1
|
Hart JL, Malik L, Li C, Summer A, Ogunduyile L, Steingrub J, Lo B, Zlatev J, White DB. Clinicians' Use of Choice Framing in ICU Family Meetings. Crit Care Med 2024:00003246-990000000-00349. [PMID: 38912880 DOI: 10.1097/ccm.0000000000006360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
OBJECTIVES To quantify the frequency and patterns of clinicians' use of choice frames when discussing preference-sensitive care with surrogate decision-makers in the ICU. DESIGN Secondary sequential content analysis. SETTING One hundred one audio-recorded and transcribed conferences between surrogates and clinicians of incapacitated, critically ill adults from a prospective, multicenter cohort study. SUBJECTS Surrogate decision-makers and clinicians. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Four coders identified preference-sensitive decision episodes addressed in the meetings, including topics such as mechanical ventilation, renal replacement, and overall goals of care. Prior critical care literature provided specific topics identified as preference-sensitive specific to the critical care context. Coders then examined each decision episode for the types of choice frames used by clinicians. The choice frames were selected a priori based on decision science literature. In total, there were 202 decision episodes across the 101 transcripts, with 20.3% of the decision episodes discussing mechanical ventilation, 19.3% overall goals of care, 14.4% renal replacement therapy, 14.4% post-discharge care (i.e., discharge location such as a skilled nursing facility), and the remaining 32.1% other topics. Clinicians used default framing, in which an option is presented that will be carried out if another option is not actively chosen, more frequently than any other choice frame (127 or 62.9% of decision episodes). Clinicians presented a polar interrogative, or a "yes or no question" to accept or reject a specific care choice, in 43 (21.3%) decision episodes. Clinicians more frequently presented options emphasizing both potential losses and gains rather than either in isolation. CONCLUSIONS Clinicians frequently use default framing and polar questions when discussing preference-sensitive choices with surrogate decision-makers, which are known to be powerful nudges. Future work should focus on designing interventions promoting the informed use of these and the other most common choice frames used by practicing clinicians.
Collapse
Affiliation(s)
- Joanna L Hart
- Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, PA
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA
| | - Leena Malik
- Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, PA
| | - Carrie Li
- Department of Neurology, Massachusetts General Hospital and Brigham Women's Hospital, Harvard University, Boston, MA
| | - Amy Summer
- Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, PA
| | - Lon Ogunduyile
- Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, PA
| | - Jay Steingrub
- University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Bernard Lo
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Julian Zlatev
- Department of Business Administration, Harvard Business School, Boston, MA
| | - Douglas B White
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
2
|
Piscitello GM, Rogal S, Schell J, Schenker Y, Arnold RM. Equity in Using Artificial Intelligence Mortality Predictions to Target Goals of Care Documentation. J Gen Intern Med 2024:10.1007/s11606-024-08849-w. [PMID: 38858343 DOI: 10.1007/s11606-024-08849-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 05/31/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Artificial intelligence (AI) algorithms are increasingly used to target patients with elevated mortality risk scores for goals-of-care (GOC) conversations. OBJECTIVE To evaluate the association between the presence or absence of AI-generated mortality risk scores with GOC documentation. DESIGN Retrospective cross-sectional study at one large academic medical center between July 2021 and December 2022. PARTICIPANTS Hospitalized adult patients with AI-defined Serious Illness Risk Indicator (SIRI) scores indicating > 30% 90-day mortality risk (defined as "elevated" SIRI) or no SIRI scores due to insufficient data. INTERVENTION A targeted intervention to increase GOC documentation for patients with AI-generated scores predicting elevated risk of mortality. MAIN MEASURES Odds ratios comparing GOC documentation for patients with elevated or no SIRI scores with similar severity of illness using propensity score matching and risk-adjusted mixed-effects logistic regression. KEY RESULTS Among 13,710 patients with elevated (n = 3643, 27%) or no (n = 10,067, 73%) SIRI scores, the median age was 64 years (SD 18). Twenty-five percent were non-White, 18% had Medicaid, 43% were admitted to an intensive care unit, and 11% died during admission. Patients lacking SIRI scores were more likely to be younger (median 60 vs. 72 years, p < 0.0001), be non-White (29% vs. 13%, p < 0.0001), and have Medicaid (22% vs. 9%, p < 0.0001). Patients with elevated versus no SIRI scores were more likely to have GOC documentation in the unmatched (aOR 2.5, p < 0.0001) and propensity-matched cohorts (aOR 2.1, p < 0.0001). CONCLUSIONS Using AI predictions of mortality to target GOC documentation may create differences in documentation prevalence between patients with and without AI mortality prediction scores with similar severity of illness. These finding suggest using AI to target GOC documentation may have the unintended consequence of disadvantaging severely ill patients lacking AI-generated scores from receiving targeted GOC documentation, including patients who are more likely to be non-White and have Medicaid insurance.
Collapse
Affiliation(s)
- Gina M Piscitello
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA, USA.
- Palliative Research Center, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Shari Rogal
- Departments of Medicine and Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare Center, Pittsburgh, PA, USA
| | - Jane Schell
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA, USA
- Palliative Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yael Schenker
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA, USA
- Palliative Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert M Arnold
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
3
|
Overkamp F. [A look into the neighboring discipline: eHealth in oncology]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:451-458. [PMID: 38727743 DOI: 10.1007/s00104-024-02089-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/09/2024] [Indexed: 05/16/2024]
Abstract
Digitalization is dramatically changing the entire healthcare system. Keywords such as artificial intelligence, electronic patient files (ePA), electronic prescriptions (eRp), telemedicine, wearables, augmented reality and digital health applications (DiGA) represent the digital transformation that is already taking place. Digital becomes real! This article outlines the state of research and development, current plans and ongoing uses of digital tools in oncology in the first half of 2024. The possibilities for using artificial intelligence and the use of DiGAs in oncology are presented in more detail in this overview according to their stage of development as they already show a noticeable benefit in oncology.
Collapse
Affiliation(s)
- Friedrich Overkamp
- OncoConsult Overkamp GmbH, Europaplatz 2, 10557, Berlin, Deutschland.
- onkowissen.de GmbH, Würzburg, Deutschland.
| |
Collapse
|
4
|
Shilling DM, Manz CR, Strand JJ, Patel MI. Let Us Have the Conversation: Serious Illness Communication in Oncology: Definitions, Barriers, and Successful Approaches. Am Soc Clin Oncol Educ Book 2024; 44:e431352. [PMID: 38788187 DOI: 10.1200/edbk_431352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Serious illness communications are crucial elements of care delivery for patients with cancer. High-quality serious illness communications are composed of open, honest discussions between patients, caregivers, and clinicians regarding patient's communication preferences, expected illness trajectory, prognosis, and risks and benefits of any recommended care. High-quality communication ideally starts at the time of a patients' cancer diagnosis, allows space for and response to patient emotions, elicits patients' values and care preferences, and is iterative and longitudinal. When integrated into cancer care, such communication can result in improved patient experiences with their care, care that matches patients' goals, and reduced care intensity at the end of life. Despite national recommendations for routine integration of these communication into cancer care, a minority of patients with cancer receive such communication. In this chapter, we describe elements of high-quality serious illness communication, patient-, clinician-, institution-, and payer-level barriers, and successful strategies that can routinely integrate such communication into cancer care delivery.
Collapse
Affiliation(s)
- Danielle M Shilling
- Division of Community Internal Medicine, Geriatrics & Palliative Care, Mayo Clinic, Rochester, MN
| | - Christopher R Manz
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Jacob J Strand
- Division of Community Internal Medicine, Geriatrics & Palliative Care, Mayo Clinic, Rochester, MN
| | - Manali I Patel
- Division of Oncology, Stanford University School of Medicine, Stanford, CA
- VA Palo Alto Health Care System, Palo Alto, CA
| |
Collapse
|
5
|
Bryant AK, Zamora‐Resendiz R, Dai X, Morrow D, Lin Y, Jungles KM, Rae JM, Tate A, Pearson AN, Jiang R, Fritsche L, Lawrence TS, Zou W, Schipper M, Ramnath N, Yoo S, Crivelli S, Green MD. Artificial intelligence to unlock real-world evidence in clinical oncology: A primer on recent advances. Cancer Med 2024; 13:e7253. [PMID: 38899720 PMCID: PMC11187737 DOI: 10.1002/cam4.7253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 02/05/2024] [Accepted: 04/28/2024] [Indexed: 06/21/2024] Open
Abstract
PURPOSE Real world evidence is crucial to understanding the diffusion of new oncologic therapies, monitoring cancer outcomes, and detecting unexpected toxicities. In practice, real world evidence is challenging to collect rapidly and comprehensively, often requiring expensive and time-consuming manual case-finding and annotation of clinical text. In this Review, we summarise recent developments in the use of artificial intelligence to collect and analyze real world evidence in oncology. METHODS We performed a narrative review of the major current trends and recent literature in artificial intelligence applications in oncology. RESULTS Artificial intelligence (AI) approaches are increasingly used to efficiently phenotype patients and tumors at large scale. These tools also may provide novel biological insights and improve risk prediction through multimodal integration of radiographic, pathological, and genomic datasets. Custom language processing pipelines and large language models hold great promise for clinical prediction and phenotyping. CONCLUSIONS Despite rapid advances, continued progress in computation, generalizability, interpretability, and reliability as well as prospective validation are needed to integrate AI approaches into routine clinical care and real-time monitoring of novel therapies.
