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Paczesny S, Hozo I, Djulbegovic B. Biomarker-derived fast-and-frugal decision tree for preemption of veno-occlusive disease/sinusoidal obstructive syndrome. Blood Adv 2024; 8:5426-5429. [PMID: 39207866 DOI: 10.1182/bloodadvances.2024013670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 08/21/2024] [Accepted: 08/21/2024] [Indexed: 09/04/2024] Open
Affiliation(s)
- Sophie Paczesny
- Departments of Microbiology and Immunology and Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Iztok Hozo
- Department of Mathematics and Actuarial Science, Indiana University Northwest, Gary, IN
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Djulbegovic B, Boylan A, Kolo S, Scheurer DB, Anuskiewicz S, Khaledi F, Youkhana K, Madgwick S, Maharjan N, Hozo I. Converting IMPROVE bleeding and VTE risk assessment models into a fast-and-frugal decision tree for optimal hospital VTE prophylaxis. Blood Adv 2024; 8:3214-3224. [PMID: 38621198 PMCID: PMC11225674 DOI: 10.1182/bloodadvances.2024013166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/04/2024] [Accepted: 04/04/2024] [Indexed: 04/17/2024] Open
Abstract
ABSTRACT Current hospital venous thromboembolism (VTE) prophylaxis for medical patients is characterized by both underuse and overuse. The American Society of Hematology (ASH) has endorsed the use of risk assessment models (RAMs) as an approach to individualize VTE prophylaxis by balancing overuse (excessive risk of bleeding) and underuse (risk of avoidable VTE). ASH has endorsed IMPROVE (International Medical Prevention Registry on Venous Thromboembolism) risk assessment models, the only RAMs to assess short-term bleeding and VTE risk in acutely ill medical inpatients. ASH, however, notes that no RAMs have been thoroughly analyzed for their effect on patient outcomes. We aimed to validate the IMPROVE models and adapt them into a simple, fast-and-frugal (FFT) decision tree to evaluate the impact of VTE prevention on health outcomes and costs. We used 3 methods: the "best evidence" from ASH guidelines, a "learning health system paradigm" combining guideline and real-world data from the Medical University of South Carolina (MUSC), and a "real-world data" approach based solely on MUSC data retrospectively extracted from electronic records. We found that the most effective VTE prevention strategy used the FFT decision tree based on an IMPROVE VTE score of ≥2 or ≥4 and a bleeding score of <7. This method could prevent 45% of unnecessary treatments, saving ∼$5 million annually for patients such as the MUSC cohort. We recommend integrating IMPROVE models into hospital electronic medical records as a point-of-care tool, thereby enhancing VTE prevention in hospitalized medical patients.
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Affiliation(s)
| | - Alice Boylan
- Medical University of South Carolina, Charleston, SC
| | - Shelby Kolo
- Medical University of South Carolina, Charleston, SC
| | | | | | - Flora Khaledi
- Medical University of South Carolina, Charleston, SC
| | | | | | | | - Iztok Hozo
- Department of Mathematics, Indiana University Northwest, Gary, IN
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3
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Djulbegovic B, Hozo I, Cuker A, Guyatt G. Improving methods of clinical practice guidelines: From guidelines to pathways to fast-and-frugal trees and decision analysis to develop individualised patient care. J Eval Clin Pract 2024; 30:393-402. [PMID: 38073027 DOI: 10.1111/jep.13953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND Current methods for developing clinical practice guidelines have several limitations: they are characterised by the "black box" operation-a process with defined inputs and outputs but an incomplete understanding of its internal workings; they have "the integration problem"-a lack of framework for explicitly integrating factors such as patient preferences and trade-offs between benefits and harms; they generate one recommendation at a time that typically are not connected in a coherent analytical framework; and they apply to "average" patients, while clinicians and their patients seek advice tailored to individual circumstances. METHODS We propose augmenting the current guideline development method by converting evidence-based pathways into fast-and-frugal decision trees (FFTs) and integrating them with generalised decision curve analysis to formulate clear, individualised management recommendations. RESULTS We illustrate the process by developing recommendations for the management of heparin-induced thrombocytopenia (HIT). We converted evidence-based pathways for HIT, developed by the American Society of Hematology, into an FFT. Here, we consider only thrombotic complications and major bleeding. We leveraged the predictive potential of FFTs to compare the effects of argatroban, bivalirudin, fondaparinux, and direct oral anticoagulants (DOACs) using generalised decision curve analysis. We found that DOACs were superior to other treatments if the FFT-predicted probability of HIT exceeded 3%. CONCLUSIONS The proposed analytical framework connects guidelines, pathways, FFTs, and decision analysis, offering risk-tailored personalised recommendations and addressing current guideline development critiques.
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Affiliation(s)
- Benjamin Djulbegovic
- Division of Medical Hematology and Oncology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Iztok Hozo
- Department of Mathematics, Indiana University Northwest, Gary, Indiana, USA
| | - Adam Cuker
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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4
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Timmons AC, Duong JB, Fiallo NS, Lee T, Vo HPQ, Ahle MW, Comer JS, Brewer LC, Frazier SL, Chaspari T. A Call to Action on Assessing and Mitigating Bias in Artificial Intelligence Applications for Mental Health. PERSPECTIVES ON PSYCHOLOGICAL SCIENCE 2023; 18:1062-1096. [PMID: 36490369 PMCID: PMC10250563 DOI: 10.1177/17456916221134490] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Advances in computer science and data-analytic methods are driving a new era in mental health research and application. Artificial intelligence (AI) technologies hold the potential to enhance the assessment, diagnosis, and treatment of people experiencing mental health problems and to increase the reach and impact of mental health care. However, AI applications will not mitigate mental health disparities if they are built from historical data that reflect underlying social biases and inequities. AI models biased against sensitive classes could reinforce and even perpetuate existing inequities if these models create legacies that differentially impact who is diagnosed and treated, and how effectively. The current article reviews the health-equity implications of applying AI to mental health problems, outlines state-of-the-art methods for assessing and mitigating algorithmic bias, and presents a call to action to guide the development of fair-aware AI in psychological science.
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Affiliation(s)
- Adela C. Timmons
- University of Texas at Austin Institute for Mental Health Research
- Colliga Apps Corporation
| | | | | | | | | | | | | | - LaPrincess C. Brewer
- Department of Cardiovascular Medicine, May Clinic College of Medicine, Rochester, Minnesota, United States
- Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, Minnesota, United States
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Robinson H, Eleuteri A, Sacco JJ, Hussain R, Heimann H, Taktak AFG, Damato B, Thompson AJ, Allen T, Kalirai H, Coupland SE. Sensitivity and Specificity of Different Prognostic Systems in Guiding Surveillance for Metastases in Uveal Melanoma. Cancers (Basel) 2023; 15:cancers15092610. [PMID: 37174076 PMCID: PMC10177440 DOI: 10.3390/cancers15092610] [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: 03/19/2023] [Revised: 04/27/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023] Open
Abstract
Uveal melanoma (UM) metastasises in ~50% of patients, most frequently to the liver. Surveillance imaging can provide early detection of hepatic metastases; however, guidance regarding UM patient risk stratification for surveillance is unclear. This study compared sensitivity and specificity of four current prognostic systems, when used for risk stratification for surveillance, on patients treated at the Liverpool Ocular Oncology Centre (LOOC) between 2007-2016 (n = 1047). It found that the Liverpool Uveal Melanoma Prognosticator Online III (LUMPOIII) or Liverpool Parsimonious Model (LPM) offered greater specificity at equal levels of sensitivity than the American Joint Committee on Cancer (AJCC) system or monosomy 3 alone, and suggests guidance to achieve 95% sensitivity and 51% specificity (i.e., how to detect the same number of patients with metastases, while reducing the number of negative scans). For example, 180 scans could be safely avoided over 5 years in 200 patients using the most specific approach. LUMPOIII also offered high sensitivity and improved specificity over the AJCC in the absence of genetic information, making the result relevant to centres that do not perform genetic testing, or where such testing is inappropriate or fails. This study provides valuable information for clinical guidelines for risk stratification for surveillance in UM.
