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Zachariah FJ, Rossi LA, Roberts LM, Bosserman LD. Prospective Comparison of Medical Oncologists and a Machine Learning Model to Predict 3-Month Mortality in Patients With Metastatic Solid Tumors. JAMA Netw Open 2022; 5:e2214514. [PMID: 35639380 PMCID: PMC9157269 DOI: 10.1001/jamanetworkopen.2022.14514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/24/2022] [Indexed: 12/29/2022] Open
Abstract
Importance To date, oncologist and model prognostic performance have been assessed independently and mostly retrospectively; however, how model prognostic performance compares with oncologist prognostic performance prospectively remains unknown. Objective To compare oncologist performance with a model in predicting 3-month mortality for patients with metastatic solid tumors in an outpatient setting. Design, Setting, and Participants This prognostic study evaluated prospective predictions for a cohort of patients with metastatic solid tumors seen in outpatient oncology clinics at a National Cancer Institute-designated cancer center and associated satellites between December 6, 2019, and August 6, 2021. Oncologists (57 physicians and 17 advanced practice clinicians) answered a 3-month surprise question (3MSQ) within clinical pathways. A model was trained with electronic health record data from January 1, 2013, to April 24, 2019, to identify patients at high risk of 3-month mortality and deployed silently in October 2019. Analysis was limited to oncologist prognostications with a model prediction within the preceding 30 days. Exposures Three-month surprise question and gradient-boosting binary classifier. Main Outcomes and Measures The primary outcome was performance comparison between oncologists and the model to predict 3-month mortality. The primary performance metric was the positive predictive value (PPV) at the sensitivity achieved by the medical oncologists with their 3MSQ answers. Results A total of 74 oncologists answered 3099 3MSQs for 2041 patients with advanced cancer (median age, 62.6 [range, 18-96] years; 1271 women [62.3%]). In this cohort with a 15% prevalence of 3-month mortality and 30% sensitivity for both oncologists and the model, the PPV of oncologists was 34.8% (95% CI, 30.1%-39.5%) and the PPV of the model was 60.0% (95% CI, 53.6%-66.3%). Area under the receiver operating characteristic curve for the model was 81.2% (95% CI, 79.1%-83.3%). The model significantly outperformed the oncologists in short-term mortality. Conclusions and Relevance In this prognostic study, the model outperformed oncologists overall and within the breast and gastrointestinal cancer cohorts in predicting 3-month mortality for patients with advanced cancer. These findings suggest that further studies may be useful to examine how model predictions could improve oncologists' prognostic confidence and patient-centered goal-concordant care at the end of life.
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Affiliation(s)
- Finly J. Zachariah
- Department of Supportive Care Medicine, City of Hope National Medical Center, Duarte, California
| | - Lorenzo A. Rossi
- Department of Applied AI and Data Science, City of Hope National Medical Center, Duarte, California
| | - Laura M. Roberts
- Department of Clinical Informatics, City of Hope National Medical Center, Duarte, California
| | - Linda D. Bosserman
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, California
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Blanes-Selva V, Doñate-Martínez A, Linklater G, García-Gómez JM. Complementary frailty and mortality prediction models on older patients as a tool for assessing palliative care needs. Health Informatics J 2022; 28:14604582221092592. [PMID: 35642719 DOI: 10.1177/14604582221092592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Palliative care (PC) has demonstrated benefits for life-limiting illnesses. Bad survival prognosis and patients' decline are working criteria to guide PC decision-making for older patients. Still, there is not a clear consensus on when to initiate early PC. This work aims to propose machine learning approaches to predict frailty and mortality in older patients in supporting PC decision-making. Predictive models based on Gradient Boosting Machines (GBM) and Deep Neural Networks (DNN) were implemented for binary 1-year mortality classification, survival estimation and 1-year frailty classification. Besides, we tested the similarity between mortality and frailty distributions. The 1-year mortality classifier achieved an Area Under the Curve Receiver Operating Characteristic (AUC ROC) of 0.87 [0.86, 0.87], whereas the mortality regression model achieved an mean absolute error (MAE) of 333.13 [323.10, 342.49] days. Moreover, the 1-year frailty classifier obtained an AUC ROC of 0.89 [0.88, 0.90]. Mortality and frailty criteria were weakly correlated and had different distributions, which can be interpreted as these assessment measurements are complementary for PC decision-making. This study provides new models that can be part of decision-making systems for PC services in older patients after their external validation.
