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Curci R, Bonfiglio C, Franco I, Bagnato CB, Verrelli N, Bianco A. Leisure-Time Physical Activity in Subjects with Metabolic-Dysfunction-Associated Steatotic Liver Disease: An All-Cause Mortality Study. J Clin Med 2024; 13:3772. [PMID: 38999337 PMCID: PMC11242783 DOI: 10.3390/jcm13133772] [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: 06/04/2024] [Revised: 06/20/2024] [Accepted: 06/25/2024] [Indexed: 07/14/2024] Open
Abstract
Background: Metabolic-dysfunction-associated steatotic liver disease (MASLD) affects 30% of adults worldwide and is associated with obesity and cardiovascular risk factors. If left untreated, it can progress to severe liver disease. Lifestyle changes such as physical activity and weight loss help to reduce the severity and risk of mortality. This study estimated the impact of MASLD and leisure-time physical activity (LTPA) on mortality and examined how gender mediates this effect in a Southern Italian population. Methods: This work is a population-based prospective cohort study of inhabitants of Castellana Grotte (>30 years old) in Southern Italy, which began in 1985. Participants provided general health information, underwent anthropometric measurements and ultrasonography, and completed a validated questionnaire on their food intake and LTPA. The vital status was tracked through local municipalities Results: In total, 1826 participants (39% with MASLD) were enrolled in this study, drawn from 2970 eligible subjects; the mean age was 51.91 (±14.76) years and 56.2% were men. Subjects with MASLD who practiced low LTPA had a significantly higher risk of death than those who did not have MASLD and practiced high LTPA. In addition, subjects with MASLD who practiced low LTPA were about 19% less likely to survive to the age of 82 years. As regards gender, both men and women with MASLD and low LTPA showed a significant risk of death, but this was higher in women. Conclusions: The presence of MASLD, especially in women, increases the risk of death from all causes. LTPA plays a key role in the disease and reduces mortality in these individuals.
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Affiliation(s)
- Ritanna Curci
- Laboratory of Movement and Wellness, National Institute of Gastroenterology, IRCCS “S. de Bellis”, Via Turi, 70013 Castellana Grotte, BA, Italy; (R.C.); (I.F.); (C.B.B.); (N.V.)
| | - Caterina Bonfiglio
- Laboratory of Epidemiology and Statistics, National Institute of Gastroenterology, IRCCS “S. de Bellis”, 70013 Castellana Grotte, BA, Italy;
| | - Isabella Franco
- Laboratory of Movement and Wellness, National Institute of Gastroenterology, IRCCS “S. de Bellis”, Via Turi, 70013 Castellana Grotte, BA, Italy; (R.C.); (I.F.); (C.B.B.); (N.V.)
| | - Claudia Beatrice Bagnato
- Laboratory of Movement and Wellness, National Institute of Gastroenterology, IRCCS “S. de Bellis”, Via Turi, 70013 Castellana Grotte, BA, Italy; (R.C.); (I.F.); (C.B.B.); (N.V.)
| | - Nicola Verrelli
- Laboratory of Movement and Wellness, National Institute of Gastroenterology, IRCCS “S. de Bellis”, Via Turi, 70013 Castellana Grotte, BA, Italy; (R.C.); (I.F.); (C.B.B.); (N.V.)
| | - Antonella Bianco
- Laboratory of Movement and Wellness, National Institute of Gastroenterology, IRCCS “S. de Bellis”, Via Turi, 70013 Castellana Grotte, BA, Italy; (R.C.); (I.F.); (C.B.B.); (N.V.)
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Lin L, Poppe K, Wood A, Martin GP, Peek N, Sperrin M. Making predictions under interventions: a case study from the PREDICT-CVD cohort in New Zealand primary care. FRONTIERS IN EPIDEMIOLOGY 2024; 4:1326306. [PMID: 38633209 PMCID: PMC11021700 DOI: 10.3389/fepid.2024.1326306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 03/11/2024] [Indexed: 04/19/2024]
Abstract
Background Most existing clinical prediction models do not allow predictions under interventions. Such predictions allow predicted risk under different proposed strategies to be compared and are therefore useful to support clinical decision making. We aimed to compare methodological approaches for predicting individual level cardiovascular risk under three interventions: smoking cessation, reducing blood pressure, and reducing cholesterol. Methods We used data from the PREDICT prospective cohort study in New Zealand to calculate cardiovascular risk in a primary care setting. We compared three strategies to estimate absolute risk under intervention: (a) conditioning on hypothetical interventions in non-causal models; (b) combining existing prediction models with causal effects estimated using observational causal inference methods; and (c) combining existing prediction models with causal effects reported in published literature. Results The median absolute cardiovascular risk among smokers was 3.9%; our approaches predicted that smoking cessation reduced this to a median between a non-causal estimate of 2.5% and a causal estimate of 2.8%, depending on estimation methods. For reducing blood pressure, the proposed approaches estimated a reduction of absolute risk from a median of 4.9% to a median between 3.2% and 4.5% (both derived from causal estimation). Reducing cholesterol was estimated to reduce median absolute risk from 3.1% to between 2.2% (non-causal estimate) and 2.8% (causal estimate). Conclusions Estimated absolute risk reductions based on non-causal methods were different to those based on causal methods, and there was substantial variation in estimates within the causal methods. Researchers wishing to estimate risk under intervention should be explicit about their causal modelling assumptions and conduct sensitivity analysis by considering a range of possible approaches.