Collapse
Affiliation(s)
- Alex K. Bryant
- Department of Radiation OncologyUniversity of Michigan School of MedicineAnn ArborMichiganUSA
- Department of Radiation Oncology, Veterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Rafael Zamora‐Resendiz
- Applied Mathematics and Computational Research Division, Lawrence Berkeley National LaboratoryBerkeleyCaliforniaUSA
| | - Xin Dai
- Computational Science Initiative, Brookhaven National LaboratoryUptonNew YorkUSA
| | - Destinee Morrow
- Applied Mathematics and Computational Research Division, Lawrence Berkeley National LaboratoryBerkeleyCaliforniaUSA
| | - Yuewei Lin
- Computational Science Initiative, Brookhaven National LaboratoryUptonNew YorkUSA
| | - Kassidy M. Jungles
- Department of PharmacologyUniversity of Michigan School of MedicineAnn ArborMichiganUSA
| | - James M. Rae
- Department of PharmacologyUniversity of Michigan School of MedicineAnn ArborMichiganUSA
- Department of Internal MedicineUniversity of Michigan School of MedicineAnn ArborMichiganUSA
| | - Akshay Tate
- Department of Radiation OncologyUniversity of Michigan School of MedicineAnn ArborMichiganUSA
| | - Ashley N. Pearson
- Department of Radiation OncologyUniversity of Michigan School of MedicineAnn ArborMichiganUSA
| | - Ralph Jiang
- Department of Radiation OncologyUniversity of Michigan School of MedicineAnn ArborMichiganUSA
- Department of StatisticsUniversity of MichiganAnn ArborMichiganUSA
| | - Lars Fritsche
- Department of StatisticsUniversity of MichiganAnn ArborMichiganUSA
| | - Theodore S. Lawrence
- Department of Radiation OncologyUniversity of Michigan School of MedicineAnn ArborMichiganUSA
| | - Weiping Zou
- Department of StatisticsUniversity of MichiganAnn ArborMichiganUSA
- Center of Excellence for Cancer Immunology and ImmunotherapyUniversity of Michigan Rogel Cancer CenterAnn ArborMichiganUSA
- Department of PathologyUniversity of MichiganAnn ArborMichiganUSA
- Graduate Program in ImmunologyUniversity of MichiganAnn ArborMichiganUSA
| | - Matthew Schipper
- Department of Radiation OncologyUniversity of Michigan School of MedicineAnn ArborMichiganUSA
- Department of PharmacologyUniversity of Michigan School of MedicineAnn ArborMichiganUSA
| | - Nithya Ramnath
- Division of Hematology Oncology, Department of MedicineUniversity of Michigan School of MedicineAnn ArborMichiganUSA
- Division of Hematology Oncology, Department of MedicineVeterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Shinjae Yoo
- Computational Science Initiative, Brookhaven National LaboratoryUptonNew YorkUSA
| | - Silvia Crivelli
- Applied Mathematics and Computational Research Division, Lawrence Berkeley National LaboratoryBerkeleyCaliforniaUSA
| | - Michael D. Green
- Department of Radiation OncologyUniversity of Michigan School of MedicineAnn ArborMichiganUSA
- Department of Radiation Oncology, Veterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
- Graduate Program in ImmunologyUniversity of MichiganAnn ArborMichiganUSA
- Graduate Program in Cancer BiologyUniversity of MichiganAnn ArborMichiganUSA
- Department of Microbiology and ImmunologyUniversity of Michigan School of MedicineAnn ArborMichiganUSA
| |
Collapse
|
6
|
Im J, Kross EK, Engelberg RA, Dotolo DG, Ungar A, Nielsen E, Torrence J, Abedini NC. Applying human-centered design to adapt the Jumpstart Guide for goals-of-care discussions in persons living with dementia. J Am Geriatr Soc 2024. [PMID: 38801253 DOI: 10.1111/jgs.18965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/16/2024] [Accepted: 04/21/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Goals-of-care discussions (GOCD) are uncommon in persons living with dementia (PLWD) despite the likelihood of eventual loss of decisional capacity in the population. The Jumpstart Guide, an existing serious illness communication priming tool, can improve GOCD in certain populations, but has not previously been adapted for use among PLWD and their caregivers. METHODS Using human-centered design (HCD), we adapted the Jumpstart Guide for use with PLWD and their caregivers. We conducted qualitative interviews with clinicians and caregivers of PLWD. Six team members conducted qualitative rapid analysis of interviews leading to the development of summary templates and integrative matrices. Four iterations of the Jumpstart Guide led to the final version. RESULTS Thirteen clinicians and 11 caregivers were interviewed. Interviews provided key insights into the unique barriers PLWD and their caregivers face during GOCD, including discomfort with accepting a dementia diagnosis and concern with using "serious illness" to describe dementia, as is commonly done in palliative care. Clinicians described differences in GOCD with PLWD compared to other serious illnesses, and the challenge of getting patients and families to think about future health states. Interviews led to Jumpstart Guide adaptations in the following domains: (1) format and structure, (2) content, and (3) specific language. Suggested changes included prioritizing naming a decision-maker, changing conversation prompts to improve accessibility and understandability, ensuring the Jumpstart Guide could be used with patients as well as their caregivers, and altering language to avoid references to "serious illness" and "abilities." CONCLUSION Using HCD yielded valuable insights from clinicians and caregivers about the unique barriers to conducting GOCD among PLWD and their caregivers. These insights were used to adapt the Jumpstart Guide for use with PLWD and their caregivers, which is currently being tested in a pragmatic randomized controlled trial in outpatient clinics.
Collapse
Affiliation(s)
- Jennifer Im
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, Washington, USA
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, Washington, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, Washington, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Danae G Dotolo
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, Washington, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Anna Ungar
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, Washington, USA
| | - Elizabeth Nielsen
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, Washington, USA
| | - Janaki Torrence
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, Washington, USA
| | - Nauzley C Abedini
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, Washington, USA
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| |
Collapse
|
7
|
He JC, Moffat GT, Podolsky S, Khan F, Liu N, Taback N, Gallinger S, Hannon B, Krzyzanowska MK, Ghassemi M, Chan KKW, Grant RC. Machine Learning to Allocate Palliative Care Consultations During Cancer Treatment. J Clin Oncol 2024; 42:1625-1634. [PMID: 38359380 DOI: 10.1200/jco.23.01291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 11/06/2023] [Accepted: 12/11/2023] [Indexed: 02/17/2024] Open
Abstract
PURPOSE For patients with advanced cancer, early consultations with palliative care (PC) specialists reduce costs, improve quality of life, and prolong survival. However, capacity limitations prevent all patients from receiving PC shortly after diagnosis. We evaluated whether a prognostic machine learning system could promote early PC, given existing capacity. METHODS Using population-level administrative data in Ontario, Canada, we assembled a cohort of patients with incurable cancer who received palliative-intent systemic therapy between July 1, 2014, and December 30, 2019. We developed a machine learning system that predicted death within 1 year of each treatment using demographics, cancer characteristics, treatments, symptoms, laboratory values, and history of acute care admissions. We trained the system in patients who started treatment before July 1, 2017, and evaluated the potential impact of the system on PC in subsequent patients. RESULTS Among 560,210 treatments received by 54,628 patients, death occurred within 1 year of 45.2% of treatments. The machine learning system recommended the same number of PC consultations observed with usual care at the 60.0% 1-year risk of death, with a first-alarm positive predictive value of 69.7% and an outcome-level sensitivity of 74.9%. Compared with usual care, system-guided care could increase early PC by 8.5% overall (95% CI, 7.5 to 9.5; P < .001) and by 15.3% (95% CI, 13.9 to 16.6; P < .001) among patients who live 6 months beyond their first treatment, without requiring more PC consultations in total or substantially increasing PC among patients with a prognosis exceeding 2 years. CONCLUSION Prognostic machine learning systems could increase early PC despite existing resource constraints. These results demonstrate an urgent need to deploy and evaluate prognostic systems in real-time clinical practice to increase access to early PC.
Collapse
Affiliation(s)
- Jiang Chen He
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Ontario Institute for Cancer Research, Toronto, ON, Canada
| | | | | | | | | | - Nathan Taback
- Department of Statistical Sciences, University of Toronto, Toronto, ON, Canada
| | - Steven Gallinger
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Breffni Hannon
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Monika K Krzyzanowska
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | | | - Kelvin K W Chan
- ICES, Toronto, ON, Canada
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Robert C Grant
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Ontario Institute for Cancer Research, Toronto, ON, Canada
| |
Collapse
|
8
|
Wang SE, Gozansky WS, Steiner C, Lee JS, Nguyen A, Shen E, Martel H, Mangels DB, Sterett AT, Zalavadia R, Hou N, Nguyen HQ. Association Between Intensity and Timing of Specialty Palliative Care and Hospice Exposure With Quality of End-of-Life Care. J Palliat Med 2024; 27:602-613. [PMID: 38483344 DOI: 10.1089/jpm.2023.0407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024] Open
Abstract
Background: Gaps remain in our understanding of the intensity and timing of specialty palliative care (SPC) exposure on end-of-life (EOL) outcomes. Objective: Examine the association between intensity and timing of SPC and hospice (HO) exposure on EOL care outcomes. Design, Settings, Participants: Data for this cohort study were drawn from 2021 adult decedents from Kaiser Permanente Southern California and Colorado (n = 26,251). Caregivers of a decedent subgroup completed a postdeath care experience survey from July to August 2022 (n = 424). Measurements: SPC intensity (inpatient, outpatient, and home-based) and HO exposure in the five years before death were categorized as: (1) No SPC or HO; (2) SPC-only; (3) HO-only; and (4) SPC-HO. Timing of SPC exposure (<90 or 90+ days) before death was stratified by HO enrollment. Death in the hospital and potentially burdensome treatments in the last 14 days of life were extracted from electronic medical records (EMRs) and claims. EOL care experience was obtained from the caregiver survey. Results: Among the EMR cohort, exposure to SPC and HO were: No SPC or HO (38%), SPC-only (14%; of whom, 55% received inpatient SPC only), HO-only (20%), and SPC-HO (28%). For decedents who did not enroll in HO, exposure to SPC 90+ days versus <90 days before death was associated with lower risk of receiving potentially burdensome treatments (adjusted relative risk, aRR: 0.69 [95% confidence interval, CI: 0.62-0.76], p < 0.001) and 23% lower risk of dying in the hospital (aRR: 0.77 [95% CI: 0.73-0.81], p < 0.001). Caregivers of patients in the HO-only (aRR: 1.27 [95% CI: 0.98-1.63], p = 0.07) and SPC-HO cohorts (aRR: 1.19 [95% CI: 0.93-1.52], p = 0.18) tended to report more positive care experience compared to the no SPC or HO cohort. Conclusion: Earlier exposure to SPC was important in reducing potentially burdensome treatments and death in the hospital for decedents who did not enroll in HO. Increasing availability and access to community-based SPC is needed.
