Analysis of care pathway variation patterns in patient records

A care/clinical pathway (CP) is a standardized care process where temporal and data constraints of clinical activities are defined to ensure quality of care. In actual care practice, various situations of compliance and non-compliance with CPs can be observed. Analysis of these CP variation patterns (CPVPs) can help improve care quality and enhance decision support. In this paper, we propose an automatic method to detect CPVPs in electronic medical records (EMR), and statistically examine their correlation with patient outcomes. From each CP constraint, we first derive a CPVP tree, where each pattern is represented using first-order linear temporal logic and translated into a Büchi automaton for pattern detection. Then we identify the CPVPs that are evidently correlated with a patient outcome by examining the odds ratios. The method has been applied to a CP for congestive heart failure and real world EMR to demonstrate the effectiveness.

Synthesizing analytic evidence to refine care pathways

Care pathways play significant roles in delivering evidence-based and coordinated care to patients with specific conditions. In order to put care pathways into practice, clinical institutions always need to adapt them based on local care settings so that the best local practices can be incorporated and used to develop refined pathways. However, it is knowledge-intensive and error-prone to incorporate various analytic insights from local data sets. In order to assist care pathway developers in working effectively and efficiently, we propose to automatically synthesize the analytical evidences derived from multiple analysis methods, and recommend modelling operations accordingly to derive a refined care pathway for a specific patient cohort. We validated our method by adapting a Congestive Heart Failure (CHF) Ambulatory Care Pathway for patients with additional condition of COPD through synthesizing the results of variation analysis and frequent pattern mining against patient records.

Mining Temporal and Data Constraints Associated with Outcomes for Care Pathways

A care/clinical pathway defines a standardized care process for a specific patient group, which consists of clinical goals, activities, data attributes, and constraints describing temporal dependencies and data preconditions of the activities. The constraints, which are the key elements to represent the best practices, are difficult to define due to the variations in different regions and populations. In this paper, we propose an approach to discover temporal and data constraints that are correlated with clinical outcomes for care pathways. For each activity of interest, we extract a set of associated event-condition-action (ECA) rules from electronic medical records (EMR) to represent the temporal and data preconditions of the activity, by using our modified association rule mining algorithm. Then the best ECA rule that is significantly more likely to lead to a positive outcome is translated into the constraint on the activity. The approach has been applied to real-world EMR, and discovered meaningful constraints for different groups of type 2 diabetes patients, which can be used to provide decision support during individual patient care.

A Decision Fusion Framework for Treatment Recommendation Systems

Treatment recommendation is a nontrivial task--it requires not only domain knowledge from evidence-based medicine, but also data insights from descriptive, predictive and prescriptive analysis. A single treatment recommendation system is usually trained or modeled with a limited (size or quality) source. This paper proposes a decision fusion framework, combining both knowledge-driven and data-driven decision engines for treatment recommendation. End users (e.g. using the clinician workstation or mobile apps) could have a comprehensive view of various engines' opinions, as well as the final decision after fusion. For implementation, we leverage several well-known fusion algorithms, such as decision templates and meta classifiers (of logistic and SVM, etc.). Using an outcome-driven evaluation metric, we compare the fusion engine with base engines, and our experimental results show that decision fusion is a promising way towards a more valuable treatment recommendation.

Outcome-driven Evaluation Metrics for Treatment Recommendation Systems

Treatment recommendation systems aim to providing clinical decision supports, e.g. with integration of Computerized Physician Order Entry (CPOE). One of the most significant issue is the quality of recommendations which needs to be quantified, before getting the acceptance from physicians. In computer science, such evaluations are typically performed by applying appropriate metrics that provides a comparison of different systems. However, a big challenge for evaluating treatment recommendation systems is that ground truth is only partially observed. In this paper, we propose an outcome-driven evaluation methodology, and present five metrics (i.e. precision, recall, accuracy, relative risk and odds ratio) with highlight of their statistic meanings in clinical context. The experimental results are based on the comparison of two well-developed treatment recommendation systems (one is knowledge-driven and based on clinical practice guidelines, while the other is data-driven and based on patient similarity analysis), using our proposed evaluation metrics. As a conclusion, physicians are less prone to comply with clinical guidelines, but once following guideline recommendations, it is much more likely to get good outcomes than not following.