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Affiliation(s)
- Lijing Lin
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Katrina Poppe
- Schools of Population Health & Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Angela Wood
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, United Kingdom
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, United Kingdom
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, United Kingdom
- Cambridge Centre of Artificial Intelligence in Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Glen P. Martin
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Niels Peek
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Matthew Sperrin
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
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Post RAJ, Petkovic M, van den Heuvel IL, van den Heuvel ER. Flexible Machine Learning Estimation of Conditional Average Treatment Effects: A Blessing and a Curse. Epidemiology 2024; 35:32-40. [PMID: 37889951 DOI: 10.1097/ede.0000000000001684] [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: 10/29/2023]
Abstract
Causal inference from observational data requires untestable identification assumptions. If these assumptions apply, machine learning methods can be used to study complex forms of causal effect heterogeneity. Recently, several machine learning methods were developed to estimate the conditional average treatment effect (ATE). If the features at hand cannot explain all heterogeneity, the individual treatment effects can seriously deviate from the conditional ATE. In this work, we demonstrate how the distributions of the individual treatment effect and the conditional ATE can differ when a causal random forest is applied. We extend the causal random forest to estimate the difference in conditional variance between treated and controls. If the distribution of the individual treatment effect equals that of the conditional ATE, this estimated difference in variance should be small. If they differ, an additional causal assumption is necessary to quantify the heterogeneity not captured by the distribution of the conditional ATE. The conditional variance of the individual treatment effect can be identified when the individual effect is independent of the outcome under no treatment given the measured features. Then, in the cases where the individual treatment effect and conditional ATE distributions differ, the extended causal random forest can appropriately estimate the variance of the individual treatment effect distribution, whereas the causal random forest fails to do so.
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Affiliation(s)
- Richard A J Post
- From the Department of Mathematics and Computer Science, Eindhoven University of Technology, the Netherlands
| | - Marko Petkovic
- From the Department of Mathematics and Computer Science, Eindhoven University of Technology, the Netherlands
| | - Isabel L van den Heuvel
- From the Department of Mathematics and Computer Science, Eindhoven University of Technology, the Netherlands
| | - Edwin R van den Heuvel
- From the Department of Mathematics and Computer Science, Eindhoven University of Technology, the Netherlands
- Department of Preventive Medicine and Epidemiology, School of Medicine, Boston University, Boston, MA
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Buss C, Genuneit J. How Many Are Too Much? Clinical and Epidemiological Considerations for the Era of Poly-Pre- and Postnatal Exposures Relevant for the Developing Brain. Biol Psychiatry 2023; 93:861-863. [PMID: 35953318 PMCID: PMC9790042 DOI: 10.1016/j.biopsych.2022.06.025] [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: 06/22/2022] [Accepted: 06/22/2022] [Indexed: 12/27/2022]
Affiliation(s)
- Claudia Buss
- German Center for Child and Youth Health, Germany; Department of Medical Psychology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Development, Health and Disease Research Program, University of California, Irvine, School of Medicine, Irvine, California; Department of Pediatrics, University of California, Irvine, School of Medicine, Irvine, California.
| | - Jon Genuneit
- German Center for Child and Youth Health, Germany; Pediatric Epidemiology, Department of Pediatrics, Medical Faculty, Leipzig University, Leipzig, Germany.