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Affiliation(s)
- Helena Robinson
- Department of Clinical Engineering, Liverpool University Hospitals NHS Foundation Trust, Liverpool L7 8YE, UK
| | - Antonio Eleuteri
- NHS Digital, Liverpool University Hospitals NHS Foundation Trust, Liverpool L7 8YE, UK
| | - Joseph J Sacco
- Liverpool Ocular Oncology Research Group, Department of Molecular and Cancer Medicine, University of Liverpool, Liverpool L7 8TX, UK
| | - Rumana Hussain
- Liverpool Ocular Oncology Research Group, Department of Molecular and Cancer Medicine, University of Liverpool, Liverpool L7 8TX, UK
- Liverpool Ocular Oncology Centre, Liverpool University Hospitals NHS Foundation Trust, Liverpool L7 8TX, UK
| | - Heinrich Heimann
- Liverpool Ocular Oncology Research Group, Department of Molecular and Cancer Medicine, University of Liverpool, Liverpool L7 8TX, UK
- Liverpool Ocular Oncology Centre, Liverpool University Hospitals NHS Foundation Trust, Liverpool L7 8TX, UK
| | - Azzam F G Taktak
- Department of Clinical Engineering, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol BS2 8HW, UK
| | - Bertil Damato
- Consultant Ocular Oncologist, St Erik's Eye Hospital & Karolinska Institutet, 171 64 Stockholm, Sweden
| | - Alexander J Thompson
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester M13 9PL, UK
| | - Thomas Allen
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester M13 9PL, UK
| | - Helen Kalirai
- Liverpool Ocular Oncology Research Group, Department of Molecular and Cancer Medicine, University of Liverpool, Liverpool L7 8TX, UK
| | - Sarah E Coupland
- Liverpool Ocular Oncology Research Group, Department of Molecular and Cancer Medicine, University of Liverpool, Liverpool L7 8TX, UK
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Djulbegovic B, Hozo I, Lizarraga D, Guyatt G. Decomposing clinical practice guidelines panels' deliberation into decision theoretical constructs. J Eval Clin Pract 2023; 29:459-471. [PMID: 36694469 DOI: 10.1111/jep.13809] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 01/09/2023] [Accepted: 01/11/2023] [Indexed: 01/26/2023]
Abstract
UNLABELLED RATIONALE, AIMS AND OBJECTIVES: The development of clinical practice guidelines (CPG) suffers from the lack of an explicit and transparent framework for synthesising the key elements necessary to formulate practice recommendations. We matched deliberations of the American Society of Haematology (ASH) CPG panel for the management of pulmonary embolism (PE) with the corresponding decision-theoretical constructs to assess agreement of the panel recommendations with explicit decision modelling. METHODS Five constructs were identified of which three were used to reformulate the panel's recommendations: (1) standard, expected utility threshold (EUT) decision model; (2) acceptable regret threshold model (ARg) to determine the frequency of tolerable false negative (FN) or false positive (FP) recommendations, and (3) fast-and-frugal tree (FFT) decision trees to formulate the entire strategy for management of PE. We compared four management strategies: withhold testing versus d-dimer → computerized pulmonary angiography (CTPA) ('ASH-Low') versus CTPA→ d-dimer ('ASH-High') versus treat without testing. RESULTS Different models generated different recommendations. For example, according to EUT, testing should be withheld for prior probability PE < 0.13%, a clinically untenable threshold which is up to 15 times (2/0.13) below the ASH guidelines threshold of ruling out PE (at post probability of PE ≤ 2%). Three models only agreed that the 'ASH low' strategy should be used for the range of pretest probabilities of PE between 0.13% and 13.27% and that the 'ASH high' management should be employed in a narrow range of the prior PE probabilities between 90.85% and 93.07%. For all other prior probabilities of PE, choosing one model did not ensure coherence with other models. CONCLUSIONS CPG panels rely on various decision-theoretical strategies to develop its recommendations. Decomposing CPG panels' deliberation can provide insights if the panels' deliberation retains a necessary coherence in developing guidelines. CPG recommendations often do not agree with the EUT decision analysis, widely used in medical decision-making modelling.
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Affiliation(s)
- Benjamin Djulbegovic
- Department of Computational & Quantitative Medicine, Beckman Research Institute, Duarte, California, USA.,Division of Health Analytics, Duarte, California, USA.,Evidence-based Medicine & Comparative Effectiveness Research, Duarte, California, USA
| | - Iztok Hozo
- Department of Mathematics, Indiana University, Gary, Indiana, USA
| | - David Lizarraga
- Department of Computational & Quantitative Medicine, Beckman Research Institute, Duarte, California, USA.,Division of Health Analytics, Duarte, California, USA.,Evidence-based Medicine & Comparative Effectiveness Research, Duarte, California, USA
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Ladbury C, Amini A, Govindarajan A, Mambetsariev I, Raz DJ, Massarelli E, Williams T, Rodin A, Salgia R. Integration of artificial intelligence in lung cancer: Rise of the machine. Cell Rep Med 2023; 4:100933. [PMID: 36738739 PMCID: PMC9975283 DOI: 10.1016/j.xcrm.2023.100933] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/14/2022] [Accepted: 01/17/2023] [Indexed: 02/05/2023]
Abstract
The goal of oncology is to provide the longest possible survival outcomes with the therapeutics that are currently available without sacrificing patients' quality of life. In lung cancer, several data points over a patient's diagnostic and treatment course are relevant to optimizing outcomes in the form of precision medicine, and artificial intelligence (AI) provides the opportunity to use available data from molecular information to radiomics, in combination with patient and tumor characteristics, to help clinicians provide individualized care. In doing so, AI can help create models to identify cancer early in diagnosis and deliver tailored therapy on the basis of available information, both at the time of diagnosis and in real time as they are undergoing treatment. The purpose of this review is to summarize the current literature in AI specific to lung cancer and how it applies to the multidisciplinary team taking care of these complex patients.
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Affiliation(s)
- Colton Ladbury
- Department of Radiation Oncology, City of Hope National Medical Center, 1500 E Duarte Road, Duarte, CA 91010, USA
| | - Arya Amini
- Department of Radiation Oncology, City of Hope National Medical Center, 1500 E Duarte Road, Duarte, CA 91010, USA.
| | - Ameish Govindarajan
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Isa Mambetsariev
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Dan J Raz
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Erminia Massarelli
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Terence Williams
- Department of Radiation Oncology, City of Hope National Medical Center, 1500 E Duarte Road, Duarte, CA 91010, USA
| | - Andrei Rodin
- Department of Computational and Quantitative Medicine, City of Hope National Medical Center, Duarte, CA, USA
| | - Ravi Salgia
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA, USA
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8
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Djulbegovic B, Hozo I, Lizarraga D, Thomas J, Barbee M, Shah N, Rubeor T, Dale J, Reiser J, Guyatt G. Evaluation of a fast-and-frugal clinical decision algorithm ('pathways') on clinical outcomes in hospitalised patients with COVID-19 treated with anticoagulants. J Eval Clin Pract 2023; 29:3-12. [PMID: 36229950 PMCID: PMC9840687 DOI: 10.1111/jep.13780] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 09/26/2022] [Accepted: 10/02/2022] [Indexed: 01/27/2023]
Abstract
RATIONALE, AIMS AND OBJECTIVES Critics have charged that evidence-based medicine (EBM) overemphasises algorithmic rules over unstructured clinical experience and intuition, but the role of structured decision support systems in improving health outcomes remains uncertain. We aim to assess if delivery of anticoagulant prophylaxis in hospitalised patients with COVID-19 according to an algorithm based on evidence-based clinical practice guideline (CPG) improved clinical outcomes compared with administration of anticoagulant treatment given at individual practitioners' discretion. METHODS An observational design consisting of the analysis of all acutely ill, consecutive patients (n = 1783) with confirmed COVID-19 diagnosis admitted between 10 March 2020 to 11 January 2022 to an US academic center. American Society of Haematology CPG for anticoagulant prophylaxis in hospitalised patients with COVID-19 was converted into a clinical pathway and translated into fast-and-frugal decision (FFT) tree ('algorithm'). We compared delivery of anticoagulant prophylaxis in hospitalised patients with COVID-19 according to the FFT algorithm with administration of anticoagulant treatment given at individual practitioners' discretion. RESULTS In an adjusted analysis, using combination of Lasso (least absolute shrinkage and selection operator) and propensity score based weighting [augmented inverse-probability weighting] statistical techniques controlling for cluster data, the algorithm did not reduce death, venous thromboembolism, or major bleeding, but helped avoid longer hospital stay [number of patients needed to be treated (NNT) = 40 (95% CI: 23-143), indicating that for every 40 patients (23-143) managed on FFT algorithm, one avoided staying in hospital longer than 10 days] and averted admission to intensive-care unit (ICU) [NNT = 19 (95% CI: 13-40)]. All model's selected covariates were well balanced. The results remained robust to sensitivity analyses used to test the stability of the findings. CONCLUSIONS When delivered using a structured FFT algorithm, CPG shortened the hospital stay and help avoided admission to ICU, but it did not affect other relevant outcomes.
