There are few certainties in medicine. But treating rotator cuff injuries has revealed one to me: People with rotator cuff tears don’t sleep well. If you want a glimpse into the life-altering symptoms of shoulder pain, just ask one of these patients how many times a night he or she wakes up with pain. Hearing the answer, it’s easy to see that improving the ability to sleep through the night would be one of the major goals of treatment.
With pay-for-performance on the horizon, interest in demonstrating that treatments are providing value to patients is peaking, and with it, patient-centered outcomes research. Yet how much should we actually trust the results of studies using these results? If you see patients’ faces as they fill out the health-related quality of life (HR-QoL) questionnaires and disease/joint specific questionnaires, you may detect a bit of skepticism.
For instance, among commonly used outcome measures for rotator cuff dysfunction, only about 9 percent of the questions ask about sleep quality or the ability to concentrate (a surrogate of fatigue). I don’t think it’s a stretch to say that most shoulder pain patients would say that their sleep should be weighted as more important in the measurement of their symptoms.
In orthopaedic surgery, my specialty, evidence-based medicine was adopted only recently. Before then, the case series ruled journal pages almost exclusively. Not only were options for measuring HR-QoL limited, but surgeons also felt they were better judges of outcomes than patients or blinded observers. Over time, however, the tools we have for measuring patient-relevant outcomes have proliferated and become more effective. There has, for example, been an improvement in the measurement of general HR-QoL with the SF-12 survey and EuroQoL-5D, now translated into many languages. Despite these advances, though, anyone who practices medicine is still reminded daily that our patients are diverse and unique; each with his or her own health goals and preferences.
On balance, evidence based medicine has been a great advance for medicine, and it has benefited many patients. My concern is that we are also failing some, and we don’t know how many. In his book the Creative Destruction of Medicine, Eric Topol, MD, brings up a similar point in the context of statins and the challenge of knowing the number we actually need to treat people. In elective surgery, it isn’t cholesterol medicine that is wasted by imprecise outcome metrics, but rather patient goals and expectations that are failed. What is the answer to this impasse? In my view, it is precision outcomes, the combination of precision medicine and outcomes measurement. I believe that union will be made possible through wearable technology, or wearables.
Wearables provide the opportunity to objectively measure aspects of health and wellness that matter to patients. They are designed as consumer devices, and as such have to measure matrices of health that are important to the public. Because of this, as I mentioned in a previous post on the Doctor Blog, patients will come to us having collected data already, meaning we can actually track the outcomes of treatments in individuals.
Like so many of my patients, I am struggling to connect the list items I’m told are important to what I’m hearing in the office. I also want to push the envelope on trying to integrate new data streams from wearables into the objective measurement of illness, wellness, and the period of recovery that lies in between. Still, much remains to be worked out for how we implement wearables for this type of assessing. What I am certain of is that the conversation will be one to watch.
Jesse Slade Shantz is an orthopedic surgeon who blogs at The Doctor Blog.