If the choice is "The Apple Watch heart monitor sends too many people to the doctor" and "The Apple Watch heart monitor sends too few people to the doctor," I'm OK with this.
I agree, but obviously it depends on how many people is "too many". From the article it looks like 10% of those who went to the doctor were diagnosed with a cardiac condition, but what if it was 1%? A 90% false positive rate is already fairly high.
Maybe it’s just more common to have heart “anomalies” than people think. Historically it’s never been common for people having heart monitors strapped to them all the time, so now we’re In uncharted territory. Maybe there’s some scientific learning we still have to do about how the heart works, and what is considered “in spec.”
Another way of looking at it is that 1 in 10 people who were alerted to a potential health issue ended up needing medical assistance. That's actually pretty good for a basic non-medical screening.
That's true with a big caveat: how many of those people get invasive treatments for things which would not have actually become problems? They've backed away from screening as aggressively for certain cancers because the risks of aggressive treatment turned out to be significant and it turned out that more people than expected had tumors which didn't develop into a problem before they died of something else. I don't know how plausible that is with heart issues — maybe aggressive prescription of something like statins with significant side-effects? — but it's very important to consider the cost of false-positives.
> how many of those people get invasive treatments for things which would not have actually become problems?
That's really the doctor's issue to address, not the device's. Sticking your head in the sand isn't the right solution to the problems of dealing with information too aggressively.
> They've backed away from screening as aggressively for certain cancers because the risks of aggressive treatment turned out to be significant and it turned out that more people than expected had tumors which didn't develop into a problem before they died of something else.
Literally the only way to build viable metrics for which tumors will develop into problems is for _everyone_ get screened, not for no one to get screened. The problem of treating too aggressively is a treatment problem, not a measurement problem. If we avoid measuring, we have no way to learn how to treat better.
If we decide to never look because we don't yet know how to handle the information, then we will never know how to handle the information.
> The problem of treating too aggressively is a treatment problem, not a measurement problem.
One of the most important questions you can ask your doctor is "what happens if I don't have this test?" and "What happens if I don't have this treatment?" But most people don't ask these questions.
And so it really is a measurement problem. Over-testing, over-diagnosis, and over-treatment are well understood mechanisms of harm.
> But most people don't ask these questions. And so it really is a measurement problem
Putting the burden of asking these questions on the patient is wrong because patients don't go through a decade of training to become patients. And expecting the doctors to always ask these questions is wrong because I guess now we're not supposed to trust our doctors. But that doesn't mean we should suddenly live in a world without patient advocacy. It means you need to put it in the right place, in the hands of neither the patient nor the doctor directly. But if you never measure, and you need to be clear that, modulo epsilon, nobody ever measures heart rhythms despite heart disease being the #1 cause of death, then you definitely have no chance for anyone to ask those questions.
> over-diagnosis and over-treatment are well understood mechanisms of harm.
So are under-diagnosis and under-treatment. Both can only ultimately be solved by more information, not less.
> That's really the doctor's issue to address, not the device's. Sticking your head in the sand isn't the right solution to the problems of dealing with information too aggressively.
Again, it's not that simple. Doctors do not have perfect knowledge and have factors to consider other than the current academic consensus. Some fraction of people will get scared and demand _something_, which will for some people lead to them doing something worse than nothing at all. If you have many people seeking out treatment for a notification which has them scared, some of the patients will try something other than good medical treatments and some of them will have doctors who recommend things which used to be or are no longer best practice, make a recommendation skewed by a financial incentive or what will turn out to be a biased study funded by a company with a financial stake, etc.
Engineers building tools like this have a tricky ethical line to walk between making information available and considering how that information could be misinterpreted or faulty. One of the biggest things I'd want to see on a system like this is careful treatment of showing confidence levels and present them in the UX. “️ Heart anomaly detected!” is not the same as “Our sensor reading was unusual but the signal was low-quality. Do you feel okay?”, etc.
You're bringing up very real issues that I think really have nothing to do with whether we decide to measure, report, and learn more about cardiac anomalies or not. I agree that we should be careful about how we report and apply information, but that isn't the same as saying we shouldn't look in the first place. Right now practically nobody ever bothers to look for symptoms of something that we believe full well to be the #1 leading cause of death by a large margin. That should really not be accepted by anyone.