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Affiliation(s)
- Benjamin Djulbegovic
- Department of Computational & Quantitative Medicine, City of Hope, Beckman Research Institute, Duarte, California, USA.,Division of Health Analytics, Beckman Research Institute, Duarte, California, USA.,Evidence-Based Medicine & Comparative Effectiveness Research, Beckman Research Institute, Duarte, California, USA
| | - Iztok Hozo
- Department of Mathematics, Indiana University, Gary, Indiana, USA
| | - David Lizarraga
- Department of Computational & Quantitative Medicine, City of Hope, Beckman Research Institute, Duarte, California, USA.,Division of Health Analytics, Beckman Research Institute, Duarte, California, USA.,Evidence-Based Medicine & Comparative Effectiveness Research, Beckman Research Institute, Duarte, California, USA
| | - Joseph Thomas
- Rush University Medical Center (RUMC), Chicago, Illinois, USA.,Division of Hospital Medicine, Department of Hospital Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Michael Barbee
- Rush University Medical Center (RUMC), Chicago, Illinois, USA.,Division of Hospital Medicine, Department of Hospital Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Nupur Shah
- Rush University Medical Center (RUMC), Chicago, Illinois, USA.,Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Tyler Rubeor
- Rush University Medical Center (RUMC), Chicago, Illinois, USA
| | - Jordan Dale
- Houston Methodist Academic Institute, Houston, Texas, USA
| | - Jochen Reiser
- Rush University Medical Center (RUMC), Chicago, Illinois, USA.,Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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Djulbegovic B, Hozo I. Formulating Management Strategies Using Fast-and-Frugal Trees (A Decision Tool to Transform Clinical Practice Guidelines and Clinical Pathways into Decision Support at the Point of Care). Cancer Treat Res 2023; 189:67-75. [PMID: 37789161 DOI: 10.1007/978-3-031-37993-2_5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Clinical management is rarely based on the collection of one data item. Instead, it is typically characterized by the continuous collection and evaluation of clinical data (symptoms, signs, laboratory, imaging tests, etc.) to establish a platform for further management decisions.
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Affiliation(s)
- Benjamin Djulbegovic
- Hematology Stewardship Program, Division of Hematology/Oncology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Iztok Hozo
- Department of Mathematics, Indiana University Northwest, Gary, IN, USA
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10
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Abstract
Today, every country struggles to provide adequate health care to its citizens. Globally, an average of $8.3 trillion or 10% of gross domestic product (GDP) is annually spent on health services. In 2019, the USA spent nearly 18% ($3.2 trillion) of its GDP on health care, projected to reach $6.2 trillion by 2028.
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Affiliation(s)
- Benjamin Djulbegovic
- Hematology Stewardship Program, Division of Hematology/Oncology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Iztok Hozo
- Department of Mathematics, Indiana University Northwest, Gary, IN, USA
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11
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Piercy DL, Kreider KE, Coviello A, Patel YA, Thompson JA. Implementing Screening for Nonalcoholic Fatty Liver Disease in Endocrinology Clinics. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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12
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Ladbury C, Zarinshenas R, Semwal H, Tam A, Vaidehi N, Rodin AS, Liu A, Glaser S, Salgia R, Amini A. Utilization of model-agnostic explainable artificial intelligence frameworks in oncology: a narrative review. Transl Cancer Res 2022; 11:3853-3868. [PMID: 36388027 PMCID: PMC9641128 DOI: 10.21037/tcr-22-1626] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 09/07/2022] [Indexed: 11/25/2022]
Abstract
Background and Objective Machine learning (ML) models are increasingly being utilized in oncology research for use in the clinic. However, while more complicated models may provide improvements in predictive or prognostic power, a hurdle to their adoption are limits of model interpretability, wherein the inner workings can be perceived as a "black box". Explainable artificial intelligence (XAI) frameworks including Local Interpretable Model-agnostic Explanations (LIME) and SHapley Additive exPlanations (SHAP) are novel, model-agnostic approaches that aim to provide insight into the inner workings of the "black box" by producing quantitative visualizations of how model predictions are calculated. In doing so, XAI can transform complicated ML models into easily understandable charts and interpretable sets of rules, which can give providers with an intuitive understanding of the knowledge generated, thus facilitating the deployment of such models in routine clinical workflows. Methods We performed a comprehensive, non-systematic review of the latest literature to define use cases of model-agnostic XAI frameworks in oncologic research. The examined database was PubMed/MEDLINE. The last search was run on May 1, 2022. Key Content and Findings In this review, we identified several fields in oncology research where ML models and XAI were utilized to improve interpretability, including prognostication, diagnosis, radiomics, pathology, treatment selection, radiation treatment workflows, and epidemiology. Within these fields, XAI facilitates determination of feature importance in the overall model, visualization of relationships and/or interactions, evaluation of how individual predictions are produced, feature selection, identification of prognostic and/or predictive thresholds, and overall confidence in the models, among other benefits. These examples provide a basis for future work to expand on, which can facilitate adoption in the clinic when the complexity of such modeling would otherwise be prohibitive. Conclusions Model-agnostic XAI frameworks offer an intuitive and effective means of describing oncology ML models, with applications including prognostication and determination of optimal treatment regimens. Using such frameworks presents an opportunity to improve understanding of ML models, which is a critical step to their adoption in the clinic.
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Affiliation(s)
- Colton Ladbury
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Reza Zarinshenas
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Hemal Semwal
- Departments of Bioengineering and Integrated Biology and Physiology, University of California Los Angeles, Los Angeles, CA, USA
| | - Andrew Tam
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Nagarajan Vaidehi
- Department of Computational and Quantitative Medicine, City of Hope National Medical Center, Duarte, CA, USA
| | - Andrei S Rodin
- Department of Computational and Quantitative Medicine, City of Hope National Medical Center, Duarte, CA, USA
| | - An Liu
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Scott Glaser
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Ravi Salgia
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Arya Amini
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA
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Fusar-Poli P, Manchia M, Koutsouleris N, Leslie D, Woopen C, Calkins ME, Dunn M, Tourneau CL, Mannikko M, Mollema T, Oliver D, Rietschel M, Reininghaus EZ, Squassina A, Valmaggia L, Kessing LV, Vieta E, Correll CU, Arango C, Andreassen OA. Ethical considerations for precision psychiatry: A roadmap for research and clinical practice. Eur Neuropsychopharmacol 2022; 63:17-34. [PMID: 36041245 DOI: 10.1016/j.euroneuro.2022.08.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 07/04/2022] [Accepted: 08/05/2022] [Indexed: 12/14/2022]
Abstract
Precision psychiatry is an emerging field with transformative opportunities for mental health. However, the use of clinical prediction models carries unprecedented ethical challenges, which must be addressed before accessing the potential benefits of precision psychiatry. This critical review covers multidisciplinary areas, including psychiatry, ethics, statistics and machine-learning, healthcare and academia, as well as input from people with lived experience of mental disorders, their family, and carers. We aimed to identify core ethical considerations for precision psychiatry and mitigate concerns by designing a roadmap for research and clinical practice. We identified priorities: learning from somatic medicine; identifying precision psychiatry use cases; enhancing transparency and generalizability; fostering implementation; promoting mental health literacy; communicating risk estimates; data protection and privacy; and fostering the equitable distribution of mental health care. We hope this blueprint will advance research and practice and enable people with mental health problems to benefit from precision psychiatry.
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Affiliation(s)
- Paolo Fusar-Poli
- Early Psychosis: Interventions and Clinical-Detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK; South London and Maudsley NHS Foundation Trust, London, UK; Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.
| | - Mirko Manchia
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy; Unit of Clinical Psychiatry, University Hospital Agency of Cagliari, Cagliari, Italy; Department of Pharmacology, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | | | | | - Monica E Calkins
- Neurodevelopment and Psychosis Section and Lifespan Brain Institute of Penn/CHOP, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, USA
| | - Michael Dunn
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore
| | - Christophe Le Tourneau
- Institut Curie, Department of Drug Development and Innovation (D3i), INSERM U900 Research unit, Paris-Saclay University, France
| | - Miia Mannikko
- European Federation of Associations of Families of People with Mental Illness (EUFAMI), Leuven, Belgium
| | - Tineke Mollema
- Global Alliance of Mental Illness Advocacy Networks-Europe (GAMIAN), Brussels, Belgium
| | - Dominic Oliver
- Early Psychosis: Interventions and Clinical-Detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Marcella Rietschel
- Department of Genetic Epidemiology in Psychiatry, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Eva Z Reininghaus
- Department of Psychiatry and Psychotherapeutic Medicine, Medical University of Graz, Graz, Austria
| | - Alessio Squassina
- Section of Neuroscience and Clinical Pharmacology, Department of Biomedical Sciences, University of Cagliari, Italy
| | - Lucia Valmaggia
- South London and Maudsley NHS Foundation Trust, London, UK; Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Department of Psychiatry, KU Leuven, Belgium
| | - Lars Vedel Kessing
- Copenhagen Affective disorder Research Center (CADIC), Psychiatric Center Copenhagen, Denmark; Department of clinical Medicine, University of Copenhagen, Denmark
| | - Eduard Vieta
- Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Christoph U Correll
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA; Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA; Center for Psychiatric Neuroscience; The Feinstein Institutes for Medical Research, Manhasset, NY, USA; Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
| | - Celso Arango
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, Gregorio Marañón; Health Research Institute (IiGSM), School of Medicine, Universidad Complutense de Madrid; Biomedical Research Center for Mental Health (CIBERSAM), Madrid, Spain
| | - Ole A Andreassen
- NORMENT, Institute of Clinical Medicine, University of Oslo and Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
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14
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Koldeweij C, Appelbaum N, Rodriguez Gonzalvez C, Nijman J, Nijman R, Sinha R, Maconochie I, Clarke J. Mind the gap: Mapping variation between national and local clinical practice guidelines for acute paediatric asthma from the United Kingdom and the Netherlands. PLoS One 2022; 17:e0267445. [PMID: 35580117 PMCID: PMC9113591 DOI: 10.1371/journal.pone.0267445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 04/11/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Clinical practice guidelines (CPGs) aim to standardize clinical care. Increasingly, hospitals rely on locally produced guidelines alongside national guidance. This study examines variation between national and local CPGs, using the example of acute paediatric asthma guidance from the United Kingdom and the Netherlands. METHODS Fifteen British and Dutch local CPGs were collected with the matching national guidance for the management of acute asthma in children under 18 years old. The drug sequences, routes and methods of administration recommended for patients with severe asthma and the tone of recommendation across both types of CPGs were schematically represented. Deviations from national guidance were measured. Variation in recommended doses of intravenous salbutamol was examined. CPG quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II. RESULTS British and Dutch national CPGs differed in the recommended drug choices, sequences, routes and methods of administration for severe asthma. Dutch national guidance was more rigidly defined. Local British CPGs diverged from national guidance for 23% of their recommended interventions compared to 8% for Dutch local CPGs. Five British local guidelines and two Dutch local guidelines differed from national guidance for multiple treatment steps. Variation in second-line recommendations was greater than for first-line recommendations across local CPGs from both countries. Recommended starting doses for salbutamol infusions varied by more than tenfold. The quality of the sampled local CPGs was low across all AGREE II domains. CONCLUSIONS Local CPGs for the management of severe acute paediatric asthma featured substantial variation and frequently diverged from national guidance. Although limited to one condition, this study suggests that unmeasured variation across local CPGs may contribute to variation of care more broadly, with possible effects on healthcare quality.
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Affiliation(s)
- Charlotte Koldeweij
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Helix Centre for Design in Healthcare, Imperial College London, London, United Kingdom
| | - Nicholas Appelbaum
- Helix Centre for Design in Healthcare, Imperial College London, London, United Kingdom
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | | | - Joppe Nijman
- Department of Pediatric Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ruud Nijman
- Faculty of Medicine, Department of Infectious Diseases, Section of Paediatric Infectious Diseases, Imperial College London, London, United Kingdom
| | - Ruchi Sinha
- Department of Paediatric Intensive Care, Division of Women and Children’s Services, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Ian Maconochie
- Centre for Paediatrics and Child Health, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Jonathan Clarke
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Centre for Mathematics of Precision Healthcare, Department of Mathematics, Imperial College London, London, United Kingdom
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15
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Das S, Sil J. Managing Boundary Uncertainty in Diagnosing the Patients of Rural Area Using Fuzzy and Rough Set. JOURNAL OF HEALTHCARE INFORMATICS RESEARCH 2022; 6:1-47. [PMID: 35419512 PMCID: PMC8982726 DOI: 10.1007/s41666-021-00109-4] [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: 11/30/2020] [Revised: 08/18/2021] [Accepted: 09/27/2021] [Indexed: 11/26/2022]
Abstract
People of rural India often suffer from acute health conditions like diarrhea, flu, lung congestion, and anemia, but they are not receiving treatment even at primary level due to scarcity of doctors and health infrastructure in remote villages. Health workers are involved in diagnosing the patients based on the symptoms and physiological signs. However, due to inadequate domain knowledge, lack of expertise, and error in measuring the health data, uncertainty creeps in the decision space, resulting many false cases in predicting the diseases. The paper proposes an uncertainty management technique using fuzzy and rough set theory to diagnose the patients with minimum false-positive and false-negative cases. We use fuzzy variables with proper semantic to represent the vagueness of input data, appearing due to measurement error. We derive initial degree of belonging of each patient in two different disease class labels (YES/NO) using the fuzzified input data. Next, we apply rough set theory to manage uncertainty in diagnosing the diseases by learning approximations of the decision boundary between the two class labels. The optimum lower and upper approximation membership functions for each disease class label have been obtained using Non-dominated Sorting Genetic Algorithm-II (NSGA-II). Finally, using the proposed disease_similarity_factor, new patients are diagnosed precisely with 98% accuracy and minimum false cases.
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Affiliation(s)
- Sayan Das
- Department of Computer Science and Technology, Indian Institute of Engineering Science and Technology, Shibpur, Howrah, West Bengal India
| | - Jaya Sil
- Department of Computer Science and Technology, Indian Institute of Engineering Science and Technology, Shibpur, Howrah, West Bengal India
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16
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Mind the Differences: How Diagnoses and Hospital Characteristics Influence Coordination in Cancer Patient Pathways. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18168818. [PMID: 34444567 PMCID: PMC8394059 DOI: 10.3390/ijerph18168818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/12/2021] [Accepted: 08/18/2021] [Indexed: 11/16/2022]
Abstract
Integrated care pathway (ICP) is a prevailing concept in health care management including cancer care. Though substantial research has been conducted on ICPs knowledge is still deficient explaining how characteristics of diagnose, applied procedures, patient group and organizational context influence specific practicing of ICPs. We studied how coordination takes place in three cancer pathways in four Norwegian hospitals. We identified how core contextual variables of cancer pathways affect complexity and predictability of the performance of each pathway. Thus, we also point at differences in core preconditions for accomplishing coordination of the cancer pathways. In addition, the findings show that three different types of coordination dynamics are present in all three pathways to a divergent degree: programmed chains, consultative hubs and problem-solving webs. Pathway coordination also depends on hierarchical interaction. Lack of corresponding roles in the medical–professional and the administrative–institutional logics presents a challenge for coordination, both within and between hospitals. We recommend that further improvement of specific ICPs by paying attention to what should be standardized and what should be kept flexible, aligning semi-formal and formal structures to pathway processes and identify the professional cancer related background and management style required by the key-roles in pathway management.
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17
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Mugerauer R. Professional judgement in clinical practice (part 2): knowledge into practice. J Eval Clin Pract 2021; 27:603-611. [PMID: 33241613 DOI: 10.1111/jep.13514] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 10/27/2020] [Indexed: 12/16/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Though strong evidence-based medicine is assertive in its claims, an insufficient theoretical basis and patchwork of arguments provide a good case that rather than introducing a new paradigm, EBM is resisting a shift to actually revolutionary complexity theory and other emergent approaches. This refusal to pass beyond discredited positivism is manifest in strong EBM's unsuccessful attempts to continually modify its already inadequate previous modifications, as did the defenders of the Ptolemaic astronomical model who increased the number of circular epicycles until the entire epicycle-deferent system proved untenable. METHODS Narrative Review. RESULTS The analysis in Part 1 of this three part series showed epistemological confusion as strong EBM plays the discredited positivistic tradition out to the end, thus repeating in a medical sphere and vocabulary the major assumptions and inadequacies that have appeared in the trajectory of modern science. Paper 2 in this series examines application, attending to strong EBM's claim of direct transferability of EBM research findings to clinical settings and its assertion of epistemological normativity. EBM's contention that it provides the "only valid" approach to knowledge and action is questioned by analyzing the troubled story of proposed hierarchies of the quality of research findings (especially of RCTs, with other factors marginalized), which falsely identifies evaluating findings with operationally utilizing them in clinical recommendations and decision-making. Further, its claim of carrying over its normative guidelines to cover the ethical responsibilities of researchers and clinicians is questioned.