CD4+Foxp3+ regulatory T cell differentiation mediated by endometrial stromal cell-derived TECK promotes the growth and invasion of endometriotic lesions

Endometriosis is associated with an abnormal immune response to endometrial cells, which can facilitate the implantation and proliferation of ectopic endometrial tissue. The proportion of CD4(+)Foxp3(+) regulatory T cells (Tregs) is significantly increased in the peritoneal fluid of women with endometriosis. The thymus-expressed chemokine TECK/CCL25 directly promotes the invasiveness of endometrial stromal cells (ESCs). The aim of this study was to investigate the effects of ESC-derived TECK on the crosstalk between Tregs and ESCs in the progress of endometriosis. We determined that the percentage of Tregs and the concentration of TECK increased in the peritoneal fluid with the progression of endometriosis. The supernatant from co-cultured human ESCs and macrophages not only induced Treg differentiation and increased Treg expression of interleukin-10 (IL-10), transforming growth factor-β (TGF-β) and CD73 by activating the AKT/STAT3 signaling pathway but also repressed Treg apoptosis by downregulating Fas and FasL expression and enhanced the Treg-mediated suppression of CD4(+)CD25(-) T cells. In addition, in vitro and in vivo trials confirmed that these effects could be inhibited by anti-TECK neutralizing Abs. The secretion of IL-10 and TGF-β by Tregs increased MMP2 expression and decreased TIMP1 expression and further stimulated the proliferation and invasion of ESCs and the growth of ectopic lesions. These results indicate that TECK derived from ESCs and macrophages upregulates the number and function of Tregs in the ectopic milieu, which contributes to endometriotic immunotolerance and high levels of ESC proliferation and invasion, thereby facilitating the progression of endometriosis.

Decellularized kidney scaffold-mediated renal regeneration

Renal regeneration approaches offer great potential for the treatment of chronic kidney disease, but their availability remains limited by the clinical challenges they pose. In the present study, we used continuous detergent perfusion to generate decellularized (DC) rat kidney scaffolds. The scaffolds retained intact vascular trees and overall architecture, along with significant concentrations of various cytokines, but lost all cellular components. To evaluate its potential in renal function recovery, DC scaffold tissue was grafted onto partially nephrectomized rat kidneys. An increase of renal size was found, and regenerated renal parenchyma cells were observed in the repair area containing the grafted scaffold. In addition, the number of nestin-positive renal progenitor cells was markedly higher in scaffold-grafted kidneys compared to controls. Moreover, radionuclide scan analysis showed significant recovery of renal functions at 6 weeks post-implantation. Our results provide further evidence to show that DC kidney scaffolds could be used to promote renal recovery in the treatment of chronic kidney disease.

The impact of the International Association of Diabetes and Pregnancy Study Groups (IADPSG) fasting glucose diagnostic criterion on the prevalence and outcomes of gestational diabetes mellitus in Han Chinese women

AIMS

The International Association of Diabetes and Pregnancy Study Groups (IADPSG) proposed that a one-time value of fasting plasma glucose of 5.1 mmol/l or over at any time of the pregnancy is sufficient to diagnose gestational diabetes. We evaluated the repercussions of the application of this threshold in pregnant Han Chinese women.

METHODS

This is a retrospective study of 5360 (72.3% of total) consecutively recruited pregnant Han Chinese women in one centre from 2008 to 2011. These women underwent a two-step gestational diabetes diagnostic protocol according to the previous American Diabetes Association criteria. The IADPSG fasting plasma glucose criterion was used to reclassify these 5360 women. The prevalence, clinical characteristics and obstetric outcomes were compared among the women classified as having gestational diabetes by the previous American Diabetes Association criteria (approximately 90% were treated), those reclassified as having gestational diabetes by the single IADPSG fasting plasma glucose criterion (untreated), but not as having gestational diabetes by the previous American Diabetes Association criteria, and those with normal glucose tolerance.

RESULTS

There were 626 cases of gestational diabetes defined by the previous American Diabetes Association criteria (11.7%) and these cases were associated with increased risks of maternal and neonatal outcomes when compared with the women with normal glucose tolerance. With the IADPSG fasting plasma glucose criterion, another 1314 (24.5%) women were reclassified as having gestational diabetes. Gestational diabetes classified by the IADPSG fasting plasma glucose criterion was associated with gestational hypertension (P = 0.0094) and neonatal admission to nursery (P = 0.035) prior to adjustment for maternal age and BMI, but was no longer a predictor for adverse pregnancy outcomes after adjustment.

CONCLUSION

The simple IADPSG fasting plasma glucose criterion increased the Chinese population with gestational diabetes by 200%. The increased population with gestational diabetes was not significantly associated with excess obstetric and neonatal morbidity.

Incremental cost-effectiveness of improving treatment results among migrant tuberculosis patients in Shanghai

SETTING

Two projects were introduced in October 2007 to improve treatment completion among rural-to-urban migrant tuberculosis (TB) patients in Shanghai. The Communicable Disease Research Consortium (COMDIS) project provided financial incentives to poor patients, whereas the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) project provided incentives to all patients and increased staff time.