Doctors will rarely subject anyone to thorough evaluation for things if they aren't over the common danger age and don't report specific symptoms. Your typical annual checkup for people not 50+ is a fairly generic blood panel and very little else. After 50 they may add, what, a prostate probe for men?
In my life I've had one doctor who performed an EKG as part of my annual checkup, once.
The other ~10 primary care physicians I've had never did -- my annual was mostly just a few questions, some blood work, quick reflex tests and I think they looked in my ears and eyes.
If my Apple Watch detected a heart irregularity, I can say with certainty it's not something that would be caught otherwise at my next annual checkup.
On the other hand, I’ve found my doctor at least is very receptive to specific concerns and happy to offer advice on whether or not I should get additional tests. In a couple of cases he’s recommended against tests but I judged them to be worthwhile. Because I’m the one paying for it, he’s been fine with that.
I see a large part of a doctor’s job as being an expert consultant for an individual to make decisions about their own healthcare. Someone who is interested in and involved in their own risks is likely an extreme outlier to begin with.
And there are actual real deaths from undertreatment. You don't have any reported reason to believe that anyone is dying because of their Apple watch reports.
I see the “the false positives is okay” sentiment widely here. Just keep in mind that medical mistakes is the 3rd leading cause of death in the US. It’s statistically in your favor to limit your exposure to medical mistakes.
It's complicated and IMO misleading to claim medical mistakes are the 3rd leading "cause" of death as if it's a fact and as if there are clear and better alternatives. No question there are mistakes and room for improvement, but you're linking to meta-studies where people decide what "mistake" means, not a recognized system of categorizing causes of death. I feel like the wording is vaguely implying general malfeasance, while the studies you linked to actually include categories of mistakes that are sometimes unavoidable and sometimes have very unclear lines of responsibility relative to the patient.
For example, "One example of a lethal error of communication between provider and patient occurred when cardiologists failed to warn their 19-year-old patient not to run. The patient had experienced syncope while running, and 5 days of inpatient, diagnostic testing were inconclusive; however, his cardiologists knew he was not ready to return to running but failed to warn him against this risk. Having not been warned against running, he resumed running and died 3 weeks later while running." https://journals.lww.com/journalpatientsafety/Fulltext/2013/...
This categorization assigns 100% of the blame to a cardiologist who was not performing a procedure and who did not know that the patient would die. The patient chose to do something for which they'd recently experienced issues with, without waiting for complete test results or clear instructions. It's an accident, and unfortunate, but my point is it's very problematic to conclude that the cause of death here is a medical mistake, rather than a heart condition. This is the representative example that the Journal of Patient Safety uses to illustrate communication errors, so it seems reasonable to assume there are many such examples.
Furthermore, how many people would be dying if there was no care instead? Probably a lot more, and that's not accounted for. To call mistakes the 3rd leading cause of death, I think we need to account for how many people were saved by medical care too... and when you think about it that way I suspect it's complicated if not impossible to tally that number, meaning that it's also complicated if not impossible to rank medical accidents as a cause of death against objectively identifiable categories like heart attack vs car accident.
I don’t have the statistics in front of me, but at one point I sourced them and was able to show that the risk of a child two years old or younger drowning in a bucket was significantly higher than being unintentionally killed with a firearm.
Following your logic here, if you have a toddler and a bucket at home, it would reduce your toddler’s overall risk profile if you bought a gun and shot holes in the bucket.
In other words, there’s a lot more that goes into using statistics to inform behavior than merely seeing what group you happen to be included in for a single breakdown.
> Only around 10 percent of people who saw a doctor at the Mayo Clinic after noticing an abnormal pulse reading on their watch were eventually diagnosed with a cardiac condition... it may take up doctor and patient time unnecessarily.
I... utterly fail to see the problem here.
If it were 0.01% that ended up having a problem, then OK I can see how this is not a signal worth paying attention to. But 10%?! 10% is huge.
Plus, there's no evidence of any harmful side effects here -- it's not like people are being sent into unnecessary surgery because of what their Apple Watch said. They're simply being given normal tests.
Now if Apple can make this more accurate, then great. But if this saves even a few lives, then the fact that 9 out of 10 warnings are false positives still seems extremely worth it, no?
The article paints this as a failure, when all I'm seeing is success.
Let's take this idea to the extreme for a moment and see if you agree that it's a problem.
A new device is created that alerts 50% of the US population that they have a condition that needs to be treated. Only 10% of those cases warranted further action.