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5
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Piccininni M, Rohmann JL, Wechsung M, Logroscino G, Kurth T. Should Cognitive Screening Tests Be Corrected for Age and Education? Insights From a Causal Perspective. Am J Epidemiol 2023; 192:93-101. [PMID: 36068941 PMCID: PMC9825732 DOI: 10.1093/aje/kwac159] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/10/2022] [Accepted: 08/31/2022] [Indexed: 01/25/2023] Open
Abstract
Cognitive screening tests such as the Mini-Mental State Examination are widely used in clinical routine to predict cognitive impairment. The raw test scores are often corrected for age and education, although documented poorer discrimination performance of corrected scores has challenged this practice. Nonetheless, test correction persists, perhaps due to the seemingly counterintuitive nature of the underlying problem. We used a causal framework to inform the long-standing debate from a more intuitive angle. We illustrate and quantify the consequences of applying the age-education correction of cognitive tests on discrimination performance. In an effort to bridge theory and practical implementation, we computed differences in discrimination performance under plausible causal scenarios using Open Access Series of Imaging Studies (OASIS)-1 data. We show that when age and education are causal risk factors for cognitive impairment and independently also affect the test score, correcting test scores for age and education removes meaningful information, thereby diminishing discrimination performance.
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Affiliation(s)
- Marco Piccininni
- Correspondence to Dr. Marco Piccininni, Institute of Public Health, Charité – Universitätsmedizin Berlin, Chariteplatz 1, Berlin, Germany 10117 (e-mail: )
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6
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Perez-de-Acha A, Pilleron S, Soto-Perez-de-Celis E. All-Cause Mortality Risk Prediction in Older Adults with Cancer: Practical Approaches and Limitations. Curr Oncol Rep 2022; 24:1377-1385. [PMID: 35648341 DOI: 10.1007/s11912-022-01303-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW The prediction of all-cause mortality is an important component of shared decision-making across the cancer care continuum, particularly in older adults with limited life expectancy, for whom there is an increased risk of over-diagnosis and treatment. RECENT FINDINGS Currently, several international societies recommend the use of all-cause mortality risk prediction tools when making decisions regarding screening and treatment in geriatric oncology. Here, we review some practical aspects of the utilization of those tools and dissect the characteristics of those most employed in geriatric oncology, highlighting both their advantages and their limitations.
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Affiliation(s)
- Andrea Perez-de-Acha
- Department of Geriatrics, Instituto Nacional de Ciencias Medicas Y Nutricion Salvador Zubiran, Vasco de Quiroga 15, Colonia Belisario Dominguez Sección XVI, Tlalpan, Ciudad de Mexico, Mexico
| | - Sophie Pilleron
- Nuffield Department of Population Health, Big Data Institute, University of Oxford, Oxford, UK
| | - Enrique Soto-Perez-de-Celis
- Department of Geriatrics, Instituto Nacional de Ciencias Medicas Y Nutricion Salvador Zubiran, Vasco de Quiroga 15, Colonia Belisario Dominguez Sección XVI, Tlalpan, Ciudad de Mexico, Mexico.
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Xu Y, Mansmann U. Validating the knowledge bank approach for personalized prediction of survival in acute myeloid leukemia: a reproducibility study. Hum Genet 2022; 141:1467-1480. [PMID: 35429300 PMCID: PMC9360099 DOI: 10.1007/s00439-022-02455-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 04/05/2022] [Indexed: 11/29/2022]
Abstract
Reproducibility is not only essential for the integrity of scientific research but is also a prerequisite for model validation and refinement for the future application of predictive algorithms. However, reproducible research is becoming increasingly challenging, particularly in high-dimensional genomic data analyses with complex statistical or algorithmic techniques. Given that there are no mandatory requirements in most biomedical and statistical journals to provide the original data, analytical source code, or other relevant materials for publication, accessibility to these supplements naturally suggests a greater credibility of the published work. In this study, we performed a reproducibility assessment of the notable paper by Gerstung et al. (Nat Genet 49:332–340, 2017) by rerunning the analysis using their original code and data, which are publicly accessible. Despite an open science setting, it was challenging to reproduce the entire research project; reasons included: incomplete data and documentation, suboptimal code readability, coding errors, limited portability of intensive computing performed on a specific platform, and an R computing environment that could no longer be re-established. We learn that the availability of code and data does not guarantee transparency and reproducibility of a study; paradoxically, the source code is still liable to error and obsolescence, essentially due to methodological and computational complexity, a lack of reproducibility checking at submission, and updates for software and operating environment. The complex code may also hide problematic methodological aspects of the proposed research. Building on the experience gained, we discuss the best programming and software engineering practices that could have been employed to improve reproducibility, and propose practical criteria for the conduct and reporting of reproducibility studies for future researchers.