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Affiliation(s)
- Vicent Blanes-Selva
- Biomedical Data Science Lab, Instituto Universitarios de Tecnologías de La Información y Comunicaciones (ITACA), Universitat Politècnica de València, Valencia, Spain
| | | | | | - Juan M García-Gómez
- Biomedical Data Science Lab, Instituto Universitarios de Tecnologías de La Información y Comunicaciones (ITACA), Universitat Politècnica de València, Valencia, Spain
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3
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Zhang H, Li Y, McConnell W. Predicting potential palliative care beneficiaries for health plans: A generalized machine learning pipeline. J Biomed Inform 2021; 123:103922. [PMID: 34607012 DOI: 10.1016/j.jbi.2021.103922] [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: 06/23/2021] [Revised: 09/25/2021] [Accepted: 09/29/2021] [Indexed: 11/28/2022]
Abstract
Recognizing that palliative care improves the care quality and reduces the healthcare costs for individuals in their end of life, health plan providers strive to better enroll the appropriate target population for palliative care. Current research has not adequately addressed challenges related to proactively select potential palliative care beneficiaries from a population health perspective. This study presents a Generalized Machine Learning Pipeline (GMLP) to predict palliative needs in patients using administrative claims data. The GMLP has five steps: data cohort creation, feature engineering, predictive modeling, scoring beneficiaries, and model maintenance. It encapsulates principles of population health management, business domain knowledge, and machine learning (ML) process knowledge with an innovative data pull strategy. The GMLP was applied in a regional health plan using a data cohort of 17,197 patients. Multiple ML models were turned and evaluated against a custom performance metric based on the business requirement. The best model was an AdaBoost model with a precision of 71.43% and a recall of 67.98%. The post-implementation evaluation of the GMLP showed that it increased the recall of high mortality risk patients, improved their quality of life, and reduced the overall cost. The GMLP is a novel approach that can be applied agnostically to the data and specific ML algorithms. To the best of our knowledge, it is the first attempt to continuously score palliative care beneficiaries using administrative data. The GMLP and its use case example presented in the paper can serve as a methodological guide for different health plans and healthcare policymakers to apply ML in solving real-world clinical challenges, such as palliative care management and other similar risk-stratified care management workflows.
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Affiliation(s)
- Hengwei Zhang
- University of Tampa, Sykes College of Business, 401 W Kennedy Blvd, Tampa, FL 33606 USA.
| | - Yan Li
- Claremont Graduate University , Center for Information Systems and Technology, 130 E. 9th Street - ABC 217, Claremont, CA 91711, USA.
| | - William McConnell
- Claremont Graduate University , School of Community and Global Health, 130 E. 9th Street, Claremont, CA 91711, USA.
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4
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Wilson PM, Philpot LM, Ramar P, Storlie CB, Strand J, Morgan AA, Asai SW, Ebbert JO, Herasevich VD, Soleimani J, Pickering BW. Improving time to palliative care review with predictive modeling in an inpatient adult population: study protocol for a stepped-wedge, pragmatic randomized controlled trial. Trials 2021; 22:635. [PMID: 34530871 PMCID: PMC8444160 DOI: 10.1186/s13063-021-05546-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 08/16/2021] [Indexed: 11/23/2022] Open
Abstract
Background Palliative care is a medical specialty centered on improving the quality of life (QOL) of patients with complex or life-threatening illnesses. The need for palliative care is increasing and with that the rigorous testing of triage tools that can be used quickly and reliably to identify patients that may benefit from palliative care. Methods To that aim, we will conduct a two-armed stepped-wedge cluster randomized trial rolled out to two inpatient hospitals to evaluate whether a machine learning algorithm accurately identifies patients who may benefit from a comprehensive review by a palliative care specialist and decreases time to receiving a palliative care consult in hospital. This is a single-center study which will be conducted from August 2019 to November 2020 at Saint Mary’s Hospital & Methodist Hospital both within Mayo Clinic Rochester in Minnesota. Clusters will be nursing units which will be chosen to be a mix of complex patients from Cardiology, Critical Care, and Oncology and had previously established relationships with palliative medicine. The stepped wedge design will have 12 units allocated to a design matrix of 5 treatment wedges. Each wedge will last 75 days resulting in a study period of 12 months of recruitment unless otherwise specified. Data will be analyzed with Bayesian hierarchical models with credible intervals denoting statistical significance. Discussion This intervention offers a pragmatic approach to delivering specialty palliative care to hospital patients in need using machine learning, thereby leading to high value care and improved outcomes. It is not enough for AI to be utilized by simply publishing research showing predictive performance; clinical trials demonstrating better outcomes are critically needed. Furthermore, the deployment of an AI algorithm is a complex process that requires multiple teams with varying skill sets. To evaluate a deployed AI, a pragmatic clinical trial can accommodate the difficulties of clinical practice while retaining scientific rigor. Trial registration ClinicalTrials.gov NCT03976297. Registered on 6 June 2019, prior to trial start. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05546-5.