Collapse
Affiliation(s)
- Susan E Wang
- The Permanente Federation, Oakland, California, USA
| | - Wendolyn S Gozansky
- Kaiser Permanente Colorado, Institute for Health Research, Denver, Colorado, USA
- Colorado Permanente Medical Group, Denver, Colorado, USA
| | - Claudia Steiner
- Kaiser Permanente Colorado, Institute for Health Research, Denver, Colorado, USA
- Colorado Permanente Medical Group, Denver, Colorado, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Janet S Lee
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - AnMarie Nguyen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Ernest Shen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Helene Martel
- Kaiser Permanente Care Management Institute, Oakland, California, USA
| | - Diana B Mangels
- Kaiser Permanente Colorado, Institute for Health Research, Denver, Colorado, USA
| | - Andrew T Sterett
- Kaiser Permanente Colorado, Institute for Health Research, Denver, Colorado, USA
| | - Ravi Zalavadia
- Kaiser Permanente Colorado, Institute for Health Research, Denver, Colorado, USA
| | - Nanjiang Hou
- Kaiser Permanente Care Management Institute, Oakland, California, USA
| | - Huong Q Nguyen
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| |
Collapse
|
9
|
Rotenstein L, Wang L, Zupanc SN, Penumarthy A, Laurentiev J, Lamey J, Farah S, Lipsitz S, Jain N, Bates DW, Zhou L, Lakin JR. Looking Beyond Mortality Prediction: Primary Care Physician Views of Patients' Palliative Care Needs Predicted by a Machine Learning Tool. Appl Clin Inform 2024; 15:460-468. [PMID: 38636542 PMCID: PMC11168809 DOI: 10.1055/a-2309-1599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 04/17/2024] [Indexed: 04/20/2024] Open
Abstract
OBJECTIVES To assess primary care physicians' (PCPs) perception of the need for serious illness conversations (SIC) or other palliative care interventions in patients flagged by a machine learning tool for high 1-year mortality risk. METHODS We surveyed PCPs from four Brigham and Women's Hospital primary care practice sites. Multiple mortality prediction algorithms were ensembled to assess adult patients of these PCPs who were either enrolled in the hospital's integrated care management program or had one of several chronic conditions. The patients were classified as high or low risk of 1-year mortality. A blinded survey had PCPs evaluate these patients for palliative care needs. We measured PCP and machine learning tool agreement regarding patients' need for an SIC/elevated risk of mortality. RESULTS Of 66 PCPs, 20 (30.3%) participated in the survey. Out of 312 patients evaluated, 60.6% were female, with a mean (standard deviation [SD]) age of 69.3 (17.5) years, and a mean (SD) Charlson Comorbidity Index of 2.80 (2.89). The machine learning tool identified 162 (51.9%) patients as high risk. Excluding deceased or unfamiliar patients, PCPs felt that an SIC was appropriate for 179 patients; the machine learning tool flagged 123 of these patients as high risk (68.7% concordance). For 105 patients whom PCPs deemed SIC unnecessary, the tool classified 83 as low risk (79.1% concordance). There was substantial agreement between PCPs and the tool (Gwet's agreement coefficient of 0.640). CONCLUSIONS A machine learning mortality prediction tool offers promise as a clinical decision aid, helping clinicians pinpoint patients needing palliative care interventions.
Collapse
Affiliation(s)
- Lisa Rotenstein
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- School of Medicine, University of California, San Francisco, San Francisco, California, United States
| | - Liqin Wang
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Sophia N. Zupanc
- School of Medicine, University of California, San Francisco, San Francisco, California, United States
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - Akhila Penumarthy
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - John Laurentiev
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Jan Lamey
- Brigham and Women's Physician Organization, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Subrina Farah
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - Stuart Lipsitz
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Nina Jain
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - David W. Bates
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Li Zhou
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Joshua R. Lakin
- Harvard Medical School, Boston, Massachusetts, United States
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, United States
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
| |
Collapse
|
10
|
Osmanodja B, Sassi Z, Eickmann S, Hansen CM, Roller R, Burchardt A, Samhammer D, Dabrock P, Möller S, Budde K, Herrmann A. Investigating the Impact of AI on Shared Decision-Making in Post-Kidney Transplant Care (PRIMA-AI): Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2024; 13:e54857. [PMID: 38557315 PMCID: PMC11019425 DOI: 10.2196/54857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/03/2024] [Accepted: 02/05/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Patients after kidney transplantation eventually face the risk of graft loss with the concomitant need for dialysis or retransplantation. Choosing the right kidney replacement therapy after graft loss is an important preference-sensitive decision for kidney transplant recipients. However, the rate of conversations about treatment options after kidney graft loss has been shown to be as low as 13% in previous studies. It is unknown whether the implementation of artificial intelligence (AI)-based risk prediction models can increase the number of conversations about treatment options after graft loss and how this might influence the associated shared decision-making (SDM). OBJECTIVE This study aims to explore the impact of AI-based risk prediction for the risk of graft loss on the frequency of conversations about the treatment options after graft loss, as well as the associated SDM process. METHODS This is a 2-year, prospective, randomized, 2-armed, parallel-group, single-center trial in a German kidney transplant center. All patients will receive the same routine post-kidney transplant care that usually includes follow-up visits every 3 months at the kidney transplant center. For patients in the intervention arm, physicians will be assisted by a validated and previously published AI-based risk prediction system that estimates the risk for graft loss in the next year, starting from 3 months after randomization until 24 months after randomization. The study population will consist of 122 kidney transplant recipients >12 months after transplantation, who are at least 18 years of age, are able to communicate in German, and have an estimated glomerular filtration rate <30 mL/min/1.73 m2. Patients with multi-organ transplantation, or who are not able to communicate in German, as well as underage patients, cannot participate. For the primary end point, the proportion of patients who have had a conversation about their treatment options after graft loss is compared at 12 months after randomization. Additionally, 2 different assessment tools for SDM, the CollaboRATE mean score and the Control Preference Scale, are compared between the 2 groups at 12 months and 24 months after randomization. Furthermore, recordings of patient-physician conversations, as well as semistructured interviews with patients, support persons, and physicians, are performed to support the quantitative results. RESULTS The enrollment for the study is ongoing. The first results are expected to be submitted for publication in 2025. CONCLUSIONS This is the first study to examine the influence of AI-based risk prediction on physician-patient interaction in the context of kidney transplantation. We use a mixed methods approach by combining a randomized design with a simple quantitative end point (frequency of conversations), different quantitative measurements for SDM, and several qualitative research methods (eg, records of physician-patient conversations and semistructured interviews) to examine the implementation of AI-based risk prediction in the clinic. TRIAL REGISTRATION ClinicalTrials.gov NCT06056518; https://clinicaltrials.gov/study/NCT06056518. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/54857.
Collapse
Affiliation(s)
- Bilgin Osmanodja
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Zeineb Sassi
- Department of Epidemiology and Preventive Medicine, Medical Sociology, University Regensburg, Regensburg, Germany
| | - Sascha Eickmann
- Department of Epidemiology and Preventive Medicine, Medical Sociology, University Regensburg, Regensburg, Germany
| | - Carla Maria Hansen
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Roland Roller
- German Research Center for Artificial Intelligence, Berlin, Germany
| | | | - David Samhammer
- Institute for Systematic Theology II (Ethics), Friedrich-Alexander University Erlangen Nürnberg, Erlangen, Germany
| | - Peter Dabrock
- Institute for Systematic Theology II (Ethics), Friedrich-Alexander University Erlangen Nürnberg, Erlangen, Germany
| | - Sebastian Möller
- German Research Center for Artificial Intelligence, Berlin, Germany
- Quality and Usability Lab, Technical University of Berlin, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anne Herrmann
- Department of Epidemiology and Preventive Medicine, Medical Sociology, University Regensburg, Regensburg, Germany
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| |
Collapse
|
11
|
Cascella M, Laudani A, Scarpati G, Piazza O. Ethical issues in pain and palliation. Curr Opin Anaesthesiol 2024; 37:199-204. [PMID: 38288778 PMCID: PMC10911254 DOI: 10.1097/aco.0000000000001345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
PURPOSE OF REVIEW Increased public awareness of ethical issues in pain and palliative care, along with patient advocacy groups, put pressure on healthcare systems and professionals to address these concerns.Our aim is to review the ethics dilemmas concerning palliative care in ICU, artificial intelligence applications in pain therapy and palliative care, and the opioids epidemics. RECENT FINDINGS In this focus review, we highlighted state of the art papers that were published in the last 18 months, on ethical issues in palliative care within the ICU, artificial intelligence trajectories, and how opioids epidemics has impacted pain management practices (see Visual Abstract). SUMMARY Palliative care in the ICU should involve a multidisciplinary team, to mitigate patients suffering and futility. Providing spiritual support in the ICU is an important aspect of holistic patient care too.Increasingly sophisticated tools for diagnosing and treating pain, as those involving artificial intelligence, might favour disparities in access, cause informed consent problems, and surely, they need prudence and reproducibility.Pain clinicians worldwide continue to face the ethical dilemma of prescribing opioids for patients with chronic noncancer pain. Balancing the need for effective pain relief with the risk of opioid misuse, addiction, and overdose is a very controversial task.
