Marcia Frellick

May 24, 2017

Dr Sei Lee

SAN ANTONIO — A mortality calculator that helps physicians assess the risks and benefits of interventions, now widely known as the Lee index, spurred controversy at first because it sometimes encourages the withholding of care from certain patients.

It can be more important to focus on back pain or depression than on mammogram or colonoscopy, Sei Lee, MD, told Medscape Medical News. Time to benefit from either screening, estimated to be about 10 years, can surpass expected lifespan, and there are risks associated with screenings, such as perforated colon and overtreatment.

Conversations about why one treatment path is pursued and another is not can be emotional, said Dr Lee, who is associate professor at the University of California, San Francisco.

The mortality calculator, which helps physicians find the sweet spot between harm and benefit, has been validated out to 10 years (JAMA. 2006;295:801-808). The practice has been worked into guidelines and is changing patient care, although Dr Lee noted, with a laugh, that he is pretty sure he has never called it the Lee index himself.

At the American Geriatrics Society (AGS) 2017 Annual Meeting, Dr Lee was honored for his life's work with the Thomas and Catherine Yoshikawa Award for Outstanding Scientific Achievement in Clinical Investigation.

"Dr Lee is a skilled clinician and recognized scholar," said AGS President Ellen Flaherty, PhD. "The future of geriatrics is rooted in providing high-quality, person-centered care for us all as we age."

After receiving the award, Dr Lee delivered a plenary, during which he explained how calculations of benefit and harm can drive care.

How can we individualize decisions so that only people who benefit from these tests will get them?

Screenings for breast, colorectal, and prostate cancers take at least 10 years to show benefit, intensive glycemic control takes at least 8 years, primary-prevention interventions, such as statins, appear to take about 3 years, and intensive blood pressure control takes about 1.5 years.

"For a patient with a life expectancy of 5 years, it probably makes sense to continue intensive blood pressure control and continue statins, but probably does not make sense to continue cancer screening or intensive glycemic control," Dr Lee said.

"How can we individualize decisions so that only people who benefit from these tests will get them?" asked Dr Lee. This kind of prioritization can be used on a wide scale, at annual Medicare wellness visits, for example. Dr Lee said he has proposed the idea, but acknowledged that it hasn't gained much traction.

Although the basis of a lot of his work is mathematics, he emphasized that numbers are just a small part of the equation.

People Behind the Stats

One of the things he enjoys most, he explained, is talking with his patients. It is the stories that come from a lifetime of choices — about habits, partners, professions, lifestyles — that drew him to geriatrics. Dr Lee said he likes the expression, "If you've seen one geriatric patient, you've seen...one geriatric patient."

"At the risk of insulting my colleagues, I'm not so sure you could say the same about treating a 1-year-old," he added. "We all come into this world fairly similar to one another. As we become adults and make more choices for ourselves, we become more and more different from each other."

During his internship in internal medicine, Dr Lee learned that in the race to complete rounds, order tests, and check vitals, a patient's story can get lost.

During one conversation, he realized his patient, whom he had known only as a man in his 70s with a history of diabetes and heart failure, was a famous science fiction writer. When Dr Lee read one of his books, he got a sense of why the work was so influential to the genre.

Personal relationships bring comfort in the reverse, as well, he pointed out.

He said he learned as much about managing diabetes as he taught from one of his patients when he was a medical student. Dr Lee prescribed a new medicine that caused a fiery full-body rash and resulted in the patient being hospitalized for a few days. Severe rash was a known, but rare, potential effect of the drug.

"I felt horrible," he explained. "But he consoled me, saying, 'I trust you. I still think you're a great doctor. I have faith in you'."

Man Behind the Doctor

Dr Sei Lee's father, the late Abraham Lee, practiced
acupuncture and Asian herbal medicine (Source, Sei Lee)

Dr Lee's family moved to the United States from Seoul, South Korea, in 1976, when Dr Lee was 7. His father, the late Abraham Lee, practiced acupuncture and Asian herbal medicine outside of Philadelphia, which gave him insight into healing.

It's incredibly frightening when our bodies are giving out.

"I tell medical students that as physicians, it's easy to think of ourselves as being very different from the unscientific tribal medicine men from backward societies," he explained. "But every society has recognized the value of people who are able to see the sick, and comfort and guide and, hopefully, cure. But if you're unable to cure, at least comfort those in dire health situations," Dr Lee said. "It's incredibly frightening when our bodies are giving out."

Dr Lee's team created the easy-to-use ePrognosis website to predict the benefit of various interventions on the basis of individual life expectancy.

Not many people do what Dr Lee does; "more than a handful but fewer than a classroom," he acknowledged.

Ideally, targeted prevention decisions — such as sticking strictly to the age ranges for procedures set by guidelines — will be tested in large randomized controlled trials against usual care.

In the meantime, Dr Lee said he will continue to work on calculating benefit and harm in prevention for older patients, at least for the next 5 years, but "probably longer."

"I'm passionate about it," he said. "It's hard to imagine I would completely move away from this."

Dr Lee and Dr Flaherty have disclosed no relevant financial relationships.

American Geriatrics Society (AGS) 2017 Annual Scientific Meeting. Presented May 19, 2017.

Follow Medscape on Twitter @Medscape and Marcia Frellick @mfrellick

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