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Rodríguez-Perálvarez ML, de la Rosa G, Gómez-Orellana AM, Aguilera MV, Pascual Vicente T, Pereira S, Ortiz ML, Pagano G, Suarez F, González Grande R, Cachero A, Tomé S, Barreales M, Martín Mateos R, Pascual S, Romero M, Bilbao I, Alonso Martín C, Otón E, González Diéguez L, Espinosa MD, Arias Milla A, Blanco Fernández G, Lorente S, Cuadrado Lavín A, Redín García A, Sánchez Cano C, Cepeda-Franco C, Pons JA, Colmenero J, Guijo-Rubio D, Otero A, Amador Navarrete A, Romero Moreno S, Rodríguez Soler M, Hervás Martínez C, Gastaca M. GEMA-Na and MELD 3.0 severity scores to address sex disparities for accessing liver transplantation: a nationwide retrospective cohort study. EClinicalMedicine 2024; 74:102737. [PMID: 39114271 PMCID: PMC11304699 DOI: 10.1016/j.eclinm.2024.102737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 06/24/2024] [Accepted: 07/01/2024] [Indexed: 08/10/2024] Open
Abstract
Background The Gender-Equity Model for liver Allocation corrected by serum sodium (GEMA-Na) and the Model for End-stage Liver Disease 3.0 (MELD 3.0) could amend sex disparities for accessing liver transplantation (LT). We aimed to assess these inequities in Spain and to compare the performance of GEMA-Na and MELD 3.0. Methods Nationwide cohort study including adult patients listed for a first elective LT (January 2016-December 2021). The primary outcome was mortality or delisting for sickness within the first 90 days. Independent predictors of the primary outcome were evaluated using multivariate Cox's regression with adjusted relative risks (RR) and 95% confidence intervals (95% CI). The discrimination of GEMA-Na and MELD 3.0was assessed using Harrell c-statistics (Hc). Findings The study included 6071 patients (4697 men and 1374 women). Mortality or delisting for clinical deterioration occurred in 286 patients at 90 days (4.7%). Women had reduced access to LT (83.7% vs. 85.9%; p = 0.037) and increased risk of mortality or delisting for sickness at 90 days (adjusted RR = 1.57 [95% CI 1.09-2.28]; p = 0.017). Female sex remained as an independent risk factor when using MELD or MELD-Na but lost its significance in the presence of GEMA-Na or MELD 3.0. Among patients included for reasons other than tumours (n = 3606; 59.4%), GEMA-Na had Hc = 0.753 (95% CI 0.715-0.792), which was higher than MELD 3.0 (Hc = 0.726 [95% CI 0.686-0.767; p = 0.001), showing both models adequate calibration. Interpretation GEMA-Na and MELD 3.0 might correct sex disparities for accessing LT, but GEMA-Na provides more accurate predictions of waiting list outcomes and could be considered the standard of care for waiting list prioritization. Funding Instituto de Salud Carlos III, Agencia Estatal de Investigación (Spain), and European Union.
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Affiliation(s)
- Manuel Luis Rodríguez-Perálvarez
- Department of Hepatology and Liver Transplantation, Hospital Universitario Reina Sofía, IMIBIC, Avda. Menéndez Pidal s/n, 14014, Córdoba, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Monforte de Lemos 3-5, 28029, Madrid, Spain
| | - Gloria de la Rosa
- Organización Nacional de Trasplantes (ONT), Sinesio Delgado, 8, Fuencarral-El Pardo, 28029, Madrid, Spain
| | - Antonio Manuel Gómez-Orellana
- Department of Computer Science and Numerical Analysis, Universidad de Córdoba, Escuela Politécnica Superior de Córdoba, IMIBIC, Campus Universitario de Rabanales, Albert Einstein Building, Ctra. N-IV, Km. 396, 14071, Córdoba, Spain
| | - María Victoria Aguilera
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Monforte de Lemos 3-5, 28029, Madrid, Spain
- Department of Hepatology and Liver Transplantation, Hospital La Fe e Instituto de Investigación sanitaria La Fe, Avenida de Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Teresa Pascual Vicente
- Department of HPB surgery and Liver Transplantation, Hospital Universitario de Cruces, Plaza de Cruces, S/N, 48903, Barakaldo, Bilbao, Spain
| | - Sheila Pereira
- Department of HPB surgery and Liver Transplantation, Hospital Virgen del Rocío, Av. Manuel Siurot, s/n, 41013, Sevilla, Spain
| | - María Luisa Ortiz
- Department of Hepatology and Liver Transplantation, Hospital Universitario Virgen Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120, Murcia, Spain
| | - Giulia Pagano
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Monforte de Lemos 3-5, 28029, Madrid, Spain
- Department of Hepatology and Liver Transplantation, Hospital Clinic, IDIBAPS, C/ Villarroel, 170, 08036, Barcelona, Spain
| | - Francisco Suarez
- Department of Hepatology and Liver Transplantation, Centro Hospitalario Universitario de A Coruña, Jubias De Arriba 82, 15006, A Coruña, Spain
| | - Rocío González Grande
- Department of Hepatology and Liver Transplantation, Hospital Regional Universitario de Málaga, Avenida Carlos de Haya, s/n, 29001, Málaga, Spain
| | - Alba Cachero
- Department of Liver Transplantation, Hospital Universitario de Bellvitge, Carrer De La Feixa Llarga, S/n, 08907, Hospitalet De Llobregat, Spain
| | - Santiago Tomé
- Department of Liver Transplantation, Centro Hospitalario Universitario de Santiago, Calle da choupana, 15706, Santiago de Compostela, Spain
| | - Mónica Barreales
- Department of Hepatology and Liver Transplantation, Hospital Universitario 12 de Octubre, Av de Córdoba, s/n, 28041, Madrid, Spain
| | - Rosa Martín Mateos
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Monforte de Lemos 3-5, 28029, Madrid, Spain
- Department of Liver Transplantation, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, Calle de Antoniorrobles, 1, 28034, Madrid, Spain
| | - Sonia Pascual
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Monforte de Lemos 3-5, 28029, Madrid, Spain
- Department of Hepatology and Liver Transplantation, Hospital General Universitario Dr. Balmis de Alicante, ISABIAL, Av. Pintor Baeza, 12, 03010, Alicante, Spain
| | - Mario Romero
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Monforte de Lemos 3-5, 28029, Madrid, Spain
- Department of Hepatology and Liver Transplantation, Hospital General Universitario e Instituto de Investigación Biomