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Connolly A, Kirwan M, Matthews A. A scoping review of the methodological approaches used in retrospective chart reviews to validate adverse event rates in administrative data. Int J Qual Health Care 2024; 36:mzae037. [PMID: 38662407 PMCID: PMC11086704 DOI: 10.1093/intqhc/mzae037] [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: 12/21/2023] [Revised: 03/08/2024] [Accepted: 04/23/2024] [Indexed: 04/26/2024] Open
Abstract
Patient safety is a key quality issue for health systems. Healthcare acquired adverse events (AEs) compromise safety and quality; therefore, their reporting and monitoring is a patient safety priority. Although administrative datasets are potentially efficient tools for monitoring rates of AEs, concerns remain over the accuracy of their data. Chart review validation studies are required to explore the potential of administrative data to inform research and health policy. This review aims to present an overview of the methodological approaches and strategies used to validate rates of AEs in administrative data through chart review. This review was conducted in line with the Joanna Briggs Institute methodological framework for scoping reviews. Through database searches, 1054 sources were identified, imported into Covidence, and screened against the inclusion criteria. Articles that validated rates of AEs in administrative data through chart review were included. Data were extracted, exported to Microsoft Excel, arranged into a charting table, and presented in a tabular and descriptive format. Fifty-six studies were included. Most sources reported on surgical AEs; however, other medical specialties were also explored. Chart reviews were used in all studies; however, few agreed on terminology for the study design. Various methodological approaches and sampling strategies were used. Some studies used the Global Trigger Tool, a two-stage chart review method, whilst others used alternative single-, two-stage, or unclear approaches. The sources used samples of flagged charts (n = 24), flagged and random charts (n = 11), and random charts (n = 21). Most studies reported poor or moderate accuracy of AE rates. Some studies reported good accuracy of AE recording which highlights the potential of using administrative data for research purposes. This review highlights the potential for administrative data to provide information on AE rates and improve patient safety and healthcare quality. Nonetheless, further work is warranted to ensure that administrative data are accurate. The variation of methodological approaches taken, and sampling techniques used demonstrate a lack of consensus on best practice; therefore, further clarity and consensus are necessary to develop a more systematic approach to chart reviewing.
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Affiliation(s)
- Anna Connolly
- School of Nursing, Psychotherapy and Community Health, Dublin City University, Dublin D09 V209, Ireland
| | - Marcia Kirwan
- School of Nursing, Psychotherapy and Community Health, Dublin City University, Dublin D09 V209, Ireland
| | - Anne Matthews
- School of Nursing, Psychotherapy and Community Health, Dublin City University, Dublin D09 V209, Ireland
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2
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Shirley AM, Morrisette KL, Choi SK, Reynolds K, Zhou H, Zhou MM, Wei R, Zhang Y, Cheng P, Wong E, Sangha N, An J. Validation of ICD-10 hospital discharge diagnosis codes to identify incident and recurrent ischemic stroke from a US integrated healthcare system. Pharmacoepidemiol Drug Saf 2023; 32:1439-1445. [PMID: 37528669 PMCID: PMC10830879 DOI: 10.1002/pds.5675] [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: 05/16/2023] [Revised: 07/14/2023] [Accepted: 07/20/2023] [Indexed: 08/03/2023]
Abstract
PURPOSE This study validated incident and recurrent ischemic stroke identified by International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) hospital discharge diagnosis codes. METHODS Using electronic health records (EHR) of adults (≥18 years) receiving care from Kaiser Permanente Southern California with ICD-10 hospital discharge diagnosis codes of ischemic stroke (I63.x, G46.3, and G46.4) between October 2015 and September 2020, we identified 75 patients with both incident and recurrent stroke events (total 150 cases). Two neurologists independently evaluated validity of ICD-10 codes through chart reviews. RESULTS The positive predictive value (PPV, 95% CI) for incident stroke was 93% (95% CI: 88%, 99%) and the PPV for recurrent stroke was 72% (95% CI: 62%, 82%). The PPV for recurrent stroke improved after applying a gap of 20 days (PPV of 75%; 95% CI: 63%, 87%) or removing hospital admissions related to stroke-related procedures (PPV of 78%; 95% CI: 68%, 88%). CONCLUSION The ICD-10 hospital discharge diagnosis codes for ischemic stroke showed a high PPV for incident cases, while the PPV for recurrent cases were less optimal. Algorithms to improve the accuracy of ICD-10 codes for recurrent ischemic stroke may be necessary.
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Affiliation(s)
- Abraelle M Shirley
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Kerresa L Morrisette
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Soon Kyu Choi
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Kristi Reynolds
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Hui Zhou
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Mengnan M Zhou
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Rong Wei
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Yiyi Zhang
- Division of General Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Pamela Cheng
- Department of Neurology, Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, California, USA
| | - Eric Wong
- Department of Neurology, Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, California, USA
| | - Navdeep Sangha
- Department of Neurology, Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, California, USA
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Jaejin An
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
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Cocoros NM, Kluberg SA, Willis SJ, Forrow S, Gessner BD, Nutt CT, Cane A, Petrou N, Sury M, Rhee C, Jodar L, Mendelsohn A, Hoffman ER, Jin R, Aucott J, Pugh SJ, Stark JH. Validation of Claims-Based Algorithm for Lyme Disease, Massachusetts, USA. Emerg Infect Dis 2023; 29:1772-1779. [PMID: 37610117 PMCID: PMC10461665 DOI: 10.3201/eid2909.221931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023] Open
Abstract
Compared with notifiable disease surveillance, claims-based algorithms estimate higher Lyme disease incidence, but their accuracy is unknown. We applied a previously developed Lyme disease algorithm (diagnosis code plus antimicrobial drug prescription dispensing within 30 days) to an administrative claims database in Massachusetts, USA, to identify a Lyme disease cohort during July 2000-June 2019. Clinicians reviewed and adjudicated medical charts from a cohort subset by using national surveillance case definitions. We calculated positive predictive values (PPVs). We identified 12,229 Lyme disease episodes in the claims database and reviewed and adjudicated 128 medical charts. The algorithm's PPV for confirmed, probable, or suspected cases was 93.8% (95% CI 88.1%-97.3%); the PPV was 66.4% (95% CI 57.5%-74.5%) for confirmed and probable cases only. In a high incidence setting, a claims-based algorithm identified cases with a high PPV, suggesting it can be used to assess Lyme disease burden and supplement traditional surveillance data.
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Singh S, Beyrer J, Zhou X, Swerdel J, Harvey RA, Hornbuckle K, Russo L, Ghauri K, Abi-Elias IH, Cox JS, Rodriguez-Watson C. Development and Evaluation of the Algorithm CErtaInty Tool (ACE-IT) to Assess Electronic Medical Record and Claims-based Algorithms' Fit for Purpose for Safety Outcomes. Drug Saf 2023; 46:87-97. [PMID: 36396894 PMCID: PMC9672644 DOI: 10.1007/s40264-022-01254-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Electronic health record (EHR) or medical claims-based algorithms (i.e., operational definitions) can be used to define safety outcomes using real-world data. However, existing tools do not allow researchers and decision-makers to adequately appraise whether a particular algorithm is fit for purpose (FFP) to support regulatory decisions on drug safety surveillance. Our objective was to develop a tool to enable regulatory decision-makers and other stakeholders to appraise whether a given algorithm is FFP for a specific decision context. METHODS We drafted a set of 77 generic items informed by regulatory guidance documents, existing instruments, and publications. The outcome of ischemic stroke served as an exemplar to inform the development of draft items. The items were designed to be outcome independent. We conducted a three-round online Delphi panel to develop and refine the tool and achieve consensus on items (> 70% agreement) among panel participants composed of regulators, researchers from pharmaceutical organizations, academic clinicians, methodologists, pharmacoepidemiologists, and cardiologists. We conducted a qualitative analysis of panel responses. Five pairs of reviewers independently evaluated two ischemic stroke algorithm validation studies to test its application. We developed a user guide, with explanation and elaboration for each item, guidance on essential and additional elements for user responses, and an illustrative example of a complete assessment. Furthermore, we conducted a 2-h online stakeholder panel of 16 participants from regulatory agencies, academic institutions, and industry. We solicited input on key factors for an FFP assessment, their general reaction to the Algorithm CErtaInty Tool (ACE-IT), limitations of the tool, and its potential use. RESULTS The expert panel reviewed and made changes to the initial list of 77 items. The panel achieved consensus on 38 items, and the final version of the ACE-IT includes 34 items after removal of duplicate items. Applying the tool to two ischemic stroke algorithms demonstrated challenges in its application and identified shared concepts addressed by more than one item. The ACE-IT was viewed positively by the majority of stakeholders. They identified that the tool could serve as an educational resource as well as an information-sharing platform. The time required to complete the assessment was identified as an important limitation. We consolidated items with shared concepts and added a preliminary screen section and a summary assessment box based on their input. The final version of the ACE-IT is a 34-item tool for assessing whether algorithm validation studies on safety outcomes are FFP. It comprises the domains of internal validity (24 items), external validity (seven items), and ethical conduct and reporting of the validation study (three items). The internal validity domain includes sections on objectives, data sources, population, outcomes, design and setting, statistical methods, reference standard, accuracy, and strengths and limitations. The external validity domain includes items that assess the generalizability to a proposed target study. The domain on ethics and transparency includes items on ethical conduct and reporting of the validation study. CONCLUSION The ACE-IT supports a structured, transparent, and flexible approach for decision-makers to appraise whether electronic health record or medical claims-based algorithms for safety outcomes are FFP for a specific decision context. Reliability and validity testing using a larger sample of participants in other therapeutic areas and further modifications to reduce the time needed to complete the assessment are needed to fully evaluate its utility for regulatory decision-making.
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Affiliation(s)
- Sonal Singh
- Department of Family Medicine and Community Health, UMass Chan Medical School, Worcester, MA USA ,Division of Health Systems Science, Department of Medicine, UMass Chan Medical School, Worcester, USA
| | | | | | | | | | | | - Leo Russo
- Pfizer, Global Medical Epidemiology, Paoli, PA USA
| | - Kanwal Ghauri
- Reagan-Udall Foundation for the FDA, Washington, DC USA
| | - Ivan H. Abi-Elias
- Division of Health Systems Science, Department of Medicine, UMass Chan Medical School, Worcester, USA
| | - John S. Cox
- Division of Health Systems Science, Department of Medicine, UMass Chan Medical School, Worcester, USA
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Lee S, Doktorchik C, Martin EA, D'Souza AG, Eastwood C, Shaheen AA, Naugler C, Lee J, Quan H. Electronic Medical Record-Based Case Phenotyping for the Charlson Conditions: Scoping Review. JMIR Med Inform 2021; 9:e23934. [PMID: 33522976 PMCID: PMC7884219 DOI: 10.2196/23934] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/20/2020] [Accepted: 12/05/2020] [Indexed: 12/16/2022] Open
Abstract
Background Electronic medical records (EMRs) contain large amounts of rich clinical information. Developing EMR-based case definitions, also known as EMR phenotyping, is an active area of research that has implications for epidemiology, clinical care, and health services research. Objective This review aims to describe and assess the present landscape of EMR-based case phenotyping for the Charlson conditions. Methods A scoping review of EMR-based algorithms for defining the Charlson comorbidity index conditions was completed. This study covered articles published between January 2000 and April 2020, both inclusive. Embase (Excerpta Medica database) and MEDLINE (Medical Literature Analysis and Retrieval System Online) were searched using keywords developed in the following 3 domains: terms related to EMR, terms related to case finding, and disease-specific terms. The manuscript follows the Preferred Reporting Items for Systematic reviews and Meta-analyses extension for Scoping Reviews (PRISMA) guidelines. Results A total of 274 articles representing 299 algorithms were assessed and summarized. Most studies were undertaken in the United States (181/299, 60.5%), followed by the United Kingdom (42/299, 14.0%) and Canada (15/299, 5.0%). These algorithms were mostly developed either in primary care (103/299, 34.4%) or inpatient (168/299, 56.2%) settings. Diabetes, congestive heart failure, myocardial infarction, and rheumatology had the highest number of developed algorithms. Data-driven and clinical rule–based approaches have been identified. EMR-based phenotype and algorithm development reflect the data access allowed by respective health systems, and algorithms vary in their performance. Conclusions Recognizing similarities and differences in health systems, data collection strategies, extraction, data release protocols, and existing clinical pathways is critical to algorithm development strategies. Several strategies to assist with phenotype-based case definitions have been proposed.
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Affiliation(s)
- Seungwon Lee
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Calgary, AB, Canada.,Data Intelligence for Health Lab, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Chelsea Doktorchik
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Elliot Asher Martin
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Calgary, AB, Canada
| | - Adam Giles D'Souza
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Calgary, AB, Canada
| | - Cathy Eastwood
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Abdel Aziz Shaheen
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Christopher Naugler
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Joon Lee
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Data Intelligence for Health Lab, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Hude Quan
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Straub L, Gagne JJ, Maro JC, Nguyen MD, Beaulieu N, Brown JS, Kennedy A, Johnson M, Wright A, Zhou L, Wang SV. Evaluation of Use of Technologies to Facilitate Medical Chart Review. Drug Saf 2020; 42:1071-1080. [PMID: 31111340 DOI: 10.1007/s40264-019-00838-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION While medical chart review remains the gold standard to validate health conditions or events identified in administrative claims and electronic health record databases, it is time consuming, expensive and can involve subjective decisions. AIM The aim of this study was to describe the landscape of technology-enhanced approaches that could be used to facilitate medical chart review within and across distributed data networks. METHOD We conducted a semi-structured survey regarding processes for medical chart review with organizations that either routinely do medical chart review or use technologies that could facilitate chart review. RESULTS Fifteen out of 17 interviewed organizations used optical character recognition (OCR) or natural language processing (NLP) in their chart review process. None used handwriting recognition software. While these organizations found OCR and NLP to be useful for expediting extraction of useful information from medical charts, they also mentioned several challenges. Quality of medical scans can be variable, interfering with the accuracy of OCR. Additionally, linguistic complexity in medical notes and heterogeneity in reporting templates used by different healthcare systems can reduce the transportability of NLP-based algorithms to diverse healthcare settings. CONCLUSION New technologies including OCR and NLP are currently in use by various organizations involved in medical chart review. While technology-enhanced approaches could scale up capacity to validate key variables and make information about important clinical variables from medical records more generally available for research purposes, they often require considerable customization when employed in a distributed data environment with multiple, diverse healthcare settings.
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Affiliation(s)
- Loreen Straub
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA.
| | - Joshua J Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA
| | - Judith C Maro
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Michael D Nguyen
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Nicolas Beaulieu
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Jeffrey S Brown
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Adee Kennedy
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Margaret Johnson
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Adam Wright
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Li Zhou
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shirley V Wang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA
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Strom JB, Tamez H, Zhao Y, Valsdottir LR, Curtis J, Brennan JM, Shen C, Popma JJ, Mauri L, Yeh RW. Validating the use of registries and claims data to support randomized trials: Rationale and design of the Extending Trial-Based Evaluations of Medical Therapies Using Novel Sources of Data (EXTEND) Study. Am Heart J 2019; 212:64-71. [PMID: 30953936 DOI: 10.1016/j.ahj.2019.02.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 02/19/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Randomized controlled trials are the "gold standard" for comparing the safety and efficacy of therapies but may be limited due to high costs, lack of feasibility, and difficulty enrolling "real-world" patient populations. The Extending Trial-Based Evaluations of Medical Therapies Using Novel Sources of Data (EXTEND) Study seeks to evaluate whether data collected within procedural registries and claims databases can reproduce trial results by substituting surrogate non-trial-based variables for exposures and outcomes. METHODS AND RESULTS Patient-level data from 2 clinical trial programs-the Dual Antiplatelet Therapy Study and the United States CoreValve Studies-will be linked to a combination of national registry, administrative claims, and health system data. The concordance between baseline and outcomes data collected within nontrial data sets and trial information, including adjudicated end point events, will be assessed. We will compare the study results obtained using these alternative data sources to those derived using trial-ascertained variables and end points using trial-adjudicated end points and covariates. CONCLUSIONS Linkage of trials to registries and claims data represents an opportunity to use alternative data sources in place of and as adjuncts to randomized clinical trial data but requires further validation. The results of this research will help determine how these data sources can be used to improve our present and future understanding of new medical treatments.
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Affiliation(s)
- Jordan B Strom
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Hector Tamez
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Yuansong Zhao
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Linda R Valsdottir
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jeptha Curtis
- Center for Outcomes Research and Evaluation, Yale University School of Medicine, New Haven, CT
| | | | - Changyu Shen
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Jeffrey J Popma
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA; Baim Institute for Clinical Research, Boston, MA
| | | | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA; Baim Institute for Clinical Research, Boston, MA.
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