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Affiliation(s)
- Yujun Xu
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377 Munich, Germany
| | - Ulrich Mansmann
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377 Munich, Germany
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Dickerman BA, Dahabreh IJ, Cantos KV, Logan RW, Lodi S, Rentsch CT, Justice AC, Hernán MA. Predicting counterfactual risks under hypothetical treatment strategies: an application to HIV. Eur J Epidemiol 2022; 37:367-376. [PMID: 35190946 PMCID: PMC9189026 DOI: 10.1007/s10654-022-00855-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 02/14/2022] [Indexed: 12/23/2022]
Abstract
The accuracy of a prediction algorithm depends on contextual factors that may vary across deployment settings. To address this inherent limitation of prediction, we propose an approach to counterfactual prediction based on the g-formula to predict risk across populations that differ in their distribution of treatment strategies. We apply this to predict 5-year risk of mortality among persons receiving care for HIV in the U.S. Veterans Health Administration under different hypothetical treatment strategies. First, we implement a conventional approach to develop a prediction algorithm in the observed data and show how the algorithm may fail when transported to new populations with different treatment strategies. Second, we generate counterfactual data under different treatment strategies and use it to assess the robustness of the original algorithm's performance to these differences and to develop counterfactual prediction algorithms. We discuss how estimating counterfactual risks under a particular treatment strategy is more challenging than conventional prediction as it requires the same data, methods, and unverifiable assumptions as causal inference. However, this may be required when the alternative assumption of constant treatment patterns across deployment settings is unlikely to hold and new data is not yet available to retrain the algorithm.
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Affiliation(s)
- Barbra A Dickerman
- CAUSALab, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Issa J Dahabreh
- CAUSALab, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Roger W Logan
- CAUSALab, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Sara Lodi
- CAUSALab, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Christopher T Rentsch
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Amy C Justice
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
| | - Miguel A Hernán
- CAUSALab, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Harvard-MIT Division of Health Sciences and Technology, Boston, MA, USA
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Methods for Evaluating Environmental Health Impacts at Different Stages of the Policy Process in Cities. Curr Environ Health Rep 2022; 9:183-195. [PMID: 35389203 PMCID: PMC8986968 DOI: 10.1007/s40572-022-00349-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE OF REVIEW Evaluating the environmental health impacts of urban policies is critical for developing and implementing policies that lead to more healthy and equitable cities. This article aims to (1) identify research questions commonly used when evaluating the health impacts of urban policies at different stages of the policy process, (2) describe commonly used methods, and (3) discuss challenges, opportunities, and future directions. RECENT FINDINGS In the diagnosis and design stages of the policy process, research questions aim to characterize environmental problems affecting human health and to estimate the potential impacts of new policies. Simulation methods using existing exposure-response information to estimate health impacts predominate at these stages of the policy process. In subsequent stages, e.g., during implementation, research questions aim to understand the actual policy impacts. Simulation methods or observational methods, which rely on experimental data gathered in the study area to assess the effectiveness of the policy, can be applied at these stages. Increasingly, novel techniques fuse both simulation and observational methods to enhance the robustness of impact evaluations assessing implemented policies. The policy process consists of interdependent stages, from inception to end, but most reviewed studies focus on single stages, neglecting the continuity of the policy life cycle. Studies assessing the health impacts of policies using a multi-stage approach are lacking. Most studies investigate intended impacts of policies; focusing also on unintended impacts may provide a more comprehensive evaluation of policies.
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Hoogland J, IntHout J, Belias M, Rovers MM, Riley RD, E. Harrell Jr F, Moons KGM, Debray TPA, Reitsma JB. A tutorial on individualized treatment effect prediction from randomized trials with a binary endpoint. Stat Med 2021; 40:5961-5981. [PMID: 34402094 PMCID: PMC9291969 DOI: 10.1002/sim.9154] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 06/08/2021] [Accepted: 07/19/2021] [Indexed: 12/23/2022]
Abstract
Randomized trials typically estimate average relative treatment effects, but decisions on the benefit of a treatment are possibly better informed by more individualized predictions of the absolute treatment effect. In case of a binary outcome, these predictions of absolute individualized treatment effect require knowledge of the individual's risk without treatment and incorporation of a possibly differential treatment effect (ie, varying with patient characteristics). In this article, we lay out the causal structure of individualized treatment effect in terms of potential outcomes and describe the required assumptions that underlie a causal interpretation of its prediction. Subsequently, we describe regression models and model estimation techniques that can be used to move from average to more individualized treatment effect predictions. We focus mainly on logistic regression-based methods that are both well-known and naturally provide the required probabilistic estimates. We incorporate key components from both causal inference and prediction research to arrive at individualized treatment effect predictions. While the separate components are well known, their successful amalgamation is very much an ongoing field of research. We cut the problem down to its essentials in the setting of a randomized trial, discuss the importance of a clear definition of the estimand of interest, provide insight into the required assumptions, and give guidance with respect to modeling and estimation options. Simulated data illustrate the potential of different modeling options across scenarios that vary both average treatment effect and treatment effect heterogeneity. Two applied examples illustrate individualized treatment effect prediction in randomized trial data.