OBJECTIVE

To assess the incremental cost-effectiveness of these two projects.

METHODS

Case study. Costs were assessed from a societal perspective. The primary measure of effectiveness was the treatment completion rate. The incremental cost-effectiveness ratio was calculated as the additional cost of the intervention divided by the additional percentage of patients completing treatment compared to controls.

RESULTS

Post intervention, the treatment completion rates in the COMDIS and Global Fund projects were respectively 89% and 88%, 17% and 16% higher than in the control district (76%). For one additional per cent of patients to complete treatment, the additional cost of the COMDIS intervention was US$1891, 91% lower than that of the Global Fund intervention (US$21,904).

CONCLUSION

The intervention that addressed the financial barriers of poor patients was more cost-effective than the comprehensive intervention that provided assistance to both patients and providers. Further study is needed to understand the process of interventions prior to wider scale-up.

Embracing case management for computerization of care pathways

The computerization of care pathways (CPs) has drawn considerable attention, for improving quality of health care and reducing costs. A well-known big challenge of implementing CPs is their flexibility and ad hoc variations in execution of clinical tasks. We observe that case management suits well to address this problem, and this paper proposes a CMMN-based CP model, where CMMN (Case Management Model and Notation) is becoming an industry standard. Via an experimental experience on modelling CHF (congestive heart failure) ambulatory CP, we illustrate that the usage of case management paves the way to popularize CPs, particularly for its quick deployment and execution in industrial products.

Care pathway workbench: evidence harmonization from guideline and data

Care pathways (CPs) as a means of healthcare quality control are getting increasing attention due to widespread recognition in the healthcare industry of the need for well coordinated, evidence based and personalized care. To keep the promise, CPs require continuous refinement in order to stay up to date with regard to both clinical guidelines and data-driven insights from real world practices. There is therefore a strong demand for a unified platform that allows harmonization of evidence coming from multiple sources. In this paper we describe Care Pathway Workbench, a web-based platform that enables users to build and continuously improve Case Management Model and Notation based CPs by harmonizing evidences from guidelines and patient data. To illustrate the functionalities, we describe how a CHF (Congestive Heart Failure) Ambulatory Care Pathway can be developed using this workbench by first extracting key elements from widely accepted guidelines for CHF management, then incorporating evidence mined from clinical practice data, and finally transforming and exporting the resulting CP model to a care management product.

Automatic variance analysis of multistage care pathways

A care pathway (CP) is a standardized process that consists of multiple care stages, clinical activities and their relations, aimed at ensuring and enhancing the quality of care. However, actual care may deviate from the planned CP, and analysis of these deviations can help clinicians refine the CP and reduce medical errors. In this paper, we propose a CP variance analysis method to automatically identify the deviations between actual patient traces in electronic medical records (EMR) and a multistage CP. As the care stage information is usually unavailable in EMR, we first align every trace with the CP using a hidden Markov model. From the aligned traces, we report three types of deviations for every care stage: additional activities, absent activities and violated constraints, which are identified by using the techniques of temporal logic and binomial tests. The method has been applied to a CP for the management of congestive heart failure and real world EMR, providing meaningful evidence for the further improvement of care quality.

First determination of the weak charge of the proton

The Q(weak) experiment has measured the parity-violating asymmetry in ep elastic scattering at Q(2)=0.025(GeV/c)(2), employing 145 μA of 89% longitudinally polarized electrons on a 34.4 cm long liquid hydrogen target at Jefferson Lab. The results of the experiment's commissioning run, constituting approximately 4% of the data collected in the experiment, are reported here. From these initial results, the measured asymmetry is A(ep)=-279±35 (stat) ± 31 (syst) ppb, which is the smallest and most precise asymmetry ever measured in ep scattering. The small Q(2) of this experiment has made possible the first determination of the weak charge of the proton Q(W)(p) by incorporating earlier parity-violating electron scattering (PVES) data at higher Q(2) to constrain hadronic corrections. The value of Q(W)(p) obtained in this way is Q(W)(p)(PVES)=0.064±0.012, which is in good agreement with the standard model prediction of Q(W)(p)(SM)=0.0710±0.0007. When this result is further combined with the Cs atomic parity violation (APV) measurement, significant constraints on the weak charges of the up and down quarks can also be extracted. That PVES+APV analysis reveals the neutron's weak charge to be Q(W)(n)(PVES+APV)=-0.975±0.010.

Comparison of endovenous laser ablation and high ligation and stripping for varicose vein treatment: a meta-analysis

Objectives:

To evaluate the efficiency and safety of endovenous laser ablation (EVLA) for primary lower extremity varicosities compared with high ligation and stripping (HLS).