Do you imagine there would be adverse side effects of hospitals being overrun with patients that didn't need to be there?
How can you utterly fail to see a problem with an influx of false positives to an already overloaded healthcare system?
This is ridiculous, if such a device exists and can detect a new condition that 5% of the US population has with a 80% false positive rate, and the condition was as serious as heart disease this would really be a miracle device and people would be grateful that such a thing exists.
I really have distaste for those comments that attempt to mask ideology with a veneer of logic. You attempt to use a limiting case argument that actually proves the original comment's argument and then end with rhetoric about how the healthcare system is being flooded already. That may be true, but that isn't relevant to the utility of the apple watch in this scenario.
> This is ridiculous, if such a device exists and can detect a new condition that 5% of the US population has with a 80% false positive rate, and the condition was as serious as heart disease this would really be a miracle device and people would be grateful that such a thing exists.
Since we're overly simplifying, there _are_ devices that can detect conditions that 5% of the population has _and_ have far fewer false positives - X-rays, CT scans, MRI. In the grand scheme amazing things, but no-one's calling them "miracle devices".
Oh, but they are miracle devices, and were considered as such initially. But the difference between them and the hypothetical miracle device is accessibility. MRIs and CT scans are not something you can use to casually test half of the country's population.
You might be right in an ideal world, but in reality there are significant resource constraints on healthcare.
What would be more likely to happen in that scenario, is that so many people would be seeking care that the 5% who were positive would be unlikely to even get the care they need.
Further, such an influx would have knock-on effects on unrelated patients, whose care would suffer due to the severe lack of resources.
This is all magnified if the resource is not a general practice physician, but a specialist.
> Further, such an influx would have knock-on effects on unrelated patients, whose care would suffer due to the severe lack of resources.
Hypothetically, let's assume over a long period of time new devices are alerting users to possible medical conditions. Those appointments are paid for (I'm guessing). Will that money not fund more availability over time? The supply of doctors is not supposed to be fixed.
That really does sound like ideology cloaked in common sense. Demand for great healthcare is already essentially infinite no matter what new technology comes along, and we need a sane way to deal with that. Pointing fingers at the demand side is a common diversionary tactic.
Wait - but if I'm reading the article correctly, it's not the case that all these people are flooding the ER, requiring urgent care. An alert pops up, a person is concerned, they decide to schedule a visit to their doctor.
If the healthcare system - paid healthcare system - can't handle a slow baseline increase in non-emergency visits, then something is seriously wrong with this picture.
That's an unrealistic scenario since 5% (10% of 50%) of the population doesn't have an otherwise difficult to detect and life threatening condition. And if they did, then there is a serious problem and we would expect the hospitals to be overrun.
Since you're feeling judgmental ("How can you utterly fail to see a problem..."), let's take it the other extreme.
Suppose a device is released that has a 30% false positive rate: two-thirds of the people it identifies have an actual underlying condition that requires treatment.
Presumably you would not be opposed to this. (If you do, you'd seem to be opposed to any effort to catch conditions early.)
So then we're at a discussion about what the correct percentage of false positives is for a further diagnostic - in this case, likely a holter monitor, to identify if it's an actual issue, which is not that expensive.
You believe it's obvious that ten percent is an outrageous number. But if the next step is a fairly inexpensive diagnostic, and the subject matter is a potentially lethal condition (often the case with hearts), it's not obvious at all.
What's your acceptable "brightline" of maximum false positivity to warrant additional diagnostic? Fifty percent? Twenty percent?
> I'm going to risk going against the zeitgeist and expose myself to a bunch of downvotes right now.
It’s off topic, but I recommend you do it. I’ve found HN to be a great place for those types of discussions provided you have a relatively thick skin and don’t engage in hostility.
The study started with 767,338 patients with clinical notes.
Out of that haystack, only 41 referred to an Apple Watch alert about abnormal pulse detection.
And of that 7 were found to have enough concern to further explore potential cardiovascular disease.
So, out of three quarters of a million visits, there were 41 with concerns from an Apple Watch, and 7 people received early treatment they might not have otherwise received (which could potentially save millions of dollars of future healthcare costs).
34 people were false positives and inconvenienced with a doctor's visit.
> A new device is created that alerts 50% of the US population that they have a condition that needs to be treated. Only 10% of those cases warranted further action.
This just improved the lives of 16 million people. That is not insignificant. And that's assuming 16 million people would have the same condition.
This also might be underestimating the number of false positives doctors already deal with and that these devices may actually lower that number.
>Now if Apple can make this more accurate, then great. But if this saves even a few lives, then the fact that 9 out of 10 warnings are false positives still seems extremely worth it, no?
No, not by a long shot, because physicians are a pretty rare commodity, care is expensive and sending nine out of ten people to the doctor for no reason is a huge drain on the system and public healthcare resources.
if you see this as success I don't think you're familiar with the concept of opportunity costs. For people who don't have any symptoms, have no history of heart conditions or other underlying risks, running around with an EKG on your wrist is absolutely ridiculous. All it will do is inflate healthcare costs with little improvement in outcome, which is already the primary disease of the US healthcare sector. And of course apple's and the healthcare sectors primary motivation to sell these things to begin with.
Not every cardiac condition even requires immediate attention by a physician, I wager most of the anomalies that show in the 10% are benign arrhythmias that would have been picked up on a yearly routine checkup in due time.
That's not happening. Only a small number of people went to the doctor. Of that number, 9 out of 10 ended up not being diagnosed with a (new) problem, but it seems that even some of them had related problems that were already diagnosed.
Regardless, we don't know the false positive rate. It's not 90%. You need to know the number of negatives before you can calculate it.
I had always been under the impression that the largest fraction of our spending was on people with chronic conditions or serious life-threatening medical issues like cancer? It's hard to imagine that people going to see the doctor once more per five years is really going to move the needle that much on resource consumption.
My GP is an “old school” family doctor in a small town. I’ve had similar inquiries in the past, and just scheduled an appointment with his receptionist. She had me describe the concern, his nurse - an NP, I think - approved the tests and the results were discussed at my next scheduled checkup. The actual physician had maybe an added couple of minutes demand on his time to view the results.
I don’t think this is anywhere near enough of an impact in terms of “false positives” to be a net negative.
50% of those 10% positive cases were atrial fibrillation which is pretty serious (can lead to stroke), and wouldn't be diagnosed at a routine checkup as it requires an ECG
I’m not making any claim about what the Apple Watch detects, or where we are w.r.t. detecting abnormalities in heart rate/rhythm/…, but the better our measurements get, the less serious the average detected abnormality will get.
In this case, all we know is they had they had a “clinically actionable cardiovascular diagnosis”. That action might have saved lives or might have added a few healthy months to the lives of a few, at the cost of requiring 20 to undergo treatment, spend time waiting for treatment, be worried, etc.
There can be a point where the cost and risks of testing people we can’t make healthier (either because they aren’t ill or because they are, but no effective treatment exists) outweighs the gains made by treating people we can treat.
That’s what the article being discussed, IMO rightfully, tries to measure.
It’s funny that this uses data from Mayo, a hospital know for medical over-utilization. Mayo has the “Medallion” program where high net worth clients can basically have any test they want. Full body MRI? No problem. Want a team of doctors to evaluate every bump on you skin? Medallion members can request that.
Arguably this allows Mayo to support lower income people but medical over-utilization is a part of Mayo’s business model.
The study found about 260 out of about 767,000 people came in because of something they saw on their watch. Out of the ~260, 41 actually had something wrong. Is it safe to assume those 41 people would NOT have gone in without the watch? Maybe.
I've had the utterly opposite experience. My father, and my wife's mother have both had cardiac issues. In both cases, doctors praised them for having a Apple Watch, and in one case, said to use that for monitoring her situation rather then send her home with a long term monitor and all that entails. Another extended family member did have a singificant issue that was first revealed with a watch.
I personally got a false alert once. I kept a eye on it, and it was fine - mentioned it my doctor, did a EKG just to be sure at my next checkup.
I, like the average person here it seems, fail to see the issue here, but that aside, this is most likely not a large enough sample size[0] to be a highly trusted statistic. That said, let's look at this from a different perspective.
> The Apple Watch abnormal pulse detection feature was designed to address asymptomatic (so-called silent) atrial fibrillation. Atrial fibrillation is the most common cardiac arrhythmia, affecting over 30 million people worldwide[0].