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Affiliation(s)
- Jeroen Hoogland
- Julius Center for Health Sciences and Primary Care, University Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Joanna IntHout
- Radboud Institute for Health Sciences (RIHS)Radboud University Medical CenterNijmegenthe Netherlands
| | - Michail Belias
- Radboud Institute for Health Sciences (RIHS)Radboud University Medical CenterNijmegenthe Netherlands
| | - Maroeska M. Rovers
- Radboud Institute for Health Sciences (RIHS)Radboud University Medical CenterNijmegenthe Netherlands
| | | | - Frank E. Harrell Jr
- Department of BiostatisticsVanderbilt University School of MedicineNashvilleTennesseeUSA
| | - Karel G. M. Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
- Cochrane Netherlands, University Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Thomas P. A. Debray
- Julius Center for Health Sciences and Primary Care, University Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
- Cochrane Netherlands, University Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Johannes B. Reitsma
- Julius Center for Health Sciences and Primary Care, University Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
- Cochrane Netherlands, University Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
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11
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Sperrin M, Diaz-Ordaz K, Pajouheshnia R. Invited Commentary: Treatment Drop-in-Making the Case for Causal Prediction. Am J Epidemiol 2021; 190:2015-2018. [PMID: 33595073 PMCID: PMC8485150 DOI: 10.1093/aje/kwab030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 01/25/2021] [Accepted: 02/02/2021] [Indexed: 11/12/2022] Open
Abstract
Clinical prediction models (CPMs) are often used to guide treatment initiation, with individuals at high risk offered treatment. This implicitly assumes that the probability quoted from a CPM represents the risk to an individual of an adverse outcome in absence of treatment. However, for a CPM to correctly target this estimand requires careful causal thinking. One problem that needs to be overcome is treatment drop-in: where individuals in the development data commence treatment after the time of prediction but before the outcome occurs. In this issue of the Journal, Xu et al. (Am J Epidemiol. 2021;190(10):2000-2014) use causal estimates from external data sources, such as clinical trials, to adjust CPMs for treatment drop-in. This represents a pragmatic and promising approach to address this issue, and it illustrates the value of utilizing causal inference in prediction. Building causality into the prediction pipeline can also bring other benefits. These include the ability to make and compare hypothetical predictions under different interventions, to make CPMs more explainable and transparent, and to improve model generalizability. Enriching CPMs with causal inference therefore has the potential to add considerable value to the role of prediction in healthcare.
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Affiliation(s)
- Matthew Sperrin
- Correspondence to Matthew Sperrin, Vaughan House, Portsmouth Street, University of Manchester, Manchester M13 9GB, UK (e-mail: )
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12
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Anikpo I, Agovi AMA, Cvitanovich MJ, Lonergan F, Johnson M, Ojha RP. The data-collection on adverse effects of anti-HIV drugs (D:A:D) model for predicting cardiovascular events: External validation in a diverse cohort of people living with HIV. HIV Med 2021; 22:936-943. [PMID: 34414654 PMCID: PMC9290794 DOI: 10.1111/hiv.13147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 07/07/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Little is known about the external validity of the Data-collection on Adverse Effects of Anti-HIV Drugs (D:A:D) model for predicting cardiovascular disease (CVD) risk among people living with HIV (PLWH). We aimed to evaluate the performance of the updated D:A:D model for 5-year CVD risk in a diverse group of PLWH engaged in HIV care. METHODS We used data from an institutional HIV registry, which includes PLWH engaged in care at a safety-net HIV clinic. Eligible individuals had a baseline clinical encounter between 1 January 2013 and 31 December 2014, with follow-up through to 31 December 2019. We estimated 5-year predicted risks of CVD as a function of the prognostic index and baseline survival of the D:A:D model, which were used to assess model discrimination (C-index), calibration and net benefit. RESULTS Our evaluable population comprised 1029 PLWH, of whom 30% were female, 50% were non-Hispanic black, and median age was 45 years. The C-index was 0.70 [95% confidence limits (CL): 0.64-0.75]. The predicted 5-year CVD risk was 3.0% and the observed 5-year risk was 8.9% (expected/observed ratio = 0.33, 95% CL: 0.26-0.54). The model had a greater net benefit than treating all or treating none at a risk threshold of 10%. CONCLUSIONS The D:A:D model was miscalibrated for CVD risk among PLWH engaged in HIV care at an urban safety-net HIV clinic, which may be related to differences in case-mix and baseline CVD risk. Nevertheless, the HIV D:A:D model may be useful for decisions about CVD intervention for high-risk patients.
