This weeks blog is brought to you by: Sir Muir Gray, Founding Director
“I’ve always had a peculiar fascination for the receiver-operating characteristic (ROC) curve. As a researcher, I appreciate that the area under the curve can be precisely mapped, so that different screening or diagnostic tests can be meaningfully compared.
This lovely interweaving of my clinical and academic perspectives took an unexpected turn just over a year ago, when I was diagnosed with breast cancer.
I hadn’t reckoned on the price of treatment. The complications. The treatment of complications. The side effects of the treatment of complications. The sepsis. The relapsing, migratory pneumonia from radiation-induced lung injury. The sleep deprivation, agitation, and bone loss from prolonged courses of steroids to suppress it. The disruptive impact of admissions and appointments.
…. So while these setbacks — and their sequelae — didn’t necessarily threaten my life, they certainly threatened my days. These threats combined forces to become my lived “reality of cancer,” which was at times exhausting and overwhelming. For me, grasping this entity, defining its boundaries, seemed key to disempowering it. So I nailed it to a curve (see graph).
The y axis represents the obvious threat to life imposed by cancer and its treatments. But the x axis represents the things that threaten to steal our days: treatment and its complications, side effects, disruption of work and relationships, the sense of vulnerability, the fear that we may be losing our identity. The area under this metaphorical curve is the answer to “How are you doing . . . really?”
My ROC curve maps out what I’d found hard to define and measure. It is strangely empowering to articulate these threats both to my well-being and that of my patients — to plot them sensitively and specifically.”
3VH – Implications for value
Bottomline – Donabedian’s curve of optimality remains as relevant today as it did in the 1980’s when he developed the concept. It has formed the basis of all value work since then; Harvard for market-based healthcare; 3V’s for population health. In this paper the author uses Donabedian’s approach to think about optimality in cancer; the paper’s conclusions could equally be applied to personal and population value.”
For decades clinicians and managers have been at loggerheads thinking they are in conflict but the management of resources for individuals and for populations are two sides of the same coin.
Lets take the perspective of people who mange resources for populations, and we always use the term people who manage rather than managers, because clinicians are people who manage. Admittingly many people who manage do so focused only on the people called patients who reach their facility at present but with the development of population health management this is changing.
To people who mange resources the Donabedian diagram is the single best expression of the fact that as investment increases the balance between benefit and harm changes. Life consists of trade-offs
So too with clinical decisions whether made by the person called the patient or the person called the clinician and when the patient is also a clinician they can express this in a diagram in which the benefits and the costs, in the case of the individual personal costs are also traded off against one another and too often the personal costs are not measured or even discussed. Here is how the relationship changes.
For the individual, as this highly skilled individual shows us in this article, the trade off between potential benefits and real costs can also be expressed diagrammatically and this curve will also change as the amount of resources invested by the population in a particular system of care increases, not necessarily favourably for every individual.