So, assuming there's 8 billion people in the world, this affects .375% of the population. Assuming this was a statistically significant study, that means that if everyone in the world had an apple watch, this would only let 300 million people know they potentially had an AFIB event. Now, an excess of 270 million might seem excessive--but I would weigh excessive with the burden this event puts on the medical community. The primary means of diagnoses for an AFIB event is an ECG[1], which costs $150 on Amazon. Assuming they don't have to buy an ECG for each individual, I would assume the cost to most health care clinics for diagnosis is around $100. However, this test
1. Does not have to be administered by anyone other than a nurse.
2. Only has to be administered once in a lifetime for a diagnosis.
So now 10% doesn't seem that bad given that the burden is distributed to the global healthcare system over time. Keep in mind too, even if every single one of these people visited the ER, then this would be completely in line with the fact that only 10% of ER visits result in an admission[2] to the hospital.
60 comments
[ 147 ms ] story [ 2389 ms ] threadThat's really the doctor's issue to address, not the device's. Sticking your head in the sand isn't the right solution to the problems of dealing with information too aggressively.
> They've backed away from screening as aggressively for certain cancers because the risks of aggressive treatment turned out to be significant and it turned out that more people than expected had tumors which didn't develop into a problem before they died of something else.
Literally the only way to build viable metrics for which tumors will develop into problems is for _everyone_ get screened, not for no one to get screened. The problem of treating too aggressively is a treatment problem, not a measurement problem. If we avoid measuring, we have no way to learn how to treat better.
If we decide to never look because we don't yet know how to handle the information, then we will never know how to handle the information.
One of the most important questions you can ask your doctor is "what happens if I don't have this test?" and "What happens if I don't have this treatment?" But most people don't ask these questions.
And so it really is a measurement problem. Over-testing, over-diagnosis, and over-treatment are well understood mechanisms of harm.
https://ebm.bmj.com/content/23/1/1
https://www.bmj.com/content/362/bmj.k2820
The harm caused by inappropriate screening is so severe that we (UK) have a committee to weigh up the harm vs benefit of different screening programmes. https://www.gov.uk/government/groups/uk-national-screening-c...
Putting the burden of asking these questions on the patient is wrong because patients don't go through a decade of training to become patients. And expecting the doctors to always ask these questions is wrong because I guess now we're not supposed to trust our doctors. But that doesn't mean we should suddenly live in a world without patient advocacy. It means you need to put it in the right place, in the hands of neither the patient nor the doctor directly. But if you never measure, and you need to be clear that, modulo epsilon, nobody ever measures heart rhythms despite heart disease being the #1 cause of death, then you definitely have no chance for anyone to ask those questions.
> over-diagnosis and over-treatment are well understood mechanisms of harm.
So are under-diagnosis and under-treatment. Both can only ultimately be solved by more information, not less.
Again, it's not that simple. Doctors do not have perfect knowledge and have factors to consider other than the current academic consensus. Some fraction of people will get scared and demand _something_, which will for some people lead to them doing something worse than nothing at all. If you have many people seeking out treatment for a notification which has them scared, some of the patients will try something other than good medical treatments and some of them will have doctors who recommend things which used to be or are no longer best practice, make a recommendation skewed by a financial incentive or what will turn out to be a biased study funded by a company with a financial stake, etc.
Engineers building tools like this have a tricky ethical line to walk between making information available and considering how that information could be misinterpreted or faulty. One of the biggest things I'd want to see on a system like this is careful treatment of showing confidence levels and present them in the UX. “️ Heart anomaly detected!” is not the same as “Our sensor reading was unusual but the signal was low-quality. Do you feel okay?”, etc.
Doctors will rarely subject anyone to thorough evaluation for things if they aren't over the common danger age and don't report specific symptoms. Your typical annual checkup for people not 50+ is a fairly generic blood panel and very little else. After 50 they may add, what, a prostate probe for men?
In my life I've had one doctor who performed an EKG as part of my annual checkup, once.
The other ~10 primary care physicians I've had never did -- my annual was mostly just a few questions, some blood work, quick reflex tests and I think they looked in my ears and eyes.
If my Apple Watch detected a heart irregularity, I can say with certainty it's not something that would be caught otherwise at my next annual checkup.
I see a large part of a doctor’s job as being an expert consultant for an individual to make decisions about their own healthcare. Someone who is interested in and involved in their own risks is likely an extreme outlier to begin with.
https://www.google.com/amp/s/www.cnbc.com/amp/2018/02/22/med...
Damned if you do, Damned if you don't.