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Affiliation(s)
- Ifedioranma Anikpo
- Center for Epidemiology & Healthcare Delivery Research, JPS Health Network, Fort Worth, TX, USA
| | - Afiba Manza-A Agovi
- Center for Epidemiology & Healthcare Delivery Research, JPS Health Network, Fort Worth, TX, USA.,Department of Medical Education, TCU and UNTHSC School of Medicine, Fort Worth, TX, USA
| | - Matthew J Cvitanovich
- Center for Epidemiology & Healthcare Delivery Research, JPS Health Network, Fort Worth, TX, USA
| | - Frank Lonergan
- True Worth Medical Home, JPS Health Network, Fort Worth, TX, USA
| | - Marc Johnson
- Healing Wings Clinic, JPS Health Network, Fort Worth, TX, USA
| | - Rohit P Ojha
- Center for Epidemiology & Healthcare Delivery Research, JPS Health Network, Fort Worth, TX, USA.,Department of Medical Education, TCU and UNTHSC School of Medicine, Fort Worth, TX, USA
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Prediction or causality? A scoping review of their conflation within current observational research. Eur J Epidemiol 2021; 36:889-898. [PMID: 34392488 PMCID: PMC8502741 DOI: 10.1007/s10654-021-00794-w] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/20/2021] [Indexed: 12/23/2022]
Abstract
Etiological research aims to uncover causal effects, whilst prediction research aims to forecast an outcome with the best accuracy. Causal and prediction research usually require different methods, and yet their findings may get conflated when reported and interpreted. The aim of the current study is to quantify the frequency of conflation between etiological and prediction research, to discuss common underlying mistakes and provide recommendations on how to avoid these. Observational cohort studies published in January 2018 in the top-ranked journals of six distinct medical fields (Cardiology, Clinical Epidemiology, Clinical Neurology, General and Internal Medicine, Nephrology and Surgery) were included for the current scoping review. Data on conflation was extracted through signaling questions. In total, 180 studies were included. Overall, 26% (n = 46) contained conflation between etiology and prediction. The frequency of conflation varied across medical field and journal impact factor. From the causal studies 22% was conflated, mainly due to the selection of covariates based on their ability to predict without taking the causal structure into account. Within prediction studies 38% was conflated, the most frequent reason was a causal interpretation of covariates included in a prediction model. Conflation of etiology and prediction is a common methodological error in observational medical research and more frequent in prediction studies. As this may lead to biased estimations and erroneous conclusions, researchers must be careful when designing, interpreting and disseminating their research to ensure this conflation is avoided.
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14
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Martin GP, Sperrin M, Snell KIE, Buchan I, Riley RD. Authors' reply to Sabour and Ghajari "Clinical prediction models to predict the risk of multiple binary outcomes: Methodological issues". Stat Med 2021; 40:1861-1862. [PMID: 33687094 DOI: 10.1002/sim.8872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 12/19/2020] [Indexed: 11/07/2022]
Affiliation(s)
- Glen Philip Martin
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Matthew Sperrin
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Kym I E Snell
- Centre for Prognosis Research, School of Primary, Community and Social Care, Keele University, Staffordshire, UK
| | - Iain Buchan
- Institute of Population Health Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Richard D Riley
- Centre for Prognosis Research, School of Primary, Community and Social Care, Keele University, Staffordshire, UK
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Nunes AP, Zhao D, Jesdale WM, Lapane KL. Multiple imputation to quantify misclassification in observational studies of the cognitively impaired: an application for pain assessment in nursing home residents. BMC Med Res Methodol 2021; 21:132. [PMID: 34174838 PMCID: PMC8235835 DOI: 10.1186/s12874-021-01327-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 05/26/2021] [Indexed: 01/26/2023] Open
Abstract
Background Despite experimental evidence suggesting that pain sensitivity is not impaired by cognitive impairment, observational studies in nursing home residents have observed an inverse association between cognitive impairment and resident-reported or staff-assessed pain. Under the hypothesis that the inverse association may be partially attributable to differential misclassification due to recall and communication limitations, this study implemented a missing data approach to quantify the absolute magnitude of misclassification of pain, pain frequency, and pain intensity by level of cognitive impairment. Methods Using the 2016 Minimum Data Set 3.0, we conducted a cross-sectional study among newly admitted US nursing home residents. Pain presence, severity, and frequency is assessed via resident-reported measures. For residents unable to communicate