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Cary MP, Zink A, Wei S, Olson A, Yan M, Senior R, Bessias S, Gadhoumi K, Jean-Pierre G, Wang D, Ledbetter LS, Economou-Zavlanos NJ, Obermeyer Z, Pencina MJ. Mitigating Racial And Ethnic Bias And Advancing Health Equity In Clinical Algorithms: A Scoping Review. Health Aff (Millwood) 2023; 42:1359-1368. [PMID: 37782868 PMCID: PMC10668606 DOI: 10.1377/hlthaff.2023.00553] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
In August 2022 the Department of Health and Human Services (HHS) issued a notice of proposed rulemaking prohibiting covered entities, which include health care providers and health plans, from discriminating against individuals when using clinical algorithms in decision making. However, HHS did not provide specific guidelines on how covered entities should prevent discrimination. We conducted a scoping review of literature published during the period 2011-22 to identify health care applications, frameworks, reviews and perspectives, and assessment tools that identify and mitigate bias in clinical algorithms, with a specific focus on racial and ethnic bias. Our scoping review encompassed 109 articles comprising 45 empirical health care applications that included tools tested in health care settings, 16 frameworks, and 48 reviews and perspectives. We identified a wide range of technical, operational, and systemwide bias mitigation strategies for clinical algorithms, but there was no consensus in the literature on a single best practice that covered entities could employ to meet the HHS requirements. Future research should identify optimal bias mitigation methods for various scenarios, depending on factors such as patient population, clinical setting, algorithm design, and types of bias to be addressed.
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Affiliation(s)
- Michael P Cary
- Michael P. Cary Jr. , Duke University, Durham, North Carolina
| | - Anna Zink
- Anna Zink, University of Chicago, Chicago, Illinois
| | - Sijia Wei
- Sijia Wei, Northwestern University, Chicago, Illinois
| | | | | | | | | | | | | | | | | | | | - Ziad Obermeyer
- Ziad Obermeyer, University of California Berkeley, Berkeley, California
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Handler J, Lee OJ, Chatrath S, McGarvey J, Fitch T, Jose D, Vozenilek J. Can a 5-to-90-day Mortality Predictor Perform Consistently Across Time and Equitably Across Populations? J Med Syst 2023; 47:67. [PMID: 37395923 PMCID: PMC10317873 DOI: 10.1007/s10916-023-01962-z] [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: 01/03/2023] [Accepted: 06/22/2023] [Indexed: 07/04/2023]
Abstract
Advance care planning (ACP) facilitates end-of-life care, yet many die without it. Timely and accurate mortality prediction may encourage ACP. However, performance of predictors typically differs among sub-populations (e.g., rural vs. urban) and worsens over time ("concept drift"). Therefore, we assessed performance equity and consistency for a novel 5-to-90-day mortality predictor across various demographies, geographies, and timeframes (n = 76,812 total encounters). Predictions were made for the first day of included adult inpatient admissions on a retrospective dataset. AUC-PR remained at 29% both pre-COVID (throughout 2018) and during COVID (8 months in 2021). Pre-COVID-19 recall and precision were 58% and 25% respectively at the 12.5% certainty cutoff, and 12% and 44% at the 37.5% cutoff. During COVID-19, recall and precision were 59% and 26% at the 12.5% cutoff, and 11% and 43% at the 37.5% cutoff. Pre-COVID, compared to the overall population, recall was lower at the 12.5% cutoff in the White, non-Hispanic subgroup and at both cutoffs in the rural subgroup. During COVID-19, precision at the 12.5% cutoff was lower than that of the overall population for the non-White and non-White female subgroups. No other significant differences were seen between subgroups and the corresponding overall population. Overall performance during COVID was unchanged from pre-pandemic performance. Although some comparisons (especially precision at the 37.5% cutoff) were underpowered, precision at the 12.5% cutoff was equitable across most demographies, regardless of the pandemic. Mortality prediction to prioritize ACP conversations can be provided consistently and equitably across many studied timeframes and sub-populations.
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Affiliation(s)
- Jonathan Handler
- Clinical Intelligence and Advanced Data Lab, OSF Healthcare System, 1306 N Berkeley Ave, Peoria, IL, 61603, USA.