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Affiliation(s)
- Robert Mugerauer
- College of Built Environments, University of Washington, Seattle, Washington, USA
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18
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Trimarchi L, Caruso R, Magon G, Odone A, Arrigoni C. Clinical pathways and patient-related outcomes in hospital-based settings: a systematic review and meta-analysis of randomized controlled trials. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021093. [PMID: 33682818 PMCID: PMC7975936 DOI: 10.23750/abm.v92i1.10639] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 09/14/2020] [Indexed: 01/01/2023]
Abstract
Clinical pathways represent a multi-disciplinary approach to translate clinical practice guidelines into practical interventions. The literature from 2010 onward regarding the efficacy of adopting a clinical pathway on patient-related outcomes within the in-hospital setting has not been synthesized yet. For this reason, this systematic review and meta-analysis of randomized controlled trials aimed to critically synthesize the literature from 2010 onward about the efficacy of clinical pathways, compared with standard of care, on patient-related outcomes in different populations and to determine the effects of clinical pathways on patient outcomes. We searched PubMed, Scopus, CINAHL, and reference lists of the included studies. Two independent reviewers screened the 360 identified articles and selected fifteen eligible articles, which were evaluated for content and risk of bias. Eleven studies were finally included. Given the commonalities of the measured outcomes, a meta-analysis including eight studies was performed to evaluate the effect size of the associations between clinical pathways and quality of life (OR=1.472 [0.483–4.486]; p=0.496), and two meta-analyses, including four studies, were performed to evaluate the effect sizes of the associations between clinical pathways with satisfaction (OR=2.226 [0.868–5.708]; p=0.096) and length of stay (OR=0,585 [0.349–0.982]; p=0.042). Reduced length of stay appeared to be associated with clinical pathways, while it remains unclear whether adopting clinical pathways could improve levels of quality of life and satisfaction. More primary research is required to determine in specific populations the efficacy of clinical pathways on patient-related outcomes. (www.actabiomedica.it)
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Affiliation(s)
- Laura Trimarchi
- Division of Anaesthesiology and Intensive Care, European Institute of Oncology, Milan, Italy.
| | - Rosario Caruso
- Health Professions Research and Development Unit, IRCCS Policlinico San Donato, San Donato Milanese, Italy.
| | - Giorgio Magon
- Nursing office, European Institute of Oncology, Milan, Italy.
| | - Anna Odone
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy.
| | - Cristina Arrigoni
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy.
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Mæhle PM, Small Hanto IK, Smeland S. Practicing Integrated Care Pathways in Norwegian Hospitals: Coordination through Industrialized Standardization, Value Chains, and Quality Management or an Organizational Equivalent to Improvised Jazz Standards. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E9199. [PMID: 33317088 PMCID: PMC7764546 DOI: 10.3390/ijerph17249199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/20/2020] [Accepted: 12/04/2020] [Indexed: 11/26/2022]
Abstract
The goal of coordinating pathways for cancer patients through their diagnostic and treatment journey is often approached by borrowing strategies from traditional industries, including standardization, process redesign, and variation reduction. However, the usefulness of these strategies is sometimes limited in the face of the complexity and uncertainty that characterize these processes over time and the situation at both patient and institutional levels. We found this to be the case when we did an in-depth qualitative study of coordination processes in patient pathways for three diagnoses in four Norwegian hospitals. What allows these hospitals to accomplish coordination is supplementing standardization with improvisation. This improvisation is embedded in four types of emerging semi-formal structures: collegial communities, networks, boundary spanners, and physical proximity. The hierarchical higher administrative levels appear to have a limited ability to manage and support coordination of these emerging structures when needed. We claim that this can be explained by viewing line management as representative of an economic-administrative institutional logic while these emerging structures represent a medical-professional logic that privileges proximity to the variation and complexity in the situations. The challenge is then to find a way for emergent and formal structures to coexist.
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Affiliation(s)
- Per Magnus Mæhle
- Institute of Health and Society, Faculty of Medicine, University of Oslo, 0314 Oslo, Norway
- Comprehensive Cancer Centre, Division of Cancer Medicine, Oslo University Hospital, 0450 Oslo, Norway; (I.K.S.H.); (S.S.)
| | - Ingrid Kristine Small Hanto
- Comprehensive Cancer Centre, Division of Cancer Medicine, Oslo University Hospital, 0450 Oslo, Norway; (I.K.S.H.); (S.S.)
| | - Sigbjørn Smeland
- Comprehensive Cancer Centre, Division of Cancer Medicine, Oslo University Hospital, 0450 Oslo, Norway; (I.K.S.H.); (S.S.)
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, 0318 Oslo, Norway
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20
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Yao X, Jin YH, Djulbegovic B. Some thoughts on conducting and implementing clinical practice guidelines in a pandemic. Chin Med J (Engl) 2020; 134:910-912. [PMID: 33879754 PMCID: PMC8078361 DOI: 10.1097/cm9.0000000000001169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Indexed: 11/27/2022] Open
Affiliation(s)
- Xiaomei Yao
- Department of Health Research, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ying-Hui Jin
- Center for Evidence-based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Benjamin Djulbegovic
- Department of Supportive Care Medicine, Department of Hematology, City of Hope National Medical Center, Duarte, CA, USA; Program for Evidence-based Medicine and Comparative Effectiveness Research, Duarte, CA, USA
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21
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Salem A, Elamir H, Alfoudri H, Shamsah M, Abdelraheem S, Abdo I, Galal M, Ali L. Improving management of hospitalised patients with COVID-19: algorithms and tools for implementation and measurement. BMJ Open Qual 2020; 9:e001130. [PMID: 33199287 PMCID: PMC7670554 DOI: 10.1136/bmjoq-2020-001130] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/12/2020] [Accepted: 11/08/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic represents an unprecedented challenge to healthcare systems and nations across the world. Particularly challenging are the lack of agreed-upon management guidelines and variations in practice. Our hospital is a large, secondary-care government hospital in Kuwait, which has increased its capacity by approximately 28% to manage the care of patients with COVID-19. The surge in capacity has necessitated the redeployment of staff who are not well-trained to manage such conditions. There was a great need to develop a tool to help redeployed staff in decision-making for patients with COVID-19, a tool which could also be used for training. METHODS Based on the best available clinical knowledge and best practices, an eight member multidisciplinary group of clinical and quality experts undertook the development of a clinical algorithm-based toolkit to guide training and practice for the management of patients with COVID-19. The team followed Horabin and Lewis' seven-step approach in developing the algorithms and a five-step method in writing them. Moreover, we applied Rosenfeld et al's five points to each algorithm. RESULTS A set of seven clinical algorithms and one illustrative layout diagram were developed. The algorithms were augmented with documentation forms, data-collection online forms and spreadsheets and an indicators' reference sheet to guide implementation and performance measurement. The final version underwent several revisions and amendments prior to approval. CONCLUSIONS A large volume of published literature on the topic of COVID-19 pandemic was translated into a user-friendly, algorithm-based toolkit for the management of patients with COVID-19. This toolkit can be used for training and decision-making to improve the quality of care provided to patients with COVID-19.