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Affiliation(s)
- Patrick M Wilson
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
| | - Lindsey M Philpot
- Department of Quantitative Health Sciences, Mayo Clinic, MN, 55905, Rochester, USA.,Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Priya Ramar
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Curtis B Storlie
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Department of Quantitative Health Sciences, Mayo Clinic, MN, 55905, Rochester, USA
| | - Jacob Strand
- Center for Palliative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alisha A Morgan
- Center for Palliative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Shusaku W Asai
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Jon O Ebbert
- Department of Quantitative Health Sciences, Mayo Clinic, MN, 55905, Rochester, USA
| | | | - Jalal Soleimani
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Brian W Pickering
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, 55905, USA
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Murphree DH, Wilson PM, Asai SW, Quest DJ, Lin Y, Mukherjee P, Chhugani N, Strand JJ, Demuth G, Mead D, Wright B, Harrison A, Soleimani J, Herasevich V, Pickering BW, Storlie CB. Improving the delivery of palliative care through predictive modeling and healthcare informatics. J Am Med Inform Assoc 2021; 28:1065-1073. [PMID: 33611523 DOI: 10.1093/jamia/ocaa211] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/28/2020] [Accepted: 02/16/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Access to palliative care (PC) is important for many patients with uncontrolled symptom burden from serious or complex illness. However, many patients who could benefit from PC do not receive it early enough or at all. We sought to address this problem by building a predictive model into a comprehensive clinical framework with the aims to (i) identify in-hospital patients likely to benefit from a PC consult, and (ii) intervene on such patients by contacting their care team. MATERIALS AND METHODS Electronic health record data for 68 349 inpatient encounters in 2017 at a large hospital were used to train a model to predict the need for PC consult. This model was published as a web service, connected to institutional data pipelines, and consumed by a downstream display application monitored by the PC team. For those patients that the PC team deems appropriate, a team member then contacts the patient's corresponding care team. RESULTS Training performance AUC based on a 20% holdout validation set was 0.90. The most influential variables were previous palliative care, hospital unit, Albumin, Troponin, and metastatic cancer. The model has been successfully integrated into the clinical workflow making real-time predictions on hundreds of patients per day. The model had an "in-production" AUC of 0.91. A clinical trial is currently underway to assess the effect on clinical outcomes. CONCLUSIONS A machine learning model can effectively predict the need for an inpatient PC consult and has been successfully integrated into practice to refer new patients to PC.
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Affiliation(s)
- Dennis H Murphree
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA.,Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Patrick M Wilson
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Shusaku W Asai
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel J Quest
- Information Technology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yaxiong Lin
- Information Technology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Nirmal Chhugani
- Information Technology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jacob J Strand
- Division of Palliative Care, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Gabriel Demuth
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - David Mead
- Information Technology, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian Wright
- Information Technology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew Harrison
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jalal Soleimani
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Vitaly Herasevich
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian W Pickering
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Curtis B Storlie
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA.,Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
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6
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Logistic regression and machine learning predicted patient mortality from large sets of diagnosis codes comparably. J Clin Epidemiol 2021; 133:43-52. [PMID: 33359319 DOI: 10.1016/j.jclinepi.2020.12.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/18/2020] [Accepted: 12/15/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The objective of the study was to compare the performance of logistic regression and boosted trees for predicting patient mortality from large sets of diagnosis codes in electronic healthcare records. STUDY DESIGN AND SETTING We analyzed national hospital records and official death records for patients with myocardial infarction (n = 200,119), hip fracture (n = 169,646), or colorectal cancer surgery (n = 56,515) in England in 2015-2017. One-year mortality was predicted from patient age, sex, and socioeconomic status, and 202 to 257 International Classification of Diseases 10th Revision codes recorded in the preceding year or not (binary predictors). Performance measures included the c-statistic, scaled Brier score, and several measures of calibration. RESULTS One-year mortality was 17.2% (34,520) after myocardial infarction, 27.2% (46,115) after hip fracture, and 9.3% (5,273) after colorectal surgery. Optimism-adjusted c-statistics for the logistic regression models were 0.884 (95% confidence interval [CI]: 0.882, 0.886), 0.798 (0.796, 0.800), and 0.811 (0.805, 0.817). The equivalent c-statistics for the boosted tree models were 0.891 (95% CI: 0.889, 0.892), 0.804 (0.802, 0.806), and 0.803 (0.797, 0.809). Model performance was also similar when measured using scaled Brier scores. All models were well calibrated overall. CONCLUSION In large datasets of electronic healthcare records, logistic regression and boosted tree models of numerous diagnosis codes predicted patient mortality comparably.