Collapse
Affiliation(s)
- Marco Cascella
- Dipartimento di Medicina, Chirurgia, Odontoiatria ‘Scuola Medica Salernitana’, Università di Salerno
| | | | - Giuliana Scarpati
- Dipartimento di Medicina, Chirurgia, Odontoiatria ‘Scuola Medica Salernitana’, Università di Salerno
- AOU San Giovanni di Dio e Ruggi d’Aragona, Salerno, Italia
| | - Ornella Piazza
- Dipartimento di Medicina, Chirurgia, Odontoiatria ‘Scuola Medica Salernitana’, Università di Salerno
| |
Collapse
|
12
|
Sloss EA, McPherson JP, Beck AC, Guo JW, Scheese CH, Flake NR, Chalkidis G, Staes CJ. Patient and Caregiver Perceptions of an Interface Design to Communicate Artificial Intelligence-Based Prognosis for Patients With Advanced Solid Tumors. JCO Clin Cancer Inform 2024; 8:e2300187. [PMID: 38657194 PMCID: PMC11161249 DOI: 10.1200/cci.23.00187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 02/22/2024] [Accepted: 03/07/2024] [Indexed: 04/26/2024] Open
Abstract
PURPOSE Use of artificial intelligence (AI) in cancer care is increasing. What remains unclear is how best to design patient-facing systems that communicate AI output. With oncologist input, we designed an interface that presents patient-specific, machine learning-based 6-month survival prognosis information designed to aid oncology providers in preparing for and discussing prognosis with patients with advanced solid tumors and their caregivers. The primary purpose of this study was to assess patient and caregiver perceptions and identify enhancements of the interface for communicating 6-month survival and other prognosis information when making treatment decisions concerning anticancer and supportive therapy. METHODS This qualitative study included interviews and focus groups conducted between November and December 2022. Purposive sampling was used to recruit former patients with cancer and/or former caregivers of patients with cancer who had participated in cancer treatment decisions from Utah or elsewhere in the United States. Categories and themes related to perceptions of the interface were identified. RESULTS We received feedback from 20 participants during eight individual interviews and two focus groups, including four cancer survivors, 13 caregivers, and three representing both. Overall, most participants expressed positive perceptions about the tool and identified its value for supporting decision making, feeling less alone, and supporting communication among oncologists, patients, and their caregivers. Participants identified areas for improvement and implementation considerations, particularly that oncologists should share the tool and guide discussions about prognosis with patients who want to receive the information. CONCLUSION This study revealed important patient and caregiver perceptions of and enhancements for the proposed interface. Originally designed with input from oncology providers, patient and caregiver participants identified additional interface design recommendations and implementation considerations to support communication about prognosis.
Collapse
Affiliation(s)
| | - Jordan P. McPherson
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
- College of Pharmacy, University of Utah, Salt Lake City, UT
| | - Anna C. Beck
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Jia-Wen Guo
- College of Nursing, University of Utah, Salt Lake City, UT
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT
| | - Carolyn H. Scheese
- College of Nursing, University of Utah, Salt Lake City, UT
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT
| | - Naomi R. Flake
- Clinical & Translational Science Institute, University of Utah, Salt Lake City, UT
| | | | - Catherine J. Staes
- College of Nursing, University of Utah, Salt Lake City, UT
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT
| |
Collapse
|
13
|
Disis MLN. JAMA Oncology-The Year in Review, 2023. JAMA Oncol 2024:2816794. [PMID: 38512293 DOI: 10.1001/jamaoncol.2024.0153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
|
14
|
Bakhtiar M, Butala AA, Berlin EE, Metz JM, Bradley JD, Jones JA, Lukens JN, Paydar I, Taunk NK. Factors Associated With and Characteristics of Patients Receiving Proton Therapy at the End of Life. Int J Part Ther 2024; 11:100014. [PMID: 38757084 PMCID: PMC11095101 DOI: 10.1016/j.ijpt.2024.100014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 03/10/2024] [Accepted: 03/11/2024] [Indexed: 05/18/2024] Open
Abstract
Purpose To identify the characteristics, indications, and toxicities among patients receiving proton beam therapy (PBT) in the final year of life at an academic medical center. Materials and Methods A retrospective review of patients who received PBT within the final 12 months of life was performed. Electronic medical records were reviewed for patient and treatment details from 2010 to 2019. Patients were followed from the start of PBT until death or last follow-up. Acute (3 months) toxicities were graded using the Common Terminology Criteria for Adverse Events v5.0. Imaging response was assessed using the Response Evaluation Criteria in Solid Tumors v1.1. The χ2 test was used to evaluate factors associated with palliative treatment. Simple logistic regression was used to evaluate factors associated with toxicity. Results Bet299 patients were treated at the end of life (EOL) out of 5802 total patients treated with PBT (5.2%). Median age was 68 years (19-94 years), 58% male. The most common cancer was nonsmall cell lung cancer (27%). Patients were treated for symptom palliation alone (11%), durable control (57%), curative intent (16%), local recurrence (14%), or oligometastatic disease (2%). Forty-five percent received reirradiation. Median treatment time was 32 days (1-189 days). Acute toxicity was noted in 85% of the patients (31% G1, 53% G2, 15% G3). Thirteen patients (4%) experienced chronic toxicity. Breast and hematologic malignancy were associated with palliative intent χ2 (1, N = 14) = 17, P = .013; (χ2 (1, N = 14) = 18, P = .009). Conclusion The number of patients treated with PBT at the EOL was low compared to all comers. Many of these patients received treatment with definitive doses and concurrent systemic therapy. Some patients spent a large portion of their remaining days on treatment. A prognostic indicator may better optimize patient selection for PBT at the EOL.
Collapse
Affiliation(s)
- Mina Bakhtiar
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Harvard Radiation Oncology Program, Dana Farber Cancer Institute/Brigham and Women's Hospital & Massachusetts General Hospital, Boston, MA 02215, USA
| | - Anish A. Butala
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Eva E. Berlin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - James M. Metz
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Jeffrey D. Bradley
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Joshua A. Jones
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - John Nicholas Lukens
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Ima Paydar
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Neil K. Taunk
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| |
Collapse
|
15
|
Golob JL, Oskotsky TT, Tang AS, Roldan A, Chung V, Ha CWY, Wong RJ, Flynn KJ, Parraga-Leo A, Wibrand C, Minot SS, Oskotsky B, Andreoletti G, Kosti I, Bletz J, Nelson A, Gao J, Wei Z, Chen G, Tang ZZ, Novielli P, Romano D, Pantaleo E, Amoroso N, Monaco A, Vacca M, De Angelis M, Bellotti R, Tangaro S, Kuntzleman A, Bigcraft I, Techtmann S, Bae D, Kim E, Jeon J, Joe S, Theis KR, Ng S, Lee YS, Diaz-Gimeno P, Bennett PR, MacIntyre DA, Stolovitzky G, Lynch SV, Albrecht J, Gomez-Lopez N, Romero R, Stevenson DK, Aghaeepour N, Tarca AL, Costello JC, Sirota M. Microbiome preterm birth DREAM challenge: Crowdsourcing machine learning approaches to advance preterm birth research. Cell Rep Med 2024; 5:101350. [PMID: 38134931 PMCID: PMC10829755 DOI: 10.1016/j.xcrm.2023.101350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 09/15/2023] [Accepted: 12/01/2023] [Indexed: 12/24/2023]
Abstract
Every year, 11% of infants are born preterm with significant health consequences, with the vaginal microbiome a risk factor for preterm birth. We crowdsource models to predict (1) preterm birth (PTB; <37 weeks) or (2) early preterm birth (ePTB; <32 weeks) from 9 vaginal microbiome studies representing 3,578 samples from 1,268 pregnant individuals, aggregated from public raw data via phylogenetic harmonization. The predictive models are validated on two independent unpublished datasets representing 331 samples from 148 pregnant individuals. The top-performing models (among 148 and 121 submissions from 318 teams) achieve area under the receiver operator characteristic (AUROC) curve scores of 0.69 and 0.87 predicting PTB and ePTB, respectively. Alpha diversity, VALENCIA community state types, and composition are important features in the top-performing models, most of which are tree-based methods. This work is a model for translation of microbiome data into clinically relevant predictive models and to better understand preterm birth.
Collapse
Affiliation(s)
- Jonathan L Golob
- Division of Infectious Disease, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA; March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA, USA.
| | - Tomiko T Oskotsky
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA, USA; Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA, USA; Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA.
