Secondary data analysis of large data sets in urology: successes and errors to avoid

Transforming a Large-Scale Prostate Cancer Outcomes Dataset to the OMOP Common Data Model-Experiences from a Scientific Data Holder's Perspective

To enhance international and joint research collaborations in prostate cancer research, data from different sources should use a common data model (CDM) that enables researchers to share their analysis scripts and merge results. The OMOP CDM maintained by OHDSI is such a data model developed for a federated data analysis with partners from different institutions that want to jointly investigate research questions using clinical care data. The German Cancer Society as the scientific lead of the Prostate Cancer Outcomes (PCO) study gathers data from prostate cancer care including routine oncological care data and survey data (incl. patient-reported outcomes) and uses a common data specification (called OncoBox Research Prostate) for this purpose. To further enhance research collaborations outside the PCO study, the purpose of this article is to describe the process of transferring the PCO study data to the internationally well-established OMOP CDM. This process was carried out together with an IT company that specialised in supporting research institutions to transfer their data to OMOP CDM. Of n = 49,692 prostate cancer cases with 318 data fields each, n = 392 had to be excluded during the OMOPing process, and n = 247 of the data fields could be mapped to OMOP CDM. The resulting PostgreSQL database with OMOPed PCO study data is now ready to use within larger research collaborations such as the EU-funded EHDEN and OPTIMA consortium.

Data Mining in Urology: Understanding Real-world Treatment Pathways for Lower Urinary Tract Systems via Exploration of Big Data

With an increasing number of novel therapeutic options for lower urinary tract symptoms (LUTS), the spectrum of potential treatment pathways resulting from different combinations of treatment decisions is expanding and evolving. Treatment decisions are frequently made with little or no evidence from randomized controlled trials (RCTs) and thus require evidence from other data sources. Clinical routine data reflect real-world treatment pathways. However, evidence for LUTS from routine data means that heterogeneous pathways need to be simultaneously analyzed for compiling evidence in the absence of RCTs. Statistical multi-state model approaches can provide a powerful framework for achieving this goal. More extensive statistical and methodological efforts in the area of similarity of small data are needed to enable the valid pooling of pathways towards joining evidence. PATIENT SUMMARY: Treatment decisions should rely primarily on evidence from clinical trials. When treatment for which there is limited trial evidence needs to be provided, analysis of results from routine clinical practice can represent valuable complementary evidence, but this requires integration of data from heterogeneous treatment pathways.

Dhavileswarapu AVL, Naik N, Karimi H, Hegde P, Rai BP, Somani BK. Big Data Analytics in urology: the story so far and the road ahead

Artificial intelligence (AI) has a proven record of application in the field of medicine and is used in various urological conditions such as oncology, urolithiasis, paediatric urology, urogynaecology, infertility and reconstruction. Data is the driving force of AI and the past decades have undoubtedly witnessed an upsurge in healthcare data. Urology is a specialty that has always been at the forefront of innovation and research and has rapidly embraced technologies to improve patient outcomes and experience. Advancements made in Big Data Analytics raised the expectations about the future of urology. This review aims to investigate the role of big data and its blend with AI for trends and use in urology. We explore the different sources of big data in urology and explicate their current and future applications. A positive trend has been exhibited by the advent and implementation of AI in urology with data available from several databases. The extensive use of big data for the diagnosis and treatment of urological disorders is still in its early stage and under validation. In future however, big data will no doubt play a major role in the management of urological conditions.

The Importance of Reporting Clinical and Epidemiological Data in Urology: Local Experiences and Insights from the International Literature

Pathologies of the genito-urinary tract are responsible for a considerable disease burden worldwide, leading to significant losses of income, lost working days, increased expenditures for national healthcare systems, and decreased quality of life (QoL) in the affected patients. Among these diseases, infections and malignancies in this anatomical region are some of the most important illnesses in human medicine; nevertheless, benign prostate hyperplasia (BPH), erectile dysfunction, hypospadias, urinary incontinence, and vesicoureteral reflux are also relevant disorders affecting millions. The publication of various microbiological and clinical studies in urology from different geographical regions has important ramifications from the standpoint of epidemiology: on one hand, reported data may influence the development of therapeutic guidelines for urinary tract infections (UTIs) (empiric antibiotic-therapy) and malignancies (including classical cytotoxic drug protocols and next-generation anticancer therapies) both locally and internationally; on the other hand, the relevant stakeholders and government representatives often base their decisions on published evidence. Therefore, novel studies in the field of urology are strongly encouraged to maintain and improve the high standard of patient care internationally and to ensure continuous information supply for international datasets on the causative agents of UTIs and cancer registries. The present Editorial aims to highlight some relevant studies published from the field of urology in Medicina over the last several years.

Cold weather increases the risk of scrotal torsion events: results of an ecological study of acute scrotal pain in Scotland over 25 years

The role of ambient temperature in the aetiology of acute scrotal pain (ASP) remains uncertain. The most common causes of ASP are torsion of the testis (TT) or its appendages (TA) and epidymo-orchitis (EO). We undertook an ecological study of ASP in Scotland to determine whether a seasonal variation could be observed. Episode reports for TT, TA and EO in Scotland over 25 years were collated monthly. Statistical analyses were performed to determine whether changes in ambient temperature during the year could explain variations in monthly frequency. 7882 episodes of TT and TA (Group A), and 25,973 episodes of EO (Group B) were reported. There was significant variance in the frequency of Group A (p < 0.0001) and B (p = 0.0031) episodes by month, higher frequency of Group A episodes in the colder half of the year (p < 0.0001), and an inverse correlation between the frequency of Group A episodes and ambient temperature (Spearman r = − 0.8757, 95% CI − 0.9661 to − 0.5941, p = 0.0004). Ambient temperature is likely to be playing a role in the aetiology of TT and TA in Scotland but not EO. Further study is warranted to explain underlying mechanisms.

The future of clinical trials in urological oncology

Well-designed clinical trials in urological oncology help to guide treatment decisions and aid in counselling patients, ultimately serving to improve outcomes. Since the term evidence-based medicine was first used by Gordon Guyatt in 1991, a renewed emphasis on methodology, transparent trial design and study reporting has helped to improve clinical research and in turn, the landscape of medical literature. Novel clinical trial designs (including multi-arm, multistage trials, basket and umbrella studies and research from big data sources, such as electronic health records, administrative claims databases and quality monitoring registries) are well suited to advance innovation in urological oncology. Existing urological clinical trials are often limited by small numbers, are statistically underpowered and many face difficulties with accrual. Thus, efforts to improve trial design are of considerable importance. The development and use of standard outcome sets and adherence to reporting guidelines offer researchers the opportunity to guide value-oriented care, minimize research waste and efficiently identify solutions to the unanswered questions in urology cancer care.

Association between physical exercise and psychosocial problems in 96 617 Dutch adolescents in secondary education: a cross-sectional study

Background

Psychosocial problems negatively affect school performance, social skills and mental development. In recent years, researchers have investigated the relationship between physical activity and psychological health. With this large school-based study, we examined whether physically inactive adolescents and slightly active adolescents experience more psychosocial problems compared with active adolescents.

Methods

This study is based on the Dutch National Youth Health Monitor. This monitor uses a, school-based, cross-sectional questionnaire conducted among 96 617 adolescents in 2015. To examine the association between physical exercise and psychosocial problems, multi-level linear regression was carried out.

Results

The weighted average Strengths and Difficulties Questionnaire score of active adolescents was lower than that of inactive adolescents. Adolescents who are inactive had 12% (β = 1.12; 95% CI: 1.10-1.14; P <0 .001) more psychosocial problems compared with active adolescents. Further, inactive adolescents had a higher score on the subscales emotional problems (β = 1.19; 95% CI: 1.17-1.22; P < 0.001) and problems with peers (β = 1.16; 95% CI: 1.14-1.19; P < 0.001). There was no statistical significant difference in total score of the Strengths and Difficulties Questionnaire between active and slightly active adolescents.

Conclusion

Physically active adolescents have fewer psychosocial problems compared with physically inactive adolescents. Not only is this association significant, but there is an indication that it is also of clinical relevance.

How to compete with Google and Co.: big data and artificial intelligence in stones

PURPOSE OF REVIEW

To elucidate the keywords big data and artificial intelligence and corresponding literature in the field of urolithiasis.

RECENT FINDINGS

Numbers of publications on big data and artificial intelligence in the field of urolithiasis are rising, but still low. Most publications describe the development, testing, and validation of automated computational analyses of clinical data sets and/or images in a preclinical setting.

SUMMARY

In the field of digital health services, there is a discrepancy between the enormous commitment of large private companies and investments of public funds. This situation means a still small number of medical publications on this topic in the urolithiasis field. Nevertheless, as doctors and scientists, we should try to provide our patients with secure and worthwhile digital services.