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Olivia J Lee
- University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Sheena Chatrath
- University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Jeremy McGarvey
- Ministry Healthcare Analytics, OSF HealthCare System, Peoria, IL, USA
| | - Tyler Fitch
- Internal Medicine and Pediatrics, OSF Healthcare System, Peoria, IL, USA
| | - Divya Jose
- Business Intelligence Consulting, Indus Group, Wheeling, IL, USA
| | - John Vozenilek
- University of Illinois College of Medicine at Peoria, Peoria, IL, USA
- OSF Innovation, OSF Healthcare System, Peoria, IL, USA
- University of Illinois College of Engineering, Urbana Champaign, Champaign, IL, USA
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Eneanya ND, Adingwupu OM, Kostelanetz S, Norris KC, Greene T, Lewis JB, Beddhu S, Boucher R, Miao S, Chaudhari J, Levey AS, Inker LA. Social Determinants of Health and Their Impact on the Black Race Coefficient in Serum Creatinine-Based Estimation of GFR: Secondary Analysis of MDRD and CRIC Studies. Clin J Am Soc Nephrol 2023; 18:446-454. [PMID: 36723299 PMCID: PMC10103283 DOI: 10.2215/cjn.0000000000000109] [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: 09/28/2022] [Accepted: 01/20/2023] [Indexed: 02/02/2023]
Abstract
BACKGROUND The cause for differences in serum creatinine between Black and non-Black individuals incorporated into prior GFR-estimating equations is not understood. We explored whether social determinants of health can account for this difference. METHODS We conducted a secondary analysis of baseline data of the Modification of Diet in Renal Disease and Chronic Renal Insufficiency Cohort studies ( N =1628 and 1423, respectively). Data in both study cohorts were stratified by race (Black versus non-Black). We first evaluated the extent to which the coefficient of Black race in estimating GFR from creatinine is explained by correlations of race with social determinants of health and non-GFR determinants of creatinine. Second, we evaluated whether the difference between race groups in adjusted mean creatinine can be explained by social determinants of health and non-GFR determinants of creatinine. RESULTS In models regressing measured GFR on creatinine, age, sex, and race, the coefficient for Black race was 21% (95% confidence interval, 0.176 to 0.245) in Modification of Diet in Renal Disease and 13% (95% confidence interval, 0.097 to 0.155) in the Chronic Renal Insufficiency Cohort and was not attenuated by the addition of social determinants of health, alone or in combination. In both studies, the coefficient for Black race was larger at lower versus higher income levels. In models, regressing creatinine on measured GFR, age, and sex, mean creatinine was higher in Black versus non-Black participants in both studies, with no effect of social determinants of health. CONCLUSIONS Adjustment for selected social determinants of health did not influence the relationship between Black race and creatinine-based estimated GFR.
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Affiliation(s)
- Nwamaka D. Eneanya
- Department of Medicine, Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ogechi M. Adingwupu
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | | | - Keith C. Norris
- Department of Medicine, VA Greater Los Angeles Healthcare System, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Tom Greene
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Julia B. Lewis
- Department of Medicine, Division of Nephrology, Vanderbilt University, Nashville, Tennessee
| | - Srinivasan Beddhu
- Department of Internal Medicine, Division of Nephrology & Hypertension, University of Utah Health Sciences, Salt Lake City, Utah
| | - Robert Boucher
- Department of Internal Medicine, Division of Nephrology & Hypertension, University of Utah Health Sciences, Salt Lake City, Utah
| | - Shiyuan Miao
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Juhi Chaudhari
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Andrew S. Levey
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Lesley A. Inker
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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Martin JA, Crane-Droesch A, Lapite FC, Puhl JC, Kmiec TE, Silvestri JA, Ungar LH, Kinosian BP, Himes BE, Hubbard RA, Diamond JM, Ahya V, Sims MW, Halpern SD, Weissman GE. Development and validation of a prediction model for actionable aspects of frailty in the text of clinicians' encounter notes. J Am Med Inform Assoc 2021; 29:109-119. [PMID: 34791302 DOI: 10.1093/jamia/ocab248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/16/2021] [Accepted: 10/28/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Frailty is a prevalent risk factor for adverse outcomes among patients with chronic lung disease. However, identifying frail patients who may benefit from interventions is challenging using standard data sources. We therefore sought to identify phrases in clinical notes in the electronic health record (EHR) that describe actionable frailty syndromes. MATERIALS AND METHODS We used an active learning strategy to select notes from the EHR and annotated each sentence for 4 actionable aspects of frailty: respiratory impairment, musculoskeletal problems, fall risk, and nutritional deficiencies. We compared the performance of regression, tree-based, and neural network models to predict the labels for each sentence. We evaluated performance with the scaled Brier score (SBS), where 1 is perfect and 0 is uninformative, and the positive predictive value (PPV). RESULTS We manually annotated 155 952 sentences from 326 patients. Elastic net regression had the best performance across all 4 frailty aspects (SBS 0.52, 95% confidence interval [CI] 0.49-0.54) followed by random forests (SBS 0.49, 95% CI 0.47-0.51), and multi-task neural networks (SBS 0.39, 95% CI 0.37-0.42). For the elastic net model, the PPV for identifying the presence of respiratory impairment was 54.8% (95% CI 53.3%-56.6%) at a sensitivity of 80%. DISCUSSION Classification models using EHR notes can effectively identify actionable aspects of frailty among patients living with chronic lung disease. Regression performed better than random forest and neural network models. CONCLUSIONS NLP-based models offer promising support to population health management programs that seek to identify and refer community-dwelling patients with frailty for evidence-based interventions.
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Affiliation(s)
- Jacob A Martin
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA.,Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew Crane-Droesch
- Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Joseph C Puhl
- Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Tyler E Kmiec
- Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jasmine A Silvestri
- Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lyle H Ungar
- Department of Computer and Information Science, University of Pennsylvania School of Engineering and Applied Science, Philadelphia, Pennsylvania, USA
| | - Bruce P Kinosian
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Geriatrics, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Geriatrics and Extended Care Data Analysis Center, Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Blanca E Himes
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Rebecca A Hubbard
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Joshua M Diamond
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Vivek Ahya
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Michael W Sims
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Scott D Halpern
- Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Pulmonary, Allergy, and Critical Care Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Gary E Weissman
- Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Pulmonary, Allergy, and Critical Care Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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