| | - Alice S Tang
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA, USA; Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA, USA; Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Alennie Roldan
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA, USA; Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA, USA; Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | | | - Connie W Y Ha
- Benioff Center for Microbiome Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Ronald J Wong
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA; March of Dimes Prematurity Research Center at Stanford University, Stanford, CA, USA
| | | | - Antonio Parraga-Leo
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA, USA; Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA; Department of Pediatrics, Obstetrics and Gynaecology, Universidad de Valencia, Valencia, Spain; IVIRMA Global Research Alliance, IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Valencia, Spain
| | - Camilla Wibrand
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA, USA; Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Samuel S Minot
- Data Core, Shared Resources, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Boris Oskotsky
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA, USA
| | - Gaia Andreoletti
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA, USA; Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA, USA; Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Idit Kosti
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA, USA; Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA, USA; Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Jifan Gao
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI, USA
| | - Zhoujingpeng Wei
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI, USA
| | - Guanhua Chen
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI, USA
| | - Zheng-Zheng Tang
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI, USA
| | - Pierfrancesco Novielli
- Dipartimento di Scienze del Suolo, della Pianta e degli Alimenti, Università degli Studi di Bari Aldo Moro, Bari, Italy; Istituto Nazionale di Fisica Nucleare, Sezione di Bari, Bari, Italy
| | - Donato Romano
- Dipartimento di Scienze del Suolo, della Pianta e degli Alimenti, Università degli Studi di Bari Aldo Moro, Bari, Italy; Istituto Nazionale di Fisica Nucleare, Sezione di Bari, Bari, Italy
| | - Ester Pantaleo
- Istituto Nazionale di Fisica Nucleare, Sezione di Bari, Bari, Italy; Dipartimento Interateneo di Fisica "M, Merlin", Università degli Studi di Bari Aldo Moro, Bari, Italy
| | - Nicola Amoroso
- Istituto Nazionale di Fisica Nucleare, Sezione di Bari, Bari, Italy; Dipartimento di Farmacia - Scienze del Farmaco, Università degli Studi di Bari Aldo Moro, Bari, Italy
| | - Alfonso Monaco
- Istituto Nazionale di Fisica Nucleare, Sezione di Bari, Bari, Italy; Dipartimento Interateneo di Fisica "M, Merlin", Università degli Studi di Bari Aldo Moro, Bari, Italy
| | - Mirco Vacca
- Dipartimento di Scienze del Suolo, della Pianta e degli Alimenti, Università degli Studi di Bari Aldo Moro, Bari, Italy
| | - Maria De Angelis
- Dipartimento di Scienze del Suolo, della Pianta e degli Alimenti, Università degli Studi di Bari Aldo Moro, Bari, Italy
| | - Roberto Bellotti
- Istituto Nazionale di Fisica Nucleare, Sezione di Bari, Bari, Italy; Dipartimento Interateneo di Fisica "M, Merlin", Università degli Studi di Bari Aldo Moro, Bari, Italy
| | - Sabina Tangaro
- Dipartimento di Scienze del Suolo, della Pianta e degli Alimenti, Università degli Studi di Bari Aldo Moro, Bari, Italy; Istituto Nazionale di Fisica Nucleare, Sezione di Bari, Bari, Italy
| | - Abigail Kuntzleman
- Department of Biological Sciences, Michigan Technological University, Houghton, MI, USA
| | - Isaac Bigcraft
- Department of Biological Sciences, Michigan Technological University, Houghton, MI, USA
| | - Stephen Techtmann
- Department of Biological Sciences, Michigan Technological University, Houghton, MI, USA
| | - Daehun Bae
- School of Electrical Engineering and Computer Science, Gwangju Institute of Science and Technology (GIST), Gwangju, Republic of Korea
| | - Eunyoung Kim
- School of Electrical Engineering and Computer Science, Gwangju Institute of Science and Technology (GIST), Gwangju, Republic of Korea
| | - Jongbum Jeon
- Korea Bioinformation Center (KOBIC), Korea Research Institute of Bioscience and Biotechnology (KRIBB), Daejeon, Republic of Korea
| | - Soobok Joe
- Korea Bioinformation Center (KOBIC), Korea Research Institute of Bioscience and Biotechnology (KRIBB), Daejeon, Republic of Korea
| | - Kevin R Theis
- Department of Biochemistry, Microbiology and Immunology, Wayne State University, Detroit, MI, USA
| | - Sherrianne Ng
- Imperial College Parturition Research Group, Division of the Institute of Reproductive and Developmental Biology, Imperial College London, London, UK; March of Dimes Prematurity Research Centre at Imperial College London, London, UK
| | - Yun S Lee
- Imperial College Parturition Research Group, Division of the Institute of Reproductive and Developmental Biology, Imperial College London, London, UK; March of Dimes Prematurity Research Centre at Imperial College London, London, UK
| | - Patricia Diaz-Gimeno
- IVIRMA Global Research Alliance, IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Valencia, Spain
| | - Phillip R Bennett
- Imperial College Parturition Research Group, Division of the Institute of Reproductive and Developmental Biology, Imperial College London, London, UK; March of Dimes Prematurity Research Centre at Imperial College London, London, UK
| | - David A MacIntyre
- Imperial College Parturition Research Group, Division of the Institute of Reproductive and Developmental Biology, Imperial College London, London, UK; March of Dimes Prematurity Research Centre at Imperial College London, London, UK
| | - Gustavo Stolovitzky
- Center for Computational Biology and Bioinformatics, Columbia University, New York, NY, USA; Thomas J. Watson Research Center, IBM, Yorktown Heights, NY, USA; Sema4, Stamford, CT, USA
| | - Susan V Lynch
- Benioff Center for Microbiome Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA; Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | | | - Nardhy Gomez-Lopez
- Department of Biochemistry, Microbiology and Immunology, Wayne State University, Detroit, MI, USA; Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Detroit, MI, USA
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Detroit, MI, USA; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI, USA; Detroit Medical Center, Detroit, MI, USA; Department of Obstetrics and Gynecology, Florida International University, Miami, FL, USA
| | - David K Stevenson
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA; Center for Academic Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Nima Aghaeepour
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA; Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA; Department of Biomedical Data Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Adi L Tarca
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Detroit, MI, USA; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA; Department of Computer Science, Wayne State University College of Engineering, Detroit, MI, USA
| | - James C Costello
- Department of Pharmacology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Marina Sirota
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA, USA; Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA, USA; Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA.
| |
Collapse
|
16
|
Van Cleave JH, Concert C, Kamberi M, Zahriah E, Most A, Mojica J, Riccobene A, Russo N, Liang E, Hu KS, Jacobson AS, Li Z, Moses LE, Persky MJ, Persky MS, Tran T, Brody AA, Kim A, Egleston BL. A Preliminary Validation of an Optimal Cutpoint in Total Number of Patient-Reported Symptoms in Head and Neck Cancer for Effective Alignment of Clinical Resources with Patients' Symptom Burden. CANCER CARE RESEARCH ONLINE 2024; 4:e051. [PMID: 38586274 PMCID: PMC10993689 DOI: 10.1097/cr9.0000000000000051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Background Patients with head and neck cancer (HNC) often experience high symptom burden leading to lower quality of life (QoL). Objective This study aims to conceptually model optimal cutpoint by examining where total number of patient-reported symptoms exceeds patients' coping capacity, leading to a decline in QoL in patients with HNC. Methods Secondary data analysis of 105 individuals with HNC enrolled in a clinical usefulness study of the NYU Electronic Patient Visit Assessment (ePVA)©, a digital patient-reported symptom measure. Patients completed ePVA and European Organization for Research and Treatment of Cancer (EORTC©) QLQ-C30 v3.0. The total number of patient-reported symptoms was the sum of symptoms as identified by the ePVA questionnaire. Analysis of variance (ANOVA) was used to define optimal cutpoint. Results Study participants had a mean age of 61.5, were primarily male (67.6%), and had Stage IV HNC (53.3%). The cutpoint of 10 symptoms was associated with significant decline of QoL (F= 44.8, P<.0001), dividing the population into categories of low symptom burden (< 10 symptoms) and high symptom burden (≥ 10 symptoms). Analyses of EORTC© function subscales supported the validity of 10 symptoms as the optimal cutpoint (Physical: F=28.3, P<.0001; Role: F=21.6, P<.0001; Emotional: F=9.5, P=.003; Social: F=33.1, P<.0001). Conclusions In HNC, defining optimal cutpoints in the total number of patient-reported symptoms is feasible. Implications for Practice Cutpoints in the total number of patient-reported symptoms may identify patients experiencing a high symptom burden from HNC. Foundational Using optimal cutpoints of the total number of patient-reported symptoms may help effectively align clinical resources with patients' symptom burden.
Collapse
Affiliation(s)
- Janet H Van Cleave
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Catherine Concert
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Maria Kamberi
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Elise Zahriah
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Allison Most
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Jacqueline Mojica
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Ann Riccobene
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Nora Russo
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Eva Liang
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Kenneth S Hu
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Adam S Jacobson
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Zujun Li
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Lindsey E Moses
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Michael J Persky
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Mark S Persky
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Theresa Tran
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Abraham A Brody
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Arum Kim
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| | - Brian L Egleston
- NYU Meyers College of Nursing (JH Van Cleave, E Liang, AA Brody); NYU Langone Perlmutter Cancer Center, Department of Radiation Oncology (C Concert); NYU Langone Perlmutter Cancer Center, Department of Head and Neck Surgical Oncology (M Kamberi, A Most, J Mojica, N Russo); NYU Langone Perlmutter Cancer Center, Department of Medical Oncology (E Zahriah, A Riccobene); NYU Grossman School of Medicine, Department of Radiation Oncology (KS Hu); NYU Grossman School of Medicine, Department of Otolaryngology - Head and Neck Surgery (AS Jacobson, LE Moses, MJ Persky, MS Persky, T Tran); NYU Grossman School of Medicine, Department of Medicine (AA Brody, Z Li, A Kim)
| |
Collapse
|
17
|
O'Reilly D, McGrath J, Martin-Loeches I. Optimizing artificial intelligence in sepsis management: Opportunities in the present and looking closely to the future. JOURNAL OF INTENSIVE MEDICINE 2024; 4:34-45. [PMID: 38263963 PMCID: PMC10800769 DOI: 10.1016/j.jointm.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 09/29/2023] [Accepted: 10/01/2023] [Indexed: 01/25/2024]
Abstract
Sepsis remains a major challenge internationally for healthcare systems. Its incidence is rising due to poor public awareness and delays in its recognition and subsequent management. In sepsis, mortality increases with every hour left untreated. Artificial intelligence (AI) is transforming worldwide healthcare delivery at present. This review has outlined how AI can augment strategies to address this global disease burden. AI and machine learning (ML) algorithms can analyze vast quantities of increasingly complex clinical datasets from electronic medical records to assist clinicians in diagnosing and treating sepsis earlier than traditional methods. Our review highlights how these models can predict the risk of sepsis and organ failure even before it occurs. This gives providers additional time to plan and execute treatment plans, thereby avoiding increasing complications associated with delayed diagnosis of sepsis. The potential for cost savings with AI implementation is also discussed, including improving workflow efficiencies, reducing administrative costs, and improving healthcare outcomes. Despite these advantages, clinicians have been slow to adopt AI into clinical practice. Some of the limitations posed by AI solutions include the lack of diverse data sets for model building so that they are widely applicable for routine clinical use. Furthermore, the subsequent algorithms are often based on complex mathematics leading to clinician hesitancy to embrace such technologies. Finally, we highlight the need for robust political and regulatory frameworks in this area to achieve the trust and approval of clinicians and patients to implement this transformational technology.