Individual- and state-level factors associated with functional limitation prevalence among Colombian elderly: a multilevel analysis

This study aimed to identify the main regional factors associated with variations in the prevalence of functional limitation on the older adult in Colombia adjusted by individual characteristics. This multilevel study used cross-sectional data from 23,694 adults over 60 years of age in the SABE, Colombia nationwide survey. State-level factors (poverty, development, inequity, violence, health coverage, and access to improved water sources), as well as individual health related, socioeconomic and demographic characteristics, were analyzed. The overall prevalence of functional impairment for the basic activities of daily living (ADL) was 22%. The presence of comorbidities, low educational level, physical inactivity, no participation in social groups, mistreatment and being over 75 years old were associated with functional limitation. At the group level, the analysis showed significant differences in the functional limitation prevalence across states, particularly regarding the socioeconomic status measured according to the Human Development Index (median OR = 1.22; 95%CI: 1.13-1.30; p = 0.011). This study provides evidence on the impact of socioeconomic variation across states on FL prevalence in the Colombian elderly once adjusted for individual characteristics. The findings of this study, through a multilevel approach methodology, provide information to effectively address the conditions that affect the functionality in this population through the identification and prioritization of public health care in groups with economic and health vulnerability.

Clinical effectiveness and cost-effectiveness of issuing longer versus shorter duration (3-month vs. 28-day) prescriptions in patients with chronic conditions: systematic review and economic modelling

BACKGROUND

To reduce expenditure on, and wastage of, drugs, some commissioners have encouraged general practitioners to issue shorter prescriptions, typically 28 days in length; however, the evidence base for this recommendation is uncertain.

OBJECTIVE

To evaluate the evidence of the clinical effectiveness and cost-effectiveness of shorter versus longer prescriptions for people with stable chronic conditions treated in primary care.

DESIGN/DATA SOURCES

The design of the study comprised three elements. First, a systematic review comparing 28-day prescriptions with longer prescriptions in patients with chronic conditions treated in primary care, evaluating any relevant clinical outcomes, adherence to treatment, costs and cost-effectiveness. Databases searched included MEDLINE (PubMed), EMBASE, Cumulative Index to Nursing and Allied Health Literature, Web of Science and Cochrane Central Register of Controlled Trials. Searches were from database inception to October 2015 (updated search to June 2016 in PubMed). Second, a cost analysis of medication wastage associated with < 60-day and ≥ 60-day prescriptions for five patient cohorts over an 11-year period from the Clinical Practice Research Datalink. Third, a decision model adapting three existing models to predict costs and effects of differing adherence levels associated with 28-day versus 3-month prescriptions in three clinical scenarios.

REVIEW METHODS

In the systematic review, from 15,257 unique citations, 54 full-text papers were reviewed and 16 studies were included, five of which were abstracts and one of which was an extended conference abstract. None was a randomised controlled trial: 11 were retrospective cohort studies, three were cross-sectional surveys and two were cost studies. No information on health outcomes was available.

RESULTS

An exploratory meta-analysis based on six retrospective cohort studies suggested that lower adherence was associated with 28-day prescriptions (standardised mean difference -0.45, 95% confidence interval -0.65 to -0.26). The cost analysis showed that a statistically significant increase in medication waste was associated with longer prescription lengths. However, when accounting for dispensing fees and prescriber time, longer prescriptions were found to be cost saving compared with shorter prescriptions. Prescriber time was the largest component of the calculated cost savings to the NHS. The decision modelling suggested that, in all three clinical scenarios, longer prescription lengths were associated with lower costs and higher quality-adjusted life-years.

LIMITATIONS

The available evidence was found to be at a moderate to serious risk of bias. All of the studies were conducted in the USA, which was a cause for concern in terms of generalisability to the UK. No evidence of the direct impact of prescription length on health outcomes was found. The cost study could investigate prescriptions issued only; it could not assess patient adherence to those prescriptions. Additionally, the cost study was based on products issued only and did not account for underlying patient diagnoses. A lack of good-quality evidence affected our decision modelling strategy.

CONCLUSIONS

Although the quality of the evidence was poor, this study found that longer prescriptions may be less costly overall, and may be associated with better adherence than 28-day prescriptions in patients with chronic conditions being treated in primary care.