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Affiliation(s)
- Ahmed Salem
- Anaesthesia and Intensive Care Department, Sabah Al Ahmad Urology Centre, Ministry of Health, Sabah, Kuwait
- Anaesthesia and Intensive Care Department, Faculty of Medicine, Banha University, Benha, Egypt
| | - Hossam Elamir
- Quality and Accreditation Directorate, Ministry of Health, Safat, Kuwait
| | - Huda Alfoudri
- Anaesthesia, Critical Care and Pain Management Department, Adan Hospital, Ministry of Health, Hadiya, Kuwait
| | - Mohammed Shamsah
- Anaesthesia, Critical Care and Pain Management Department, Adan Hospital, Ministry of Health, Hadiya, Kuwait
| | - Shams Abdelraheem
- Critical Care Department, Manchester University NHS Foundation Trust, Manchester, Greater Manchester, UK
| | - Ibtissam Abdo
- Quality and Accreditation Directorate, Ministry of Health, Safat, Kuwait
| | - Mohammad Galal
- Quality and Accreditation Directorate, Ministry of Health, Safat, Kuwait
| | - Lamiaa Ali
- Quality and Accreditation Directorate, Ministry of Health, Safat, Kuwait
- Public Health Department, Fayoum University Faculty of Medicine, Fayoum, Egypt
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22
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Abstract
SARS-CoV-19 PCR testing has a turn-around time that makes it impractical for real-time decision-making, and current point-of-care tests have limited sensitivity, with frequent false negatives. The study objective was to develop a clinical prediction rule to use with a point-of-care test to diagnose COVID-19 in symptomatic outpatients. A standardized clinical questionnaire was administered prior to SARS-CoV-2 PCR testing. Data was extracted by a physician blinded to the result status. Individual symptoms were combined into 326 unique clinical phenotypes. Multivariable logistic regression was used to identify independent predictors of COVID-19, from which a weighted clinical prediction rule was developed, to yield stratified likelihood ratios for varying scores. A retrospective cohort of 120 SARS-CoV-2-positive cases and 120 SARS-CoV-2-negative matched controls among symptomatic outpatients in a Connecticut HMO was used for rule development. A temporally distinct cohort of 40 cases was identified for validation of the rule. Clinical phenotypes independently associated with COVID-19 by multivariable logistic regression include loss of taste or smell (olfactory phenotype, 2 points) and fever and cough (febrile respiratory phenotype, 1 point). Wheeze or chest tightness (reactive airways phenotype, − 1 point) predicted non-COVID-19 respiratory viral infection. The AUC of the model was 0.736 (0.674–0.798). Application of a weighted C19 rule yielded likelihood ratios for COVID-19 diagnosis for varying scores ranging from LR 15.0 for 3 points to LR 0.1 for − 1 point. Using a Bayesian diagnostic approach, combining community prevalence with the evidence-based C19 rule to adjust pretest probability, clinicians can apply a point of care test with limited sensitivity across a range of clinical scenarios to differentiate COVID-19 infection from influenza and respiratory viral infection.
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23
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Salgia R, Mambetsariev I, Pharaon R, Fricke J, Baroz AR, Hozo I, Chen C, Koczywas M, Massarelli E, Reckamp K, Djulbegovic B. Evaluation of Omics-Based Strategies for the Management of Advanced Lung Cancer. JCO Oncol Pract 2020; 17:e257-e265. [PMID: 32639928 DOI: 10.1200/op.20.00117] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Omic-informed therapy is being used more frequently for patients with non-small-cell lung cancer (NSCLC) being treated on the basis of evidence-based decision-making. However, there is a lack of a standardized framework to evaluate those decisions and understand the association between omics-based management strategies and survival among patients. Therefore, we compared outcomes between patients with lung adenocarcinoma who received omics-driven targeted therapy versus patients who received standard therapeutic options. PATIENTS AND METHODS This was a retrospective study of patients with advanced NSCLC adenocarcinoma (N = 798) at City of Hope who received genomic sequencing at the behest of their treating oncologists. A thoracic oncology registry was used as a clinicogenomic database to track patient outcomes. RESULTS Of 798 individuals with advanced NSCLC (median age, 65 years [range, 22-99 years]; 60% white; 50% with a history of smoking), 662 patients (83%) had molecular testing and 439 (55%) received targeted therapy on the basis of the omic-data. A fast-and-frugal decision tree (FFT) model was developed to evaluate the impact of omics-based strategy on decision-making, progression-free survival (PFS), and overall survival (OS). We calculated that the overall positive predictive value of the entire FFT strategy for predicting decisions regarding the use of tyrosine kinase inhibitor-based targeted therapy was 88% and the negative predictive value was 96%. In an adjusted Cox regression analysis, there was a significant correlation with survival benefit with the FFT omics-driven therapeutic strategy for both PFS (hazard ratio [HR], 0.56; 95% CI, 0.42 to 0.74; P < .001) and OS (HR, 0.51; 95% CI, 0.36 to 0.71; P < .001) as compared with standard therapeutic options. CONCLUSION Among patients with advanced NSCLC who received care in the academic oncology setting, omics-driven therapy decisions directly informed treatment in patients and was correlated with better OS and PFS.
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Affiliation(s)
- Ravi Salgia
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA
| | - Isa Mambetsariev
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA
| | - Rebecca Pharaon
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA
| | - Jeremy Fricke
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA
| | - Angel Ray Baroz
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA
| | - Iztok Hozo
- Department of Mathematics, Indiana University Northwest, Gary, IN
| | - Chen Chen
- Applied AI and Data Science, City of Hope, Duarte, CA
| | - Marianna Koczywas
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA
| | - Erminia Massarelli
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA
| | - Karen Reckamp
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA.,Division of Medical Oncology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Benjamin Djulbegovic
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
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24
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Salgia R, Mambetsariev I, Tan T, Schwer A, Pearlstein DP, Chehabi H, Baroz A, Fricke J, Pharaon R, Romo H, Waddington T, Babikian R, Buck L, Kulkarni P, Cianfrocca M, Djulbegovic B, Pal SK. Complex Oncological Decision-Making Utilizing Fast-and-Frugal Trees in a Community Setting-Role of Academic and Hybrid Modeling. J Clin Med 2020; 9:E1884. [PMID: 32560187 PMCID: PMC7356888 DOI: 10.3390/jcm9061884] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 12/24/2022] Open
Abstract
Non-small cell lung cancer is a devastating disease and with the advent of targeted therapies and molecular testing, the decision-making process has become complex. While established guidelines and pathways offer some guidance, they are difficult to utilize in a busy community practice and are not always implemented in the community. The rationale of the study was to identify a cohort of patients with lung adenocarcinoma at a City of Hope community site (n = 11) and utilize their case studies to develop a decision-making framework utilizing fast-and-frugal tree (FFT) heuristics. Most patients had stage IV (N = 9, 81.8%) disease at the time of the first consultation. The most common symptoms at initial presentation were cough (N = 5, 45.5%), shortness of breath (N = 3, 27.2%), and weight loss (N = 3, 27.2%). The Eastern Cooperative Oncology Group (ECOG) performance status ranged from 0-1 in all patients in this study. Distribution of molecular drivers among the patients were as follows: EGFR (N = 5, 45.5%), KRAS (N = 2, 18.2%), ALK (N = 2, 18.2%), MET (N = 2, 18.2%), and RET (N = 1, 9.1%). Seven initial FFTs were developed for the various case scenarios, but ultimately the decisions were condensed into one FFT, a molecular stage IV FFT, that arrived at accurate decisions without sacrificing initial information. While these FFT decision trees may seem arbitrary to an experienced oncologist at an academic site, the simplicity of their utility is essential for community practice where patients often do not get molecular testing and are not assigned proper therapy.
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Affiliation(s)
- Ravi Salgia
- Department of Medical Oncology and Therapeutics Research, 1500 E Duarte Road, City of Hope National Medical Center, Duarte, CA 91010, USA; (I.M.); (T.T.); (A.B.); (J.F.); (R.P.); (H.R.); (R.B.); (L.B.); (P.K.); (M.C.); (S.K.P.)
| | - Isa Mambetsariev
- Department of Medical Oncology and Therapeutics Research, 1500 E Duarte Road, City of Hope National Medical Center, Duarte, CA 91010, USA; (I.M.); (T.T.); (A.B.); (J.F.); (R.P.); (H.R.); (R.B.); (L.B.); (P.K.); (M.C.); (S.K.P.)
| | - Tingting Tan
- Department of Medical Oncology and Therapeutics Research, 1500 E Duarte Road, City of Hope National Medical Center, Duarte, CA 91010, USA; (I.M.); (T.T.); (A.B.); (J.F.); (R.P.); (H.R.); (R.B.); (L.B.); (P.K.); (M.C.); (S.K.P.)
| | - Amanda Schwer
- Newport Diagnostic Center, Newport Beach, CA 92660, USA; (A.S.); (H.C.)
| | | | - Hazem Chehabi
- Newport Diagnostic Center, Newport Beach, CA 92660, USA; (A.S.); (H.C.)
| | - Angel Baroz
- Department of Medical Oncology and Therapeutics Research, 1500 E Duarte Road, City of Hope National Medical Center, Duarte, CA 91010, USA; (I.M.); (T.T.); (A.B.); (J.F.); (R.P.); (H.R.); (R.B.); (L.B.); (P.K.); (M.C.); (S.K.P.)