Collapse
Affiliation(s)
- Darragh O'Reilly
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James’ Hospital, Dublin, Ireland
| | - Jennifer McGrath
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James’ Hospital, Dublin, Ireland
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James’ Hospital, Dublin, Ireland
- Department of Respiratory Intensive care, Hospital Clinic, Universitat de Barcelona, IDIBAPS, CIBERES, Barcelona, Spain
| |
Collapse
|
18
|
Staes CJ, Beck AC, Chalkidis G, Scheese CH, Taft T, Guo JW, Newman MG, Kawamoto K, Sloss EA, McPherson JP. Design of an interface to communicate artificial intelligence-based prognosis for patients with advanced solid tumors: a user-centered approach. J Am Med Inform Assoc 2023; 31:174-187. [PMID: 37847666 PMCID: PMC10746322 DOI: 10.1093/jamia/ocad201] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/18/2023] [Accepted: 10/02/2023] [Indexed: 10/19/2023] Open
Abstract
OBJECTIVES To design an interface to support communication of machine learning (ML)-based prognosis for patients with advanced solid tumors, incorporating oncologists' needs and feedback throughout design. MATERIALS AND METHODS Using an interdisciplinary user-centered design approach, we performed 5 rounds of iterative design to refine an interface, involving expert review based on usability heuristics, input from a color-blind adult, and 13 individual semi-structured interviews with oncologists. Individual interviews included patient vignettes and a series of interfaces populated with representative patient data and predicted survival for each treatment decision point when a new line of therapy (LoT) was being considered. Ongoing feedback informed design decisions, and directed qualitative content analysis of interview transcripts was used to evaluate usability and identify enhancement requirements. RESULTS Design processes resulted in an interface with 7 sections, each addressing user-focused questions, supporting oncologists to "tell a story" as they discuss prognosis during a clinical encounter. The iteratively enhanced interface both triggered and reflected design decisions relevant when attempting to communicate ML-based prognosis, and exposed misassumptions. Clinicians requested enhancements that emphasized interpretability over explainability. Qualitative findings confirmed that previously identified issues were resolved and clarified necessary enhancements (eg, use months not days) and concerns about usability and trust (eg, address LoT received elsewhere). Appropriate use should be in the context of a conversation with an oncologist. CONCLUSION User-centered design, ongoing clinical input, and a visualization to communicate ML-related outcomes are important elements for designing any decision support tool enabled by artificial intelligence, particularly when communicating prognosis risk.
Collapse
Affiliation(s)
- Catherine J Staes
- College of Nursing, University of Utah, Salt Lake City, UT 84112, United States
- Department of Biomedical Informatics, School of Medicine, University of Utah, Salt Lake City, UT 84108, United States
| | - Anna C Beck
- Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84112, United States
| | - George Chalkidis
- Healthcare IT Research Department, Center for Digital Services, Hitachi Ltd., Tokyo, Japan
| | - Carolyn H Scheese
- College of Nursing, University of Utah, Salt Lake City, UT 84112, United States
- Department of Biomedical Informatics, School of Medicine, University of Utah, Salt Lake City, UT 84108, United States
| | - Teresa Taft
- Department of Biomedical Informatics, School of Medicine, University of Utah, Salt Lake City, UT 84108, United States
| | - Jia-Wen Guo
- College of Nursing, University of Utah, Salt Lake City, UT 84112, United States
- Department of Biomedical Informatics, School of Medicine, University of Utah, Salt Lake City, UT 84108, United States
| | - Michael G Newman
- Department of Population Sciences, Huntsman Cancer Institute, Salt Lake City, UT 84112, United States
| | - Kensaku Kawamoto
- Department of Biomedical Informatics, School of Medicine, University of Utah, Salt Lake City, UT 84108, United States
| | - Elizabeth A Sloss
- College of Nursing, University of Utah, Salt Lake City, UT 84112, United States
| | - Jordan P McPherson
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT 84108, United States
- Department of Pharmacy, Huntsman Cancer Institute, Salt Lake City, UT 84112, United States
| |
Collapse
|
19
|
Epstein AS, Knezevic A, Romano DR, Hoque A, Raj N, Reidy D, Rosa WE, Cruz E, Calderon C, O'Shaughnessy S, Sansone A, Okpako M, Nelson JE. Patient Portals to Elicit Essential Patient-Reported Elements of Communication Supporting Person-Centered Oncologic Care: A Pilot Study of the PERSON Approach. JCO Clin Cancer Inform 2023; 7:e2300125. [PMID: 37890120 PMCID: PMC10642868 DOI: 10.1200/cci.23.00125] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/14/2023] [Accepted: 09/06/2023] [Indexed: 10/29/2023] Open
Abstract
PURPOSE Patient portal technology offers important new opportunities to support person-centered clinician-patient communication. METHODS Questionnaires relating to understanding of illness and treatment intent were sent quarterly via portal to all patients scheduled for follow-up in GI medical oncology clinics. For patients in selected clinics, items eliciting health-related values were added. Patient responses were available to all oncology team members in the electronic health record. Workflow and content of clinician-patient discussions about illness, treatment, and care goals stayed within clinicians' discretion. Feasibility (patient response rate), patient understanding, acceptability (three-item patient questionnaire), and efficacy (quality of clinician communication) were evaluated. RESULTS From May 2021 through December 2022, a total of 12,233 questionnaires about illness/treatment understanding were sent to 6,325 patients (one to six per patient), with 97% response, including 9,358 with both open- and closed-ended responses. Fewer than 0.1% of patients indicated distress related to the questionnaire/process. Open-ended responses complemented closed-ended answers by revealing prognostic awareness and illness concerns. Of 48 patients approached to complete the full questionnaire including values items via portal, 15 first received and completed them in clinic (5 on iPad, 10 on paper), while 33 received and 27 (82%) completed the portal questionnaire. Patients found the portal process acceptable, and ratings of clinician communication were higher after clinic visits informed by patients' questionnaire responses (average prescore 6.8 v 5.9 post; P = .03). CONCLUSION Almost all patients in this large GI cancer cohort responded via the portal about their understanding of illness and treatment goals. Eliciting their personal values by portal was also feasible, accepted by patients, and improved patient ratings of clinicians' communication. Portals represent a promising tool for scaling assessment of essential patient-reported elements of person-centered communication.
Collapse
Affiliation(s)
- Andrew S. Epstein
- Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medical College, New York, NY
| | | | | | - Afshana Hoque
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nitya Raj
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Diane Reidy
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | | | - Molly Okpako
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Judith E. Nelson
- Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medical College, New York, NY
| |
Collapse
|
20
|
Kather JN. Artificial intelligence in oncology: chances and pitfalls. J Cancer Res Clin Oncol 2023; 149:7995-7996. [PMID: 36920564 PMCID: PMC10374782 DOI: 10.1007/s00432-023-04666-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 02/23/2023] [Indexed: 03/16/2023]
Abstract
Artificial intelligence (AI) has been available in rudimentary forms for many decades. Early AI programs were successful in niche areas such as chess or handwriting recognition. However, AI methods had little practical impact on the practice of medicine until recently. Beginning around 2012, AI has emerged as an increasingly important tool in healthcare, and AI-based devices are now approved for clinical use. These devices are capable of processing image data, making diagnoses, and predicting biomarkers for solid tumors, among other applications. Despite this progress, the development of AI in medicine is still in its early stages, and there have been exponential technical advancements since 2022, with some AI programs now demonstrating human-level understanding of image and text data. In the past, technical advances have led to new medical applications with a delay of a few years. Therefore, now we might be at the beginning of a new era in which AI will become even more important in clinical practice. It is essential that this transformation is humane and evidence based, and physicians must take a leading role in ensuring this, particularly in hematology and oncology.
Collapse
Affiliation(s)
- Jakob Nikolas Kather
- Else Kröner Fresenius Zentrum für Digitale Gesundheit and Medizinische Klinik und Poliklinik 1, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| |
Collapse
|
21
|
Manz CR, Rocque GB, Patel MI. Leveraging Goals of Care Interventions to Deliver Personalized Care Near the End of Life. JAMA Oncol 2023; 9:1029-1030. [PMID: 37382970 DOI: 10.1001/jamaoncol.2023.1981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
This Viewpoint discusses barriers to and opportunities for incorporating goal of care communications into end-of-life care.
Collapse
Affiliation(s)
- Christopher R Manz
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gabrielle B Rocque
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham
| | - Manali I Patel
- Division of Oncology, Department of Medicine, Stanford University, Stanford, California
- Medical Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| |
Collapse
|
22
|
Piscitello GM, Rojas JC, Arnold RM. Equity in Using Artificial Intelligence to Target Serious Illness Conversations for Patients With Life-Limiting Illness. J Pain Symptom Manage 2023; 66:e299-e301. [PMID: 37054955 DOI: 10.1016/j.jpainsymman.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/01/2023] [Indexed: 04/15/2023]
Affiliation(s)
- Gina M Piscitello
- Division of General Internal Medicine (G.M.P., R.M.A.), Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania; Palliative Research Center (G.M.P. R.M.A.), University of Pittsburgh, Pittsburgh, Pennsylvania; Division of Pulmonary and Critical Care Medicine (J.C.R.), Rush University Medical Center, Chicago, IL, USA.
| | - Juan Carlos Rojas
- Division of General Internal Medicine (G.M.P., R.M.A.), Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania; Palliative Research Center (G.M.P. R.M.A.), University of Pittsburgh, Pittsburgh, Pennsylvania; Division of Pulmonary and Critical Care Medicine (J.C.R.), Rush University Medical Center, Chicago, IL, USA.
| | - Robert M Arnold
- Division of General Internal Medicine (G.M.P., R.M.A.), Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania; Palliative Research Center (G.M.P. R.M.A.), University of Pittsburgh, Pittsburgh, Pennsylvania; Division of Pulmonary and Critical Care Medicine (J.C.R.), Rush University Medical Center, Chicago, IL, USA.