Method:

Prospective non-randomized studies and randomized control trials on comparison of EVLA and HLS in treating varicose vein were included in this study. A meta-analysis on the data of suitable 13 clinical trials was performed using the Mantel–Haenszel method and the risk ratio was calculated. Thirteen studies including a total of 2245 limbs were eligible for inclusion. Among them, 1128 limbs were treated with endovenous laser ablation, whereas 1117 were treated with high ligation and stripping. Primary outcome measures were technical success rates and recurrence rates at different follow-up duration and complication rates.

Results:

No significant difference in initial technical success rates, Procedural failures were more common following EVLA compared with conventional surgery at one- and two-year follow-up. However, the duplex-detected and clinical recurrence rate was similar between conventional surgery and EVLA after one and two years. No statistical significance was found in postoperative phlebitis and bruise in EVLA and HLS (17.9% versus 21.5%). However, fewer complications were observed in EVLA compared with HLS, including bleeding and haematoma (1.28% versus 4.83%), wound infection (0.33% versus 1.91%) and paraesthesia (6.73% versus 11.27%).

Conclusions:

EVLA for varicose veins is safe and effective compared with HLS in a two-year range. More randomized controlled studies follow-up results are needed to clarify longterm recurrence (5 years).

A framework for evaluating sequential clinical interventions with disease progression

This work proposes to leverage an advanced modeling technique, namely Markov Decision Process, to evaluate sequential clinical interventions in disease management. We have demonstrated our evaluation framework on a diabetes case study over two real data sets, and discovered valuable clinical insights towards better interventions during disease progression.

An efficacy driven approach for medication recommendation in type 2 diabetes treatment using data mining techniques

We demonstrate how data mining techniques can help recommend effective medications when physicians need to control the glucose level of patients with type 2 diabetes. We first identify the factors that may affect physicians' medication decisions and then develop a patient-similarity based approach to automatically recommend medications for a patient with the specific condition so that his blood glucose level (measured by HbA1C value) can be well controlled. The approach is validated through experiments on real data sets and compared with the recommendations by following a clinical guideline.

An engine for compliance checking of clinical guidelines

Although, clinical guidelines are regarded as best practices for clinicians, clinician activities are not always compliant with guideline recommendations. This paper aims to improve clinician compliance with guidelines. We have developed an engine to automatically report three non-compliance situations: 1) guideline recommendations exist, and the clinician performed some activities, but not according to the guidelines; 2) guideline recommendations exist, but the clinician did nothing; 3) guideline recommendations do not exist, but the clinician performed some activities. In particular, we highlight effective time for compliance checking, as well as membership, numeric relationships, concept subsumption and contextualization. We deployed our engine to a clinical setting involving the daily care routine of diabetes patients, and generated non-compliance reports for pilot users.

Towards collaborative chronic care using a clinical guideline-based decision support system

Few clinical guideline-based decision support systems (DSS) have been successfully applied in chronic disease management. This paper investigates how clinical guideline-based DSS can help to put innovative chronic care models into practice and improve the quality of chronic care. A prototype of a guideline-based collaborative chronic care system called GC3 was developed based on a framework integrating guidelines into care workflow where a business process engine and a GELLO-based decision engine are integrated together to execute guidelines. We deployed the system in one of the largest hospitals in China and its affiliated community centers in order to manage type 2 diabetic patients. Pilot use of GC3 demonstrates its benefits to regional chronic care including evidence-based decision support, shared care content, improved clinician adherence to guidelines and enhanced patient self-management. This study verifies the feasibility and effectiveness in implementing collaborative chronic care across health providers using clinical guideline-based DSS.

Genetic diversity analysis of an indigenous Chinese buffalo breed and hybrids based on microsatellite data

Chinese native buffaloes have faced the threat of extinction, along with an increase in crossbreeding with domesticated river buffaloes; consequently, conservation of local buffalo genetic resources has become a priority. A Chinese native breed, Jianghan, is often crossed intentionally and unintentionally with imported breeds from India and Pakistan, Murrah, and Nili-Ravi. A total of 128 buffaloes of the breeds Jianghan, Murrah, and Nili-Ravi and their presumed hybrid offspring were genotyped for 10 microsatellite markers. Heterozygosity and Wright's F-statistics were calculated to determine the genetic variation in those populations. The observed average heterozygosities ranged from 0.836 (Murrah) to 0.986 (Jianghan), higher than the expected heterozygosities and all the inbreeding values within the populations were negative. The genetic distances between the presumed hybrid buffaloes and the two imported river type dairy buffalo breeds (Murrah and Nili-Ravi) were lower than with the native Jianghan, indicating strong contributions of the imported breeds to this presumed hybrid buffalo population. This information will be useful for the development of rational breeding for the dairy buffalo industry and for conservation strategies for the Jianghan buffalo.