their pain, nursing home staff document pain based on direct resident observation and record review. We estimate a counterfactual expected level of pain in the absence of cognitive impairment by multiply imputing modified pain indicators for which the values were retained for residents with no/mild cognitive impairment and set to missing for residents with moderate/severe cognitive impairment. Absolute differences (∆) in the presence and magnitude of pain were calculated as the difference between documented pain and the expected level of pain. Results The difference between observed and expected resident reported pain was greater in residents with severe cognitive impairment (∆ = -10.2%, 95% Confidence Interval (CI): -10.9% to -9.4%) than those with moderate cognitive impairment (∆ = -4.5%, 95% CI: -5.4% to -3.6%). For staff-assessed pain, the magnitude of apparent underreporting was similar between residents with moderate impairment (∆ = -7.2%, 95% CI: -8.3% to -6.0%) and residents with severe impairment (∆ = -7.2%, 95% CI: -8.0% to -6.3%). Pain characterized as “mild” had the highest magnitude of apparent underreporting. Conclusions In residents with moderate to severe cognitive impairment, documentation of any pain was lower than expected in the absence of cognitive impairment. This finding supports the hypothesis that an inverse association between pain and cognitive impairment may be explained by differential misclassification. This study highlights the need to develop analytic and/or procedural solutions to correct for recall/reporter bias resulting from cognitive impairment. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-021-01327-5.
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Affiliation(s)
- Anthony P Nunes
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Danni Zhao
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - William M Jesdale
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Kate L Lapane
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA.
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Walsh CG, Johnson KB, Ripperger M, Sperry S, Harris J, Clark N, Fielstein E, Novak L, Robinson K, Stead WW. Prospective Validation of an Electronic Health Record-Based, Real-Time Suicide Risk Model. JAMA Netw Open 2021; 4:e211428. [PMID: 33710291 PMCID: PMC7955273 DOI: 10.1001/jamanetworkopen.2021.1428] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Numerous prognostic models of suicide risk have been published, but few have been implemented outside of integrated managed care systems. OBJECTIVE To evaluate performance of a suicide attempt risk prediction model implemented in a vendor-supplied electronic health record to predict subsequent (1) suicidal ideation and (2) suicide attempt. DESIGN, SETTING, AND PARTICIPANTS This observational cohort study evaluated implementation of a suicide attempt prediction model in live clinical systems without alerting. The cohort comprised patients seen for any reason in adult inpatient, emergency department, and ambulatory surgery settings at an academic medical center in the mid-South from June 2019 to April 2020. MAIN OUTCOMES AND MEASURES Primary measures assessed external, prospective, and concurrent validity. Manual medical record validation of coded suicide attempts confirmed incident behaviors with intent to die. Subgroup analyses were performed based on demographic characteristics, relevant clinical context/setting, and presence or absence of universal screening. Performance was evaluated using discrimination (number needed to screen, C statistics, positive/negative predictive values) and calibration (Spiegelhalter z statistic). Recalibration was performed with logistic calibration. RESULTS The system generated 115 905 predictions for 77 973 patients (42 490 [54%] men, 35 404 [45%] women, 60 586 [78%] White, 12 620 [16%] Black). Numbers needed to screen in highest risk quantiles were 23 and 271 for suicidal ideation and attempt, respectively. Performance was maintained across demographic subgroups. Numbers needed to screen for suicide attempt by sex were 256 for men and 323 for women; and by race: 373, 176, and 407 for White, Black, and non-White/non-Black patients, respectively. Model C statistics were, across the health system: 0.836 (95% CI, 0.836-0.837); adult hospital: 0.77 (95% CI, 0.77-0.772); emergency department: 0.778 (95% CI, 0.777-0.778); psychiatry inpatient settings: 0.634 (95% CI, 0.633-0.636). Predictions were initially miscalibrated (Spiegelhalter z = -3.1; P = .001) with improvement after recalibration (Spiegelhalter z = 1.1; P = .26). CONCLUSIONS AND RELEVANCE In this study, this real-time predictive model of suicide attempt risk showed reasonable numbers needed to screen in nonpsychiatric specialty settings in a large clinical system. Assuming that research-valid models will translate without performing this type of analysis risks inaccuracy in clinical practice, misclassification of risk, wasted effort, and missed opportunity to correct and prevent such problems. The next step is careful pairing with low-cost, low-harm preventive strategies in a pragmatic trial of effectiveness in preventing future suicidality.