| | - Jeremy Fricke
- Department of Medical Oncology and Therapeutics Research, 1500 E Duarte Road, City of Hope National Medical Center, Duarte, CA 91010, USA; (I.M.); (T.T.); (A.B.); (J.F.); (R.P.); (H.R.); (R.B.); (L.B.); (P.K.); (M.C.); (S.K.P.)
| | - Rebecca Pharaon
- Department of Medical Oncology and Therapeutics Research, 1500 E Duarte Road, City of Hope National Medical Center, Duarte, CA 91010, USA; (I.M.); (T.T.); (A.B.); (J.F.); (R.P.); (H.R.); (R.B.); (L.B.); (P.K.); (M.C.); (S.K.P.)
| | - Hannah Romo
- Department of Medical Oncology and Therapeutics Research, 1500 E Duarte Road, City of Hope National Medical Center, Duarte, CA 91010, USA; (I.M.); (T.T.); (A.B.); (J.F.); (R.P.); (H.R.); (R.B.); (L.B.); (P.K.); (M.C.); (S.K.P.)
| | - Thomas Waddington
- Department of Medicine, City of Hope National Medical Center, Duarte, CA 91010, USA;
| | - Razmig Babikian
- Department of Medical Oncology and Therapeutics Research, 1500 E Duarte Road, City of Hope National Medical Center, Duarte, CA 91010, USA; (I.M.); (T.T.); (A.B.); (J.F.); (R.P.); (H.R.); (R.B.); (L.B.); (P.K.); (M.C.); (S.K.P.)
| | - Linda Buck
- Department of Medical Oncology and Therapeutics Research, 1500 E Duarte Road, City of Hope National Medical Center, Duarte, CA 91010, USA; (I.M.); (T.T.); (A.B.); (J.F.); (R.P.); (H.R.); (R.B.); (L.B.); (P.K.); (M.C.); (S.K.P.)
| | - Prakash Kulkarni
- Department of Medical Oncology and Therapeutics Research, 1500 E Duarte Road, City of Hope National Medical Center, Duarte, CA 91010, USA; (I.M.); (T.T.); (A.B.); (J.F.); (R.P.); (H.R.); (R.B.); (L.B.); (P.K.); (M.C.); (S.K.P.)
| | - Mary Cianfrocca
- Department of Medical Oncology and Therapeutics Research, 1500 E Duarte Road, City of Hope National Medical Center, Duarte, CA 91010, USA; (I.M.); (T.T.); (A.B.); (J.F.); (R.P.); (H.R.); (R.B.); (L.B.); (P.K.); (M.C.); (S.K.P.)
| | - Benjamin Djulbegovic
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA 91010, USA;
| | - Sumanta K. Pal
- Department of Medical Oncology and Therapeutics Research, 1500 E Duarte Road, City of Hope National Medical Center, Duarte, CA 91010, USA; (I.M.); (T.T.); (A.B.); (J.F.); (R.P.); (H.R.); (R.B.); (L.B.); (P.K.); (M.C.); (S.K.P.)
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25
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Djulbegovic B, Bennett CL, Guyatt G. A unifying framework for improving health care. J Eval Clin Pract 2019; 25:358-362. [PMID: 30461136 DOI: 10.1111/jep.13066] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/12/2018] [Accepted: 10/18/2018] [Indexed: 12/30/2022]
Abstract
The quality health care around world is suboptimal. To improve the quality of contemporary health care delivery, advocates have proposed a number of scientific and technical initiatives. All these initiatives, however, have arisen and continue to operate in siloes, resulting in confusion and incommensurability among those concerned with health care improvement. Participants in the quality improvement (QI) space typically stress their own, often narrow, perspective, failing to place QI in context or to acknowledge other approaches. In order to improve delivery of health care, the following is required: Provide a unifying framework for improving health care. We argue this is best done under a Health System Science (HSS) framework but with full understanding that the fundamental principles of HSS are rooted in evidence-based medicine (EBM) and decision sciences. Understand that QI initiatives are fundamentally local activities. Hence, incentivizing bottom-up, local QI initiatives would improve health care delivery to a far greater extent than the current top-down initiatives undertaken in a response to various regulatory mandates. Akin to the "Choosing Wisely" initiative, which challenged professional societies, each institution should identify (a) the extent to which its practices are evidence-based and (b) the top 5 health care practices or interventions that, at a given institution, represent overuse, underuse, or misuse/error or undermine clinicians' efforts to deliver kind and empathic care. Providing a framework that can unify the current patchwork of the initiatives would help create a common basis to help align all the existing QI efforts. In addition, thinking small (at local level) may lead to health care quality improvements that national initiatives (thinking big), focused on regulation, competition, or legal requirements, have failed to achieve.
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Affiliation(s)
- Benjamin Djulbegovic
- Department of Supportive Care Medicine, City of Hope National Medical Center, Duarte, CA, USA.,Department of Hematology, City of Hope National Medical Center, Duarte, CA, USA
| | - Charles L Bennett
- South Carolina Center of Economic Excellence for Medication Safety, College of Pharmacy, University of South Carolina, Columbia, SC, USA
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26
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Djulbegovic B, Hozo I, Mayrhofer T, van den Ende J, Guyatt G. The threshold model revisited. J Eval Clin Pract 2019; 25:186-195. [PMID: 30575227 PMCID: PMC6590161 DOI: 10.1111/jep.13091] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 11/24/2018] [Accepted: 11/26/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND The threshold model represents one of the most significant advances in the field of medical decision-making, yet it often does not apply to the most common class of clinical problems, which include health outcomes as a part of definition of disease. In addition, the original threshold model did not take a decision-maker's values and preferences explicitly into account. METHODS We reformulated the threshold model by (1) applying it to those clinical scenarios, which define disease according to outcomes that treatment is designed to affect, (2) taking into account a decision-maker's values. RESULTS We showed that when outcomes (eg, morbidity) are integral part of definition of disease, the classic threshold model does not apply (as this leads to double counting of outcomes in the probabilities and utilities branches of the model). To avoid double counting, the model can be appropriately analysed by assuming diagnosis is certain (P = 1). This results in deriving a different threshold-the threshold for outcome of disease (Mt ) instead of threshold for probability of disease (Pt ) above which benefits of treatment outweigh its harms. We found that Mt ≤ Pt , which may explain differences between normative models and actual behaviour in practice. When a decision-maker values outcomes related to benefit and harms differently, the new threshold model generates decision thresholds that could be descriptively more accurate. CONCLUSIONS Calculation of the threshold depends on careful disease versus utility definitions and a decision-maker's values and preferences.
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Affiliation(s)
- Benjamin Djulbegovic
- Department of Supportive Care Medicine, Department of Hematology, City of Hope National Medical Center, Duarte, California, USA.,Program for Evidence-based Medicine and Comparative Effectiveness Research, Duarte, California, USA
| | - Iztok Hozo
- Department of Mathematics and Actuarial Science, Indiana University Northwest, Gary, Indiana, USA
| | - Thomas Mayrhofer
- Cardiac MR PET CT Program, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts, USA
| | - Jef van den Ende
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
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27
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Loughlin M, Mercuri M, Pârvan A, Copeland SM, Tonelli M, Buetow S. Treating real people: Science and humanity. J Eval Clin Pract 2018; 24:919-929. [PMID: 30159956 DOI: 10.1111/jep.13024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 07/25/2018] [Indexed: 12/16/2022]
Abstract
Something important is happening in applied, interdisciplinary research, particularly in the field of applied health research. The vast array of papers in this edition are evidence of a broad change in thinking across an impressive range of practice and academic areas. The problems of complexity, the rise of chronic conditions, overdiagnosis, co-morbidity, and multi-morbidity are serious and challenging, but we are rising to that challenge. Key conceptions regarding science, evidence, disease, clinical judgement, and health and social care are being revised and their relationships reconsidered: Boundaries are indeed being redrawn; reasoning is being made "fit for practice." Ideas like "person-centred care" are no longer phrases with potential to be helpful in some yet-to-be-clarified way: Theorists and practitioners are working in collaboration to give them substantive import and application.
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Affiliation(s)
| | - Mathew Mercuri
- Division of Emergency Medicine, McMaster University, Hamilton, Canada
| | - Alexandra Pârvan
- Department of Psychology and Communication Sciences, University of Piteşti, Piteşti, Romania
| | | | | | - Stephen Buetow
- Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand
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28
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Wyer PC. From MARS to MAGIC: The remarkable journey through time and space of the Grading of Recommendations Assessment, Development and Evaluation initiative. J Eval Clin Pract 2018; 24:1191-1202. [PMID: 30109760 DOI: 10.1111/jep.13019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 07/19/2018] [Indexed: 02/05/2023]
Abstract
For over 30 years, "evidence-based" clinical guidelines remained entrenched in an oversimplified, design-based, framework for rating the strength of evidence supporting clinical recommendations. The approach frequently equated the rating of evidence with that of the recommendations themselves. "Grading Recommendations Assessment, Development and Evaluation (GRADE)" has emerged as a proposed antidote to obsolete guideline methodology. GRADE sponsors and collaborators are in the process of attempting to amplify and extend the framework to encompass implementation and adaptation of guidelines, above and beyond the evaluation and rating of clinical research. Alternative schemes and models for such extensions are beginning to appear. This commentary reviews the strengths and weaknesses of GRADE with reference to other recent critiques. It considers the GRADE Working Group's "evidence-to-decision" extension of the evidence rating framework, together with proposed alternatives. It identifies pitfalls of the GRADE system's cooptation of relational processes necessary to the interpretation and uptake of recommendations that properly belong to end-users. It also identifies dangers inherent in blurring important boundaries between clinical and policy applications of guidelines. Finally, it addresses criticisms regarding the lack of a theoretical framework supporting the different facets of the GRADE approach and proposes a social constructivist orientation to clinical guideline development and use. Recommendations are offered to potential guideline developers and users regarding how to draw upon the strengths of the GRADE framework without succumbing to its pitfalls.
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Affiliation(s)
- Peter C Wyer
- Columbia University Medical Center, New York, New York
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29
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Mercuri M. How do we know if a clinical practice guideline is good? A response to Djulbegovic and colleagues' use of fast-and-frugal decision trees to improve clinical care strategies. J Eval Clin Pract 2018; 24:1255-1258. [PMID: 29665247 DOI: 10.1111/jep.12928] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 03/16/2018] [Indexed: 11/26/2022]
Abstract
Clinical practice guidelines (CPGs) and clinical pathways have become important tools for improving the uptake of evidence-based care. Where CPGs are good, adherence to the recommendations within is thought to result in improved patient outcomes. However, the usefulness of such tools for improving patient important outcomes depends both on adherence to the guideline and whether or not the CPG in question is good. This begs the question of what it is that makes a CPG good? In this issue of the Journal, Djulbegovic and colleagues offer a theory to help guide the development of CPGs. The "fast-and-frugal tree" (FFT) heuristic theory is purported to provide the theoretical structure needed to quantitatively assess clinical guidelines in practice, something that the lack of theory to guide CPG development has precluded. In this paper, I examine the role of FFTs in providing an adequate theoretical framework for developing CPGs. In my view, positioning guideline development within the FFT framework may help with problems related to adherence. However, I believe that FTTs fall short in providing panel members with the theoretical basis needed to justify which factors should be considered when developing a CPG, how information on those factors derived from research studies should be interpreted, and how those factors should be integrated into the recommendation.
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Affiliation(s)
- Mathew Mercuri
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Canada.,Institute for the History and Philosophy of Science and Technology, University of Toronto, Toronto, Canada.,African Centre for Epistemology and Philosophy of Science, University of Johannesburg, Auckland Park, South Africa
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30
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Mercuri M, Gafni A. The evolution of GRADE (part 1): Is there a theoretical and/or empirical basis for the GRADE framework? J Eval Clin Pract 2018; 24:1203-1210. [PMID: 30009394 DOI: 10.1111/jep.12998] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 06/27/2018] [Indexed: 11/27/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework has been presented as the best method available for developing clinical recommendations. GRADE has undergone a series of modifications. Here, we present the first part of a three article series examining the evolution of GRADE. Our purpose is to explore if (and if so, how) GRADE provides: (1) a justification (ie, theoretical and/or empirical) for why the criteria/components under consideration in the system are included (and other factors excluded), as well as why some criteria/components where added/modified in the evolution process, (2) clear and functional (ie, how to operationalize them) definitions of the included criteria/components, and (3) instruction and justification for how all the criteria/components are to be integrated when determining a recommendation. In part 1 of the series, we examine the first two versions of GRADE. METHODS Narrative review. RESULTS The justification scheme that sustains GRADE is not articulated in the first two versions of the framework. Why some criteria/components were included, and others excluded, is not justified theoretically nor is empirical support provided to suggest that the framework as presented includes that which is needed to produce valid recommendations. The first two versions of GRADE show a lack of clear instruction on how to operationalize the criteria for assessing the quality of evidence and the components for making a recommendation (including how to integrate the criteria/components at each step), which leaves substantial room for judgement on the part of the user of GRADE for guideline development. CONCLUSIONS This article revealed an absence of a justification (theoretical and/or empirical) to support important aspects of the GRADE framework, as well as a lack of clear instruction on how to operationalize the criteria and components in the framework. These issues limit one's ability to scientifically assess the appropriateness of GRADE for determining clinical recommendations.
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Affiliation(s)
- Mathew Mercuri
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada.,Institute for the History and Philosophy of Science and Technology, University of Toronto, Toronto, ON, Canada.,African Centre for Epistemology and Philosophy of Science, University of Johannesburg, Auckland Park, South Africa
| | - Amiram Gafni
- Centre for Health Economics and Policy Analysis, Department of Health Research Methods, Evaluation and Impact (formerly, Clinical Epidemiology and Biostatistics), McMaster University, Hamilton, ON, Canada
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Upshur REG. Fast and frugal decision trees: How can the patient come last in a patient-centred world? J Eval Clin Pract 2018; 24:1259-1261. [PMID: 29927032 DOI: 10.1111/jep.12969] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 05/21/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Ross E G Upshur
- Dalla Lana School of Public Health, Division of Clinical Public Health, Toronto, ON, Canada.,Bridgepoint Collaboratory for Research and Innovation, Toronto, ON, Canada.,Lunenfeld Tanenbaum Research Institute, Sinai Health Systems, Toronto, ON, Canada.,University of Toronto, Department of Family and Community Medicine and Dalla Lana School of Public Health, Toronto, ON, Canada
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32
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Mambetsariev I, Pharaon R, Nam A, Knopf K, Djulbegovic B, Villaflor VM, Vokes EE, Salgia R. Heuristic value-based framework for lung cancer decision-making. Oncotarget 2018; 9:29877-29891. [PMID: 30042820 PMCID: PMC6057456 DOI: 10.18632/oncotarget.25643] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 06/04/2018] [Indexed: 11/25/2022] Open
Abstract
Heuristics and the application of fast-and-frugal trees may play a role in establishing a clinical decision-making framework for value-based oncology. We determined whether clinical decision-making in oncology can be structured heuristically based on the timeline of the patient's treatment, clinical intuition, and evidence-based medicine. A group of 20 patients with advanced non-small cell lung cancer (NSCLC) were enrolled into the study for extensive treatment analysis and sequential decision-making. The extensive clinical and genomic data allowed us to evaluate the methodology and efficacy of fast-and-frugal trees as a way to quantify clinical decision-making. The results of the small cohort will be used to further advance the heuristic framework as a way of evaluating a large number of patients within registries. Among the cohort whose data was analyzed, substitution and amplification mutations occurred most frequently. The top five most prevalent genomic alterations were TP53 (45%), ALK (40%), LRP1B (30%), CDKN2A (25%), and MYC (25%). These 20 cases were analyzed by this clinical decision-making process and separated into two distinctions: 10 straightforward cases that represented a clearer decision-making path and 10 complex cases that represented a more intricate treatment pathway. The myriad of information from each case and their distinct pathways was applied to create the foundation of a framework for lung cancer decision-making as an aid for oncologists. In late-stage lung cancer patients, the fast-and-frugal heuristics can be utilized as a strategy of quantifying proper decision-making with limited information.
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Affiliation(s)
- Isa Mambetsariev
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA, USA
| | - Rebecca Pharaon
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA, USA
| | - Arin Nam
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA, USA
| | - Kevin Knopf
- California Pacific Medical Center Research Institute, San Francisco, CA, USA
| | | | - Victoria M. Villaflor
- Department of Medicine (Hematology and Oncology), Northwestern University, Chicago, IL, USA
| | | | - Ravi Salgia
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA, USA
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