| |
Collapse
|
23
|
Golob JL, Oskotsky TT, Tang AS, Roldan A, Chung V, Ha CWY, Wong RJ, Flynn KJ, Parraga-Leo A, Wibrand C, Minot SS, Andreoletti G, Kosti I, Bletz J, Nelson A, Gao J, Wei Z, Chen G, Tang ZZ, Novielli P, Romano D, Pantaleo E, Amoroso N, Monaco A, Vacca M, De Angelis M, Bellotti R, Tangaro S, Kuntzleman A, Bigcraft I, Techtmann S, Bae D, Kim E, Jeon J, Joe S, Theis KR, Ng S, Lee Li YS, Diaz-Gimeno P, Bennett PR, MacIntyre DA, Stolovitzky G, Lynch SV, Albrecht J, Gomez-Lopez N, Romero R, Stevenson DK, Aghaeepour N, Tarca AL, Costello JC, Sirota M. Microbiome Preterm Birth DREAM Challenge: Crowdsourcing Machine Learning Approaches to Advance Preterm Birth Research. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.03.07.23286920. [PMID: 36945505 PMCID: PMC10029035 DOI: 10.1101/2023.03.07.23286920] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Globally, every year about 11% of infants are born preterm, defined as a birth prior to 37 weeks of gestation, with significant and lingering health consequences. Multiple studies have related the vaginal microbiome to preterm birth. We present a crowdsourcing approach to predict: (a) preterm or (b) early preterm birth from 9 publicly available vaginal microbiome studies representing 3,578 samples from 1,268 pregnant individuals, aggregated from raw sequences via an open-source tool, MaLiAmPi. We validated the crowdsourced models on novel datasets representing 331 samples from 148 pregnant individuals. From 318 DREAM challenge participants we received 148 and 121 submissions for our two separate prediction sub-challenges with top-ranking submissions achieving bootstrapped AUROC scores of 0.69 and 0.87, respectively. Alpha diversity, VALENCIA community state types, and composition (via phylotype relative abundance) were important features in the top performing models, most of which were tree based methods. This work serves as the foundation for subsequent efforts to translate predictive tests into clinical practice, and to better understand and prevent preterm birth.
Collapse
Affiliation(s)
- Jonathan L Golob
- Division of Infectious Disease. Department of Internal Medicine. University of Michigan. Ann Arbor, MI. USA
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
| | - Tomiko T Oskotsky
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
| | - Alice S Tang
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
| | - Alennie Roldan
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
| | | | - Connie W Y Ha
- Benioff Center for Microbiome Medicine, Department of Medicine, University of California, San Francisco, CA. USA
| | - Ronald J Wong
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA. USA
- March of Dimes Prematurity Research Center at Stanford University, Stanford, CA USA
| | | | - Antonio Parraga-Leo
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
| | - Camilla Wibrand
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
| | - Samuel S Minot
- Data Core, Shared Resources, Fred Hutchinson Cancer Center. Seattle, WA. USA
| | - Gaia Andreoletti
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
| | - Idit Kosti
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
| | | | | | - Jifan Gao
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. USA
| | - Zhoujingpeng Wei
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. USA
| | - Guanhua Chen
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. USA
| | - Zheng-Zheng Tang
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. USA
| | - Pierfrancesco Novielli
- Division of Infectious Disease. Department of Internal Medicine. University of Michigan. Ann Arbor, MI. USA
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
- Sage Bionetworks, Seattle, WA. USA
- Benioff Center for Microbiome Medicine, Department of Medicine, University of California, San Francisco, CA. USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA. USA
- March of Dimes Prematurity Research Center at Stanford University, Stanford, CA USA
- Data Core, Shared Resources, Fred Hutchinson Cancer Center. Seattle, WA. USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. USA
| | - Donato Romano
- Division of Infectious Disease. Department of Internal Medicine. University of Michigan. Ann Arbor, MI. USA
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
- Sage Bionetworks, Seattle, WA. USA
- Benioff Center for Microbiome Medicine, Department of Medicine, University of California, San Francisco, CA. USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA. USA
- March of Dimes Prematurity Research Center at Stanford University, Stanford, CA USA
- Data Core, Shared Resources, Fred Hutchinson Cancer Center. Seattle, WA. USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. USA
| | - Ester Pantaleo
- Division of Infectious Disease. Department of Internal Medicine. University of Michigan. Ann Arbor, MI. USA
| | - Nicola Amoroso
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
| | - Alfonso Monaco
- Division of Infectious Disease. Department of Internal Medicine. University of Michigan. Ann Arbor, MI. USA
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
- Sage Bionetworks, Seattle, WA. USA
- Benioff Center for Microbiome Medicine, Department of Medicine, University of California, San Francisco, CA. USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA. USA
- March of Dimes Prematurity Research Center at Stanford University, Stanford, CA USA
- Data Core, Shared Resources, Fred Hutchinson Cancer Center. Seattle, WA. USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. USA
| | - Mirco Vacca
- Division of Infectious Disease. Department of Internal Medicine. University of Michigan. Ann Arbor, MI. USA
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
- Sage Bionetworks, Seattle, WA. USA
- Benioff Center for Microbiome Medicine, Department of Medicine, University of California, San Francisco, CA. USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA. USA
- March of Dimes Prematurity Research Center at Stanford University, Stanford, CA USA
- Data Core, Shared Resources, Fred Hutchinson Cancer Center. Seattle, WA. USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. USA
| | - Maria De Angelis
- Division of Infectious Disease. Department of Internal Medicine. University of Michigan. Ann Arbor, MI. USA
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
- Sage Bionetworks, Seattle, WA. USA
- Benioff Center for Microbiome Medicine, Department of Medicine, University of California, San Francisco, CA. USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA. USA
- March of Dimes Prematurity Research Center at Stanford University, Stanford, CA USA
- Data Core, Shared Resources, Fred Hutchinson Cancer Center. Seattle, WA. USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. USA
| | - Roberto Bellotti
- Division of Infectious Disease. Department of Internal Medicine. University of Michigan. Ann Arbor, MI. USA
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
- Sage Bionetworks, Seattle, WA. USA
- Benioff Center for Microbiome Medicine, Department of Medicine, University of California, San Francisco, CA. USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA. USA
- March of Dimes Prematurity Research Center at Stanford University, Stanford, CA USA
- Data Core, Shared Resources, Fred Hutchinson Cancer Center. Seattle, WA. USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. USA
| | - Sabina Tangaro
- Division of Infectious Disease. Department of Internal Medicine. University of Michigan. Ann Arbor, MI. USA
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
- Sage Bionetworks, Seattle, WA. USA
- Benioff Center for Microbiome Medicine, Department of Medicine, University of California, San Francisco, CA. USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA. USA
- March of Dimes Prematurity Research Center at Stanford University, Stanford, CA USA
- Data Core, Shared Resources, Fred Hutchinson Cancer Center. Seattle, WA. USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. USA
| | - Abigail Kuntzleman
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
| | - Isaac Bigcraft
- Division of Infectious Disease. Department of Internal Medicine. University of Michigan. Ann Arbor, MI. USA
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
- Sage Bionetworks, Seattle, WA. USA
- Benioff Center for Microbiome Medicine, Department of Medicine, University of California, San Francisco, CA. USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA. USA
- March of Dimes Prematurity Research Center at Stanford University, Stanford, CA USA
- Data Core, Shared Resources, Fred Hutchinson Cancer Center. Seattle, WA. USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. USA
| | - Stephen Techtmann
- Division of Infectious Disease. Department of Internal Medicine. University of Michigan. Ann Arbor, MI. USA
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
- Sage Bionetworks, Seattle, WA. USA
- Benioff Center for Microbiome Medicine, Department of Medicine, University of California, San Francisco, CA. USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA. USA
- March of Dimes Prematurity Research Center at Stanford University, Stanford, CA USA
- Data Core, Shared Resources, Fred Hutchinson Cancer Center. Seattle, WA. USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. USA
| | - Daehun Bae
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
| | - Eunyoung Kim
- Division of Infectious Disease. Department of Internal Medicine. University of Michigan. Ann Arbor, MI. USA
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
- Sage Bionetworks, Seattle, WA. USA
- Benioff Center for Microbiome Medicine, Department of Medicine, University of California, San Francisco, CA. USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA. USA
- March of Dimes Prematurity Research Center at Stanford University, Stanford, CA USA
- Data Core, Shared Resources, Fred Hutchinson Cancer Center. Seattle, WA. USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. USA
| | | | - Soobok Joe
- Division of Infectious Disease. Department of Internal Medicine. University of Michigan. Ann Arbor, MI. USA
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
- Sage Bionetworks, Seattle, WA. USA
- Benioff Center for Microbiome Medicine, Department of Medicine, University of California, San Francisco, CA. USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA. USA
- March of Dimes Prematurity Research Center at Stanford University, Stanford, CA USA
- Data Core, Shared Resources, Fred Hutchinson Cancer Center. Seattle, WA. USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. USA
| | - Kevin R Theis
- Benioff Center for Microbiome Medicine, Department of Medicine, University of California, San Francisco, CA. USA
| | - Sherrianne Ng
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA. USA
- March of Dimes Prematurity Research Center at Stanford University, Stanford, CA USA
| | - Yun S Lee Li
- Division of Infectious Disease. Department of Internal Medicine. University of Michigan. Ann Arbor, MI. USA
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
- Sage Bionetworks, Seattle, WA. USA
- Benioff Center for Microbiome Medicine, Department of Medicine, University of California, San Francisco, CA. USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA. USA
- March of Dimes Prematurity Research Center at Stanford University, Stanford, CA USA
- Data Core, Shared Resources, Fred Hutchinson Cancer Center. Seattle, WA. USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. USA
| | - Patricia Diaz-Gimeno
- Division of Infectious Disease. Department of Internal Medicine. University of Michigan. Ann Arbor, MI. USA
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
- Sage Bionetworks, Seattle, WA. USA
- Benioff Center for Microbiome Medicine, Department of Medicine, University of California, San Francisco, CA. USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA. USA
- March of Dimes Prematurity Research Center at Stanford University, Stanford, CA USA
- Data Core, Shared Resources, Fred Hutchinson Cancer Center. Seattle, WA. USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. USA
| | - Phillip R Bennett
- Division of Infectious Disease. Department of Internal Medicine. University of Michigan. Ann Arbor, MI. USA
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
- Sage Bionetworks, Seattle, WA. USA
- Benioff Center for Microbiome Medicine, Department of Medicine, University of California, San Francisco, CA. USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA. USA
- March of Dimes Prematurity Research Center at Stanford University, Stanford, CA USA
- Data Core, Shared Resources, Fred Hutchinson Cancer Center. Seattle, WA. USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. USA
| | - David A MacIntyre
- Division of Infectious Disease. Department of Internal Medicine. University of Michigan. Ann Arbor, MI. USA
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
- Sage Bionetworks, Seattle, WA. USA
- Benioff Center for Microbiome Medicine, Department of Medicine, University of California, San Francisco, CA. USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA. USA
- March of Dimes Prematurity Research Center at Stanford University, Stanford, CA USA
- Data Core, Shared Resources, Fred Hutchinson Cancer Center. Seattle, WA. USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. USA
| | - Gustavo Stolovitzky
- Data Core, Shared Resources, Fred Hutchinson Cancer Center. Seattle, WA. USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. USA
| | - Susan V Lynch
- Benioff Center for Microbiome Medicine, Department of Medicine, University of California, San Francisco, CA. USA
| | | | - Nardhy Gomez-Lopez
- Division of Infectious Disease. Department of Internal Medicine. University of Michigan. Ann Arbor, MI. USA
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
- Sage Bionetworks, Seattle, WA. USA
- Benioff Center for Microbiome Medicine, Department of Medicine, University of California, San Francisco, CA. USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA. USA
- March of Dimes Prematurity Research Center at Stanford University, Stanford, CA USA
- Data Core, Shared Resources, Fred Hutchinson Cancer Center. Seattle, WA. USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. USA
| | - Roberto Romero
- Division of Infectious Disease. Department of Internal Medicine. University of Michigan. Ann Arbor, MI. USA
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
- Sage Bionetworks, Seattle, WA. USA
- Benioff Center for Microbiome Medicine, Department of Medicine, University of California, San Francisco, CA. USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA. USA
- March of Dimes Prematurity Research Center at Stanford University, Stanford, CA USA
- Data Core, Shared Resources, Fred Hutchinson Cancer Center. Seattle, WA. USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. USA
| | - David K Stevenson
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA. USA
| | - Nima Aghaeepour
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA. USA
| | - Adi L Tarca
- Division of Infectious Disease. Department of Internal Medicine. University of Michigan. Ann Arbor, MI. USA
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
- Sage Bionetworks, Seattle, WA. USA
- Benioff Center for Microbiome Medicine, Department of Medicine, University of California, San Francisco, CA. USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA. USA
- March of Dimes Prematurity Research Center at Stanford University, Stanford, CA USA
- Data Core, Shared Resources, Fred Hutchinson Cancer Center. Seattle, WA. USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. USA
| | - James C Costello
- Division of Infectious Disease. Department of Internal Medicine. University of Michigan. Ann Arbor, MI. USA
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
- Sage Bionetworks, Seattle, WA. USA
- Benioff Center for Microbiome Medicine, Department of Medicine, University of California, San Francisco, CA. USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA. USA
- March of Dimes Prematurity Research Center at Stanford University, Stanford, CA USA
- Data Core, Shared Resources, Fred Hutchinson Cancer Center. Seattle, WA. USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. USA
| | - Marina Sirota
- March of Dimes Prematurity Research Center at the University of California San Francisco, San Francisco, CA USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA. USA
- Department of Pediatrics. University of California San Francisco, San Francisco, CA. USA
| |
Collapse
|
24
|
Chi S, Kim S, Reuter M, Ponzillo K, Oliver DP, Foraker R, Heard K, Liu J, Pitzer K, White P, Moore N. Advanced Care Planning for Hospitalized Patients Following Clinician Notification of Patient Mortality by a Machine Learning Algorithm. JAMA Netw Open 2023; 6:e238795. [PMID: 37071421 PMCID: PMC10114011 DOI: 10.1001/jamanetworkopen.2023.8795] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 02/28/2023] [Indexed: 04/19/2023] Open
Abstract
Importance Goal-concordant care is an ongoing challenge in hospital settings. Identification of high mortality risk within 30 days may call attention to the need to have serious illness conversations, including the documentation of patient goals of care. Objective To examine goals of care discussions (GOCDs) in a community hospital setting with patients identified as having a high risk of mortality by a machine learning mortality prediction algorithm. Design, Setting, and Participants This cohort study took place at community hospitals within 1 health care system. Participants included adult patients with a high risk of 30-day mortality who were admitted to 1 of 4 hospitals between January 2 and July 15, 2021. Patient encounters of inpatients in the intervention hospital where physicians were notified of the computed high risk mortality score were compared with patient encounters of inpatients in 3 community hospitals without the intervention (ie, matched control). Intervention Physicians of patients with a high risk of mortality within 30 days received notification and were encouraged to arrange for GOCDs. Main Outcomes and Measures The primary outcome was the percentage change of documented GOCDs prior to discharge. Propensity-score matching was completed on a preintervention and postintervention period using age, sex, race, COVID-19 status, and machine learning-predicted mortality risk scores. A difference-in-difference analysis validated the results. Results Overall, 537 patients were included in this study with 201 in the preintervention period (94 in the intervention group; 104 in the control group) and 336 patients in the postintervention period. The intervention and control groups included 168 patients per group and were well-balanced in age (mean [SD], 79.3 [9.60] vs 79.6 [9.21] years; standardized mean difference [SMD], 0.03), sex (female, 85 [51%] vs 85 [51%]; SMD, 0), race (White patients, 145 [86%] vs 144 [86%]; SMD 0.006), and Charlson comorbidities (median [range], 8.00 [2.00-15.0] vs 9.00 [2.00 to 19.0]; SMD, 0.34). Patients in the intervention group from preintervention to postintervention period were associated with being 5 times more likely to have documented GOCDs (OR, 5.11 [95% CI, 1.93 to 13.42]; P = .001) by discharge compared with matched controls, and GOCD occurred significantly earlier in the hospitalization in the intervention patients as compared with matched controls (median, 4 [95% CI, 3 to 6] days vs 16 [95% CI, 15 to not applicable] days; P < .001). Similar findings were observed for Black patient and White patient subgroups. Conclusions and Relevance In this cohort study, patients whose physicians had knowledge of high-risk predictions from machine learning mortality algorithms were associated with being 5 times more likely to have documented GOCDs than matched controls. Additional external validation is needed to determine if similar interventions would be helpful at other institutions.
Collapse
Affiliation(s)
- Stephen Chi
- Division of Pulmonary and Critical Care Medicine, Washington University in St Louis, St Louis, Missouri
| | - Seunghwan Kim
- Institute for Informatics, Washington University in St Louis, St Louis, Missouri
| | | | | | - Debra Parker Oliver
- Division of Palliative Medicine, Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Randi Foraker
- Institute for Informatics, Washington University in St Louis, St Louis, Missouri
| | | | - Jingxia Liu
- Division of Public Health Sciences, Department of Surgery, Washington University in St Louis, St Louis, Missouri
- Division of Biostatistics, Washington University in St Louis, St Louis, Missouri
| | - Kyle Pitzer
- Division of Palliative Medicine, Department of Medicine, Washington University in St Louis, St Louis, Missouri
- Division of Biostatistics, Washington University in St Louis, St Louis, Missouri
| | - Patrick White
- Division of Palliative Medicine, Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | | |
Collapse
|
25
|
Huang AA, Huang SY. Computation of the distribution of model accuracy statistics in machine learning: Comparison between analytically derived distributions and simulation-based methods. Health Sci Rep 2023; 6:e1214. [PMID: 37091362 PMCID: PMC10119581 DOI: 10.1002/hsr2.1214] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/16/2023] [Accepted: 03/20/2023] [Indexed: 04/25/2023] Open
Abstract
Background and Aims All fields have seen an increase in machine-learning techniques. To accurately evaluate the efficacy of novel modeling methods, it is necessary to conduct a critical evaluation of the utilized model metrics, such as sensitivity, specificity, and area under the receiver operator characteristic curve (AUROC). For commonly used model metrics, we proposed the use of analytically derived distributions (ADDs) and compared it with simulation-based approaches. Methods A retrospective cohort study was conducted using the England National Health Services Heart Disease Prediction Cohort. Four machine learning models (XGBoost, Random Forest, Artificial Neural Network, and Adaptive Boost) were used. The distribution of the model metrics and covariate gain statistics were empirically derived using boot-strap simulation (N = 10,000). The ADDs were created from analytic formulas from the covariates to describe the distribution of the model metrics and compared with those of bootstrap simulation. Results XGBoost had the most optimal model having the highest AUROC and the highest aggregate score considering six other model metrics. Based on the Anderson-Darling test, the distribution of the model metrics created from bootstrap did not significantly deviate from a normal distribution. The variance created from the ADD led to smaller SDs than those derived from bootstrap simulation, whereas the rest of the distribution remained not statistically significantly different. Conclusions ADD allows for cross study comparison of model metrics, which is usually done with bootstrapping that rely on simulations, which cannot be replicated by the reader.
Collapse
Affiliation(s)
- Alexander A. Huang
- Northwestern University Feinberg School of MedicineNorthwestern UniversityChicagoIllinoisUSA
| | - Samuel Y. Huang
- Virginia Commonwealth School of MedicineVirginia Commonwealth UniversityRichmondVirginiaUSA
| |
Collapse
|