For example, "One example of a lethal error of communication between provider and patient occurred when cardiologists failed to warn their 19-year-old patient not to run. The patient had experienced syncope while running, and 5 days of inpatient, diagnostic testing were inconclusive; however, his cardiologists knew he was not ready to return to running but failed to warn him against this risk. Having not been warned against running, he resumed running and died 3 weeks later while running." https://journals.lww.com/journalpatientsafety/Fulltext/2013/...
This categorization assigns 100% of the blame to a cardiologist who was not performing a procedure and who did not know that the patient would die. The patient chose to do something for which they'd recently experienced issues with, without waiting for complete test results or clear instructions. It's an accident, and unfortunate, but my point is it's very problematic to conclude that the cause of death here is a medical mistake, rather than a heart condition. This is the representative example that the Journal of Patient Safety uses to illustrate communication errors, so it seems reasonable to assume there are many such examples.
Furthermore, how many people would be dying if there was no care instead? Probably a lot more, and that's not accounted for. To call mistakes the 3rd leading cause of death, I think we need to account for how many people were saved by medical care too... and when you think about it that way I suspect it's complicated if not impossible to tally that number, meaning that it's also complicated if not impossible to rank medical accidents as a cause of death against objectively identifiable categories like heart attack vs car accident.
Following your logic here, if you have a toddler and a bucket at home, it would reduce your toddler’s overall risk profile if you bought a gun and shot holes in the bucket.
In other words, there’s a lot more that goes into using statistics to inform behavior than merely seeing what group you happen to be included in for a single breakdown.
I... utterly fail to see the problem here.
If it were 0.01% that ended up having a problem, then OK I can see how this is not a signal worth paying attention to. But 10%?! 10% is huge.
Plus, there's no evidence of any harmful side effects here -- it's not like people are being sent into unnecessary surgery because of what their Apple Watch said. They're simply being given normal tests.
Now if Apple can make this more accurate, then great. But if this saves even a few lives, then the fact that 9 out of 10 warnings are false positives still seems extremely worth it, no?
The article paints this as a failure, when all I'm seeing is success.
A new device is created that alerts 50% of the US population that they have a condition that needs to be treated. Only 10% of those cases warranted further action.
Do you imagine there would be adverse side effects of hospitals being overrun with patients that didn't need to be there?
How can you utterly fail to see a problem with an influx of false positives to an already overloaded healthcare system?
I really have distaste for those comments that attempt to mask ideology with a veneer of logic. You attempt to use a limiting case argument that actually proves the original comment's argument and then end with rhetoric about how the healthcare system is being flooded already. That may be true, but that isn't relevant to the utility of the apple watch in this scenario.
Since we're overly simplifying, there _are_ devices that can detect conditions that 5% of the population has _and_ have far fewer false positives - X-rays, CT scans, MRI. In the grand scheme amazing things, but no-one's calling them "miracle devices".
Perhaps, but you can't wear one on your wrist and you generally have to be quite sure something is wrong first.
What would be more likely to happen in that scenario, is that so many people would be seeking care that the 5% who were positive would be unlikely to even get the care they need.
Further, such an influx would have knock-on effects on unrelated patients, whose care would suffer due to the severe lack of resources.
This is all magnified if the resource is not a general practice physician, but a specialist.
Hypothetically, let's assume over a long period of time new devices are alerting users to possible medical conditions. Those appointments are paid for (I'm guessing). Will that money not fund more availability over time? The supply of doctors is not supposed to be fixed.
If the healthcare system - paid healthcare system - can't handle a slow baseline increase in non-emergency visits, then something is seriously wrong with this picture.
Suppose a device is released that has a 30% false positive rate: two-thirds of the people it identifies have an actual underlying condition that requires treatment.
Presumably you would not be opposed to this. (If you do, you'd seem to be opposed to any effort to catch conditions early.)
So then we're at a discussion about what the correct percentage of false positives is for a further diagnostic - in this case, likely a holter monitor, to identify if it's an actual issue, which is not that expensive.
You believe it's obvious that ten percent is an outrageous number. But if the next step is a fairly inexpensive diagnostic, and the subject matter is a potentially lethal condition (often the case with hearts), it's not obvious at all.
What's your acceptable "brightline" of maximum false positivity to warrant additional diagnostic? Fifty percent? Twenty percent?
But what you described sounds reminiscent of the PCR test we have for COVID right now. I at least hope many are aware of this here.
It’s off topic, but I recommend you do it. I’ve found HN to be a great place for those types of discussions provided you have a relatively thick skin and don’t engage in hostility.