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Abstract
PURPOSE OF REVIEW Healthcare has already been impacted by the fourth industrial revolution exemplified by tip of spear technology, such as artificial intelligence and quantum computing. Yet, there is much to be accomplished as systems remain suboptimal, and full interoperability of digital records is not realized. Given the footprint of technology in healthcare, the field of clinical immunology will certainly see improvements related to these tools. RECENT FINDINGS Biomedical informatics spans the gamut of technology in biomedicine. Within this distinct field, advances are being made, which allow for engineering of systems to automate disease detection, create computable phenotypes and improve record portability. Within clinical immunology, technologies are emerging along these lines and are expected to continue. SUMMARY This review highlights advancements in digital health including learning health systems, electronic phenotyping, artificial intelligence and use of registries. Technological advancements for improving diagnosis and care of patients with primary immunodeficiency diseases is also highlighted.
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Rasmy L, Tiryaki F, Zhou Y, Xiang Y, Tao C, Xu H, Zhi D. Representation of EHR data for predictive modeling: a comparison between UMLS and other terminologies. J Am Med Inform Assoc 2020; 27:1593-1599. [PMID: 32930711 PMCID: PMC7647355 DOI: 10.1093/jamia/ocaa180] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 07/24/2020] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE Predictive disease modeling using electronic health record data is a growing field. Although clinical data in their raw form can be used directly for predictive modeling, it is a common practice to map data to standard terminologies to facilitate data aggregation and reuse. There is, however, a lack of systematic investigation of how different representations could affect the performance of predictive models, especially in the context of machine learning and deep learning. MATERIALS AND METHODS We projected the input diagnoses data in the Cerner HealthFacts database to Unified Medical Language System (UMLS) and 5 other terminologies, including CCS, CCSR, ICD-9, ICD-10, and PheWAS, and evaluated the prediction performances of these terminologies on 2 different tasks: the risk prediction of heart failure in diabetes patients and the risk prediction of pancreatic cancer. Two popular models were evaluated: logistic regression and a recurrent neural network. RESULTS For logistic regression, using UMLS delivered the optimal area under the receiver operating characteristics (AUROC) results in both dengue hemorrhagic fever (81.15%) and pancreatic cancer (80.53%) tasks. For recurrent neural network, UMLS worked best for pancreatic cancer prediction (AUROC 82.24%), second only (AUROC 85.55%) to PheWAS (AUROC 85.87%) for dengue hemorrhagic fever prediction. DISCUSSION/CONCLUSION In our experiments, terminologies with larger vocabularies and finer-grained representations were associated with better prediction performances. In particular, UMLS is consistently 1 of the best-performing ones. We believe that our work may help to inform better designs of predictive models, although further investigation is warranted.