FUTURE WORK

There is a need to more reliably evaluate the impact of differing prescription lengths on adherence, on patient health outcomes and on total costs to the NHS. The priority should be to identify patients with particular conditions or characteristics who should receive shorter or longer prescriptions. To determine the need for any further research, an expected value of perfect information analysis should be performed.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015027042.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

A review of routinely collected data studies in urology: Methodological considerations, reporting quality, and future directions

Studies using routinely collected data (RCD) are common in the urological literature; however, there are important considerations in the creation and review of RCD discoveries. A recent reporting guideline (REporting of studies Conducted using Observational Routinely-collected health Data, RECORD) was developed to improve the reporting of these studies. This narrative review examines important considerations for RCD studies. To assess the current level of reporting in the urological literature, we reviewed all the original research articles published in Journal of Urology and European Urology in 2014, and determined the proportion of the RECORD checklist items that were reported for RCD studies. There were 56 RCD studies identified among the 608 articles. When the RECORD items were considered applicable to the specific study, they were reported in 52.5% of cases. Studies most consistently (>80% of them) reported the names of the data sources, the study time frame, the extent to which the authors could access the database source, the patient selection, and discussed missing data. Few studies (<25%) discussed validation of key coding elements, details on data-linkage, data-cleaning, the impact of changing eligibility over time, or provided the complete list of coding elements used to define key study variables. Reporting factors specifically relevant in RCD studies may serve to increase the quality of these studies in the urological literature. With increased technological integration in healthcare and the proliferation of electronic medical records, RCD will continue to be an important source for urological research.

Pediatric urolithiasis associated with acute gastroenteritis: an inpatient database study in Japan

Pediatric urolithiasis associated with acute gastroenteritis (AGE) has not been systematically investigated, including its prevalence, risk estimate, and outcome. Using a national inpatient database in Japan, we searched for children (≤59 months old) who were hospitalized for AGE and those complicated by urolithiasis over a 24-month period. We found 23 cases of urolithiasis among 62,800 children who were hospitalized for AGE (3.7 cases/10,000 AGE admissions). AGE was associated with an increased risk of urolithiasis (odds ratio 2.01; p = 0.015). The patients' mean age was 24 months and there was male dominance. Four patients had chronic medical conditions, including two with renal conditions. None of the patients had congenital metabolic disorders. Nine patients had causative agents for AGE, including rotavirus (n = 5), norovirus (n = 2), and bacteria (n = 2). Two patients required placement of a nephrostomy tube and the remaining 21 patients were discharged without invasive procedures.

CONCLUSION

Childhood AGE is associated with a twofold risk of urolithiasis in a hospitalized cohort, but the absolute risk is low. Our study shows that AGE-related urolithiasis occurs through a variety of pathogens, and the outcomes of patients are favorable, which is in contrast to previous reports. What is Known: • There are several sporadic reports of pediatric urolithiasis associated with acute gastroenteritis (AGE), predominantly from Japan. • The epidemiology of AGE-related urolithiasis is however unclear. What is New: • AGE is associated with a two-fold risk of urolithiasis in a hospitalized cohort, with its absolute risk of 3.7 cases/10,000 AGE admissions.

Use of patient registries and administrative datasets for the study of pediatric cancer

Analysis of data from large administrative databases and patient registries is increasingly being used to study childhood cancer care, although the value of these data sources remains unclear to many clinicians. Interpretation of large databases requires a thorough understanding of how the dataset was designed, how data were collected, and how to assess data quality. This review will detail the role of administrative databases and registry databases for the study of childhood cancer, tools to maximize information from these datasets, and recommendations to improve the use of these databases for the study of pediatric oncology.

Epidemiology and cost of hospital care for Lyme borreliosis in Germany: lessons from a health care utilization database analysis

To date, relatively little is known about the economic and medical impact of Lyme borreliosis (LB) on European health care systems, especially for the inpatient sector. This retrospective analysis is based on data provided for the years 2007-2011 by a German statutory health insurance company (DAK-Gesundheit) covering approximately 6 million insured. Total cost was calculated for a 1-year period both from the third-party payers and from the societal perspective, respectively. In our cohort the incident diagnosis of LB was coded for 2163 inpatient cases during the years 2008-2011. The median inpatient time was 9 days resulting in a median direct medical cost per hospital stay of 3917€ for adolescents and 2843€ for adults. Based on extrapolation of our findings to the German population, we would expect an average hospital admission of 5200 adults and 2300 adolescents (<18 years) for LB treatment incurring direct medical costs of more than 23 million Euro annually. The annual indirect costs due to loss of productivity would add up to more than 7 million Euro as assessed by the human capital method. Cases tended to accumulate between June and September with remarkable changes in disease manifestations in the course of the year documented in the coded secondary diagnoses. Also specific differences in the disease pattern of adolescents and adults became obvious. Age-specific incidence showed male predominance and a bimodal distribution. Incidence was highest in children aged between 3 and 17 (highest mean incidence of 29 cases/100,000 inhabitants in 6-9 year olds) with a second peak in 60-79 year old individuals. During the study period the nationwide inpatient incidence was 9/100,000 with marked regional variability. In summary, our study is one of the first European investigations on hospital care for LB inpatients and identifies LB as a possibly underestimated socioeconomic factor for health care in Germany.