Out of that haystack, only 41 referred to an Apple Watch alert about abnormal pulse detection.
And of that 7 were found to have enough concern to further explore potential cardiovascular disease.
So, out of three quarters of a million visits, there were 41 with concerns from an Apple Watch, and 7 people received early treatment they might not have otherwise received (which could potentially save millions of dollars of future healthcare costs).
34 people were false positives and inconvenienced with a doctor's visit.
This seems like a net positive.
This just improved the lives of 16 million people. That is not insignificant. And that's assuming 16 million people would have the same condition.
This also might be underestimating the number of false positives doctors already deal with and that these devices may actually lower that number.
No, not by a long shot, because physicians are a pretty rare commodity, care is expensive and sending nine out of ten people to the doctor for no reason is a huge drain on the system and public healthcare resources.
if you see this as success I don't think you're familiar with the concept of opportunity costs. For people who don't have any symptoms, have no history of heart conditions or other underlying risks, running around with an EKG on your wrist is absolutely ridiculous. All it will do is inflate healthcare costs with little improvement in outcome, which is already the primary disease of the US healthcare sector. And of course apple's and the healthcare sectors primary motivation to sell these things to begin with.
Not every cardiac condition even requires immediate attention by a physician, I wager most of the anomalies that show in the 10% are benign arrhythmias that would have been picked up on a yearly routine checkup in due time.
> No, not by a long shot, because... [opportunity costs, overloading the healthcare system]
Totally agree with all of that.
Why don't EKG salons exist (like nail and hair salons)? New market opportunity created by the Apple Watch?
That's not happening. Only a small number of people went to the doctor. Of that number, 9 out of 10 ended up not being diagnosed with a (new) problem, but it seems that even some of them had related problems that were already diagnosed.
Regardless, we don't know the false positive rate. It's not 90%. You need to know the number of negatives before you can calculate it.
10% positive predictive value for something like this is pretty good. It’s certainly better than “hey look at this weird mole.”
I don’t think this is anywhere near enough of an impact in terms of “false positives” to be a net negative.
https://academic.oup.com/jamia/article/27/9/1359/5911974
In this case, all we know is they had they had a “clinically actionable cardiovascular diagnosis”. That action might have saved lives or might have added a few healthy months to the lives of a few, at the cost of requiring 20 to undergo treatment, spend time waiting for treatment, be worried, etc.
There can be a point where the cost and risks of testing people we can’t make healthier (either because they aren’t ill or because they are, but no effective treatment exists) outweighs the gains made by treating people we can treat.
That’s what the article being discussed, IMO rightfully, tries to measure.
Arguably this allows Mayo to support lower income people but medical over-utilization is a part of Mayo’s business model.
Here's the numbers from the study:
https://academic.oup.com/view-large/figure/207880397/ocaa137...
Full study:
https://academic.oup.com/jamia/article/27/9/1359/5911974
I personally got a false alert once. I kept a eye on it, and it was fine - mentioned it my doctor, did a EKG just to be sure at my next checkup.
That's the way this should work.
> The Apple Watch abnormal pulse detection feature was designed to address asymptomatic (so-called silent) atrial fibrillation. Atrial fibrillation is the most common cardiac arrhythmia, affecting over 30 million people worldwide[0].
So, assuming there's 8 billion people in the world, this affects .375% of the population. Assuming this was a statistically significant study, that means that if everyone in the world had an apple watch, this would only let 300 million people know they potentially had an AFIB event. Now, an excess of 270 million might seem excessive--but I would weigh excessive with the burden this event puts on the medical community. The primary means of diagnoses for an AFIB event is an ECG[1], which costs $150 on Amazon. Assuming they don't have to buy an ECG for each individual, I would assume the cost to most health care clinics for diagnosis is around $100. However, this test
1. Does not have to be administered by anyone other than a nurse. 2. Only has to be administered once in a lifetime for a diagnosis.
So now 10% doesn't seem that bad given that the burden is distributed to the global healthcare system over time. Keep in mind too, even if every single one of these people visited the ER, then this would be completely in line with the fact that only 10% of ER visits result in an admission[2] to the hospital.
[0] https://academic.oup.com/jamia/article/27/9/1359/5911974
[1] https://www.mayoclinic.org/diseases-conditions/atrial-fibril...
[2] https://www.cdc.gov/nchs/fastats/emergency-department.htm