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Affiliation(s)
- Laila Rasmy
- School of Biomedical Informatics University of Texas Health Science Center, Houston, Texas, USA
| | - Firat Tiryaki
- School of Biomedical Informatics University of Texas Health Science Center, Houston, Texas, USA
| | - Yujia Zhou
- School of Biomedical Informatics University of Texas Health Science Center, Houston, Texas, USA
| | - Yang Xiang
- School of Biomedical Informatics University of Texas Health Science Center, Houston, Texas, USA
| | - Cui Tao
- School of Biomedical Informatics University of Texas Health Science Center, Houston, Texas, USA
| | - Hua Xu
- School of Biomedical Informatics University of Texas Health Science Center, Houston, Texas, USA
| | - Degui Zhi
- School of Biomedical Informatics University of Texas Health Science Center, Houston, Texas, USA
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Dillon EC, Meehan A, Li J, Liang SY, Lai S, Colocci N, Roth J, Szwerinski NK, Luft H. How, when, and why individuals with stage IV cancer seen in an outpatient setting are referred to palliative care: a mixed methods study. Support Care Cancer 2020; 29:669-678. [PMID: 32430601 DOI: 10.1007/s00520-020-05492-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 04/20/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Early palliative care (PC) for individuals with advanced cancer improves patient and family outcomes and experience. However, it is unknown when, why, and how in an outpatient setting individuals with stage IV cancer are referred to PC. METHODS At a large multi-specialty group in the USA with outpatient PC implemented beginning in 2011, clinical records were used to identify adults diagnosed with stage IV cancer after January 1, 2012 and deceased by December 31, 2017 and their PC referrals and hospice use. In-depth interviews were also conducted with 25 members of medical oncology, gynecological oncology, and PC teams and thematically analyzed. RESULTS A total of 705 individuals were diagnosed and died between 2012 and 2017: of these, 332 (47%) were referred to PC, with 48.5% referred early (within 60 days of diagnosis). Among referred patients, 79% received hospice care, versus 55% among patients not referred. Oncologists varied dramatically in their rates of referral to PC. Interviews revealed four referral pathways: early referrals, referrals without active anti-cancer treatment, problem-based referrals, and late referrals (when stopping treatment). Participants described PC's benefits as enhancing pain/symptom management, advance care planning, transitions to hospice, end-of-life experiences, a larger team, and more flexible patient care. Challenges reported included variation in oncologist practices, patient fears and misconceptions, and access to PC teams. CONCLUSION We found high rates of use and appreciation of PC. However, interviews revealed that exclusively focusing on rates of referrals may obscure how referrals vary in timing, reason for referral, and usefulness to patients, families, and clinical teams.
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Affiliation(s)
- Ellis C Dillon
- Center for Health Systems Research, Sutter Health, Palo Alto, CA, USA. .,Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Palo Alto, CA, 94301, USA.
| | - Amy Meehan
- Center for Health Systems Research, Sutter Health, Palo Alto, CA, USA.,Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Palo Alto, CA, 94301, USA
| | - Jinnan Li
- Lilly Suzhou Pharmaceutical Co. Ltd, Shanghai, China.,formerly at Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
| | - Su-Ying Liang
- Center for Health Systems Research, Sutter Health, Palo Alto, CA, USA.,Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Palo Alto, CA, 94301, USA
| | - Steve Lai
- Palo Alto Medical Foundation, Palo Alto, CA, USA
| | | | - Julie Roth
- Palo Alto Medical Foundation, Palo Alto, CA, USA
| | - Nina K Szwerinski
- Center for Health Systems Research, Sutter Health, Palo Alto, CA, USA.,Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Palo Alto, CA, 94301, USA
| | - Hal Luft
- Center for Health Systems Research, Sutter Health, Palo Alto, CA, USA.,Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Palo Alto, CA, 94301, USA
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Abstract
Introduction In observational studies with mortality endpoints, one needs to consider how to account for subjects whose interventions appear to be part of ‘end-of-life’ care. Objective The objective of this study was to develop a diagnostic predictive model to identify those in end-of-life care at the time of a drug exposure. Methods We used data from four administrative claims datasets from 2000 to 2017. The index date was the date of the first prescription for the last new drug subjects received during their observation period. The outcome of end-of-life care was determined by the presence of one or more codes indicating terminal or hospice care. Models were developed using regularized logistic regression. Internal validation was through examination of the area under the receiver operating characteristic curve (AUC) and through model calibration in a 25% subset of the data held back from model training. External validation was through examination of the AUC after applying the model learned on one dataset to the three other datasets. Results The models showed excellent performance characteristics. Internal validation resulted in AUCs ranging from 0.918 (95% confidence interval [CI] 0.905–0.930) to 0.983 (95% CI 0.978–0.987) for the four different datasets. Calibration results were also very good, with slopes near unity. External validation also produced very good to excellent performance metrics, with AUCs ranging from 0.840 (95% CI 0.834–0.846) to 0.956 (95% CI 0.952–0.960). Conclusion These results show that developing diagnostic predictive models for determining subjects in end-of-life care at the time of a drug treatment is possible and may improve the validity of the risk profile for those treatments. Electronic supplementary material The online version of this article (10.1007/s40264-020-00906-7) contains supplementary material, which is available to authorized users.
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