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Affiliation(s)
- Colin G. Walsh
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kevin B. Johnson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael Ripperger
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sarah Sperry
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joyce Harris
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nathaniel Clark
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Elliot Fielstein
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Laurie Novak
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Katelyn Robinson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William W. Stead
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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Covariates adjustment questioned conclusions of predictive analyses: an illustration with the Kidney Donor Risk Index. J Clin Epidemiol 2021; 135:103-114. [PMID: 33577986 DOI: 10.1016/j.jclinepi.2021.02.007] [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: 08/19/2020] [Revised: 01/27/2021] [Accepted: 02/03/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVES We aimed to illustrate that considering covariates can lead to meaningful interpretation of the discriminative capacities of a prognostic marker. For this, we evaluated the ability of the Kidney Donor Risk Index (KDRI) to discriminate kidney graft failure risk. STUDY DESIGN AND SETTING From 4114 French patients, we estimated the adjusted area under the time-dependent ROC curve by standardizing the marker and weighting the observations. By weighting the contributions, we also studied the impact of KDRI-based transplantations on the patient and graft survival. RESULTS The covariate-adjusted AUC varied from 55% (95% confidence interval [CI]: 51-60%) for a prognostic up to 1 year post-transplantation to 56% (95% CI: 52-59%) up to 7 years. The Restricted Mean Survival Time (RMST) was 6.44 years for high-quality graft recipients (95% CI: 6.30-6.56) and would have been 6.31 years (95% CI: 6.13-6.46) if they had medium-quality transplants. The RMST was 5.10 years for low-quality graft recipients (95% CI: 4.90-5.31) and would have been 5.52 years (95% CI: 5.17-5.83) if they had medium-quality transplants. CONCLUSION We demonstrated that the KDRI discriminative capacities were mainly explained by the recipient characteristics. We also showed that counterfactual estimations, often used in causal studies, are also interesting in predictive studies, especially regarding the new available methods.
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Lin L, Sperrin M, Jenkins DA, Martin GP, Peek N. A scoping review of causal methods enabling predictions under hypothetical interventions. Diagn Progn Res 2021; 5:3. [PMID: 33536082 PMCID: PMC7860039 DOI: 10.1186/s41512-021-00092-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 01/02/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The methods with which prediction models are usually developed mean that neither the parameters nor the predictions should be interpreted causally. For many applications, this is perfectly acceptable. However, when prediction models are used to support decision making, there is often a need for predicting outcomes under hypothetical interventions. AIMS We aimed to identify published methods for developing and validating prediction models that enable risk estimation of outcomes under hypothetical interventions, utilizing causal inference. We aimed to identify the main methodological approaches, their underlying assumptions, targeted estimands, and potential pitfalls and challenges with using the method. Finally, we aimed to highlight unresolved methodological challenges. METHODS We systematically reviewed literature published by December 2019, considering papers in the health domain that used causal considerations to enable prediction models to be used for predictions under hypothetical interventions. We included both methodologies proposed in statistical/machine learning literature and methodologies used in applied studies. RESULTS We identified 4919 papers through database searches and a further 115 papers through manual searches. Of these, 87 papers were retained for full-text screening, of which 13 were selected for inclusion. We found papers from both the statistical and the machine learning literature. Most of the identified methods for causal inference from observational data were based on marginal structural models and g-estimation. CONCLUSIONS There exist two broad methodological approaches for allowing prediction under hypothetical intervention into clinical prediction models: (1) enriching prediction models derived from observational studies with estimated causal effects from clinical trials and meta-analyses and (2) estimating prediction models and causal effects directly from observational data. These methods require extending to dynamic treatment regimes, and consideration of multiple interventions to operationalise a clinical decision support system. Techniques for validating 'causal prediction models' are still in their infancy.
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Affiliation(s)
- Lijing Lin
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
| | - Matthew Sperrin
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - David A Jenkins
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester, UK
| | - Glen P Martin
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Niels Peek
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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19
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Dekkers OM, Mulder JM. When will individuals meet their personalized probabilities? A philosophical note on risk prediction. Eur J Epidemiol 2020; 35:1115-1121. [DOI: 10.1007/s10654-020-00700-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/13/2020] [Indexed: 12/25/2022]
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20
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Abstract
Reasons to be cautious
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Affiliation(s)
- Matthew Sperrin
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Brian McMillan
- Centre for Primary Care and Health Services Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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