognized as being exceptionally elevated in certain genetically predisposed families (e.g., hereditary pancreatitis,), but only about 10% of all PC cases can be attributed to genetic causes...

From pancreas.org

Lightening strikes yet again. I've alluded briefly to this new circumstance here and there in prior posts.

On March 29th, the radiologist's report from a CT scan done at a Kaiser Permanente facility indicated that my younger daughter Danielle is afflicted with Stage IV metastatic pancreatic cancer, a finding confirmed by a subsequent liver biopsy. (She's given permission to go public with this horrific news.)

Our world has been turned upside down ever since. My KHIT efforts have been significantly hamstrung. Danielle started Folfirinox chemo (after first being accepted into and then, in the wake of some subsequent disqualifyingly elevated adverse labs, excluded from a UCSF clinical trial). Her severe side-effects reaction to the first chemo round landed her in the hospital, where my wife and I spent all of last week by her bedside in shifts.

Above, Sissy (top) and Danielle (bottom) in 1974 in Seattle, the year I got a divorce and custody of both of them. The backstory on my salt and pepper kids.

Needless to say, we are all reeling. One of her friends started a crowdfunding page for her, for which we could not be more grateful. She will need every dime. Danielle's out-of-pocket expenses to date alone are mind-boggling (KP membership notwithstanding). If her illness doesn't kill her, it will most certainly bankrupt her -- in relatively short order. She will shortly be the former Executive Director of The Stepping Stones Project (they've generously given her extended "medical leave," which, though, necessarily runs out by month's end).

We've moved her back home, and I will be breaking her lease and packing up and stowing her apartment shortly, and tending to the myriad piling-up logistical and legal assistance details.

And, get excused from the jury duty summons I just got.

So, yeah, I'm a bit behind the curve. My life the past seven weeks has been an endless recursion of "oh, SHIT!" moments.

Prior to this news. I'd been trying to finish out my "One in Three" book. Gonna have to scrap the title and cover photo and broaden the scope.

1980, Knoxville

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AUGUST 13TH UPDATE
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More to come... dxFromHell

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Brave New Health

Commonwell Health Alliance

Another important read (pdf)

I love this kind of stuff. It sustains and humbles me. "As politicians, advertisers, salesmen, and propagandists for various political, economic, moral, religious, psychic, environmental, dietary, and artistic doctrinaire positions know only too well, fallible human minds are easily tricked, by clever verbiage... Common language—or at least, the English language—has an almost universal tendency to disguise epistemological statements by putting them into a grammatical form which suggests to the unwary an ontological statement. A major source of error in current probability theory arises from an unthinking failure to perceive this."

Quotes

"An economist is a person who sees something that works in practice and tries to figure out whether it will work in theory."

- J.D. Kleinke, medical economist
___

"The only person who enjoys change is a baby with a wet diaper."

"Every misspent dollar in our health care system is part of somebody's paycheck.

- Brent James, M.D., M.Stat

“We could do healthcare, at markedly higher quality, for everyone in this country, without rationing or denying anybody the care that they need, without having the government dictate how doctors practice or whether hospitals could expand, at half the cost we do it now.”

- Health Care Futurist Joe Flower

Most of the sciences, unlike parts of medical science, are not concerned with the impossible. There is not complementary and alternative physics, or chemistry, or biochemistry, or engineering. These disciplines compare their ideas against reality, and, if the ideas are found wanting, abandoned."

- Mark A. Crislip, MD

"Q: How much alcohol is too much?
A: More than your doctor drinks."

- a physician I once heard speak during a CME presentation

“Just because science doesn’t know everything, doesn’t mean you get to fill in the gaps with whatever fairy tale most appeals to you.”

- Dara O’Briain

'[I]t is one small step from using the computer for "helping" doctors to monitoring them, judging them, dictating to them what to do, and withdrawing payment for computer non-compliance. The use of computer data is a multi-edged sword. It can be used for the "good," facilitating diagnosis and treatment and making it more accurate and up-to-date, and for “evil,” invading privacy, inviting security breechs, and making decisions based on the opinions of remote authorities rather than those present at the patient-doctor encounter.'

- Richard Reece, MD

“[T]here ARE statistics which are non-political. Just because The Washington Post/Fox News reports the temperature is 75 degrees doesn’t mean it’s really snowing and sunscreen is a liberal/conservative plot. Even if you earn a living being ideological.”

- Michael L. Millenson

"It is a generally a fairly convincing argument that people shouldn’t have to be subsidized to undertake a change which is in their best interest.

The reconciliation seems to be that EHR is not supposed to make a doctor’s practice more efficient and higher quality. It is supposed to make the system of care more efficient and higher quality, which is not the same thing. Those of you who took calc recall that maximizing the total of variables is not achieved by maximizing any one variable and this is a perfect example of that.

Those of you have served in combat certainly noticed that too — if everyone works as a team the unit takes fewer casualties. If you try to save your own hide, you might, but at the expense of more casualties overall."

- Al Lewis

"There are two ideas to keep in mind about Bayesian reasoning and how we tend to mess it up. The first is that base rates matter, even in the presence of evidence about the case at hand. This is often not intuitively obvious. The second is that intuitive impressions of the diagnosticity of evidence are often exaggerated."

- Daniel Kahneman, "Thinking, Fast and Slow"

"Physicians apply advanced scientific knowledge, but they must do so without the favorable conditions that experimental scientists create for themselves. Multitasking is forced on physicians, often in chaotic environments and under severe time and resource constraints."

- Lawrence and Lincoln Weed, "Medicine in Denial"

"It’s time to stop the whining about Obama care and acknowledge we already have universal health care. We just pay for it in the stupidest way possible that ensures problems are that much more disastrous and complicated when they’re finally treated."

- Mark Hoofnagle, MD, PhD

"Every act of conscious learning requires the willingness to suffer an injury to one's self-esteem. That is why young children, before they are aware of their own self-importance, learn so easily."

- Thomas Szasz, MD
___

"Of course, one reason that process metrics* are so popular is that processes are much easier to define and measure than outcomes."

- The Skeptical Scalpel
___

"There is an “illusion of validity” for any random data point, a seductive sense that is colored by what we hope will be true. Mountains of pharmaceutical claims are often made from mere molehills of data."

- Danielle Ofri, MD
___

"Joy empowers people. It is a source of energy that enables people to hope and plan and change their lives for the better. Spend some time around someone who is relentlessly negative and how do you feel–drained, right? More and more research shows that joy is not something that just happens to you, like a bolt of lightening out of the blue. Joy is, instead, a habit to cultivate. Negative thinking and despair are the crabgrass of our souls–weeds that take root and spread, sometimes to all areas of life. Joy, in contrast, is a soul’s rose–hardy when cared for, able to put down roots over time and withstand disease and extremes. Like a rose, however, your joy can become blighted from neglect or harsh conditions. We all need to tend to our joy–to prune away the badness, and to know that, even though it may look like a prickly bare root, if you invest time in a joyous outlook, gorgeous things will bloom, even in the harshest conditions."

- Dr. Jan Gurley
___

"'Solutions' exist only in mathematics."

- Karen Martin
___

"The issue of how to regulate clinical software is, in the long run, indistinguishable from the issue of how to regulate medicine. The only difference is that medicine is practiced in the open, without secrecy, subject to peer review, and under a merit-based state license."

- Adrian Gropper, MD
___

"Economist, rope, tree: some assembly required."

- Source unknown

DISCLAIMER:

I write this blog wholly on my own time and my own dime. The views proffered are expressly my own as a concerned and active citizen/taxpayer (in addition to being the result of my substantive experience in the various IT fields), and in no way reflect any policy views of my former employer, notwithstanding that some of the thinking has indeed obviously been spurred by the implications of the work with which I have been doing for them.

FAIR USE POLICY
I cite a ton of news and web sources spanning the breadth of relevant technical and policy domains, sometimes at substantial length. I believe I remain well within the bounds of "Fair Use," as [1] I am not doing any of this for profit, [2] I always provide attribution and links -- which, [3] far from negatively impacting any copyright holders' commercial interests, might actually increase traffic to and interest in their offerings.

Nonetheless, should I post anything of yours regarding which you have any objection, just let me know and I will remove it forthwith.

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Monday, May 15, 2017

The dx from Hell: ICD-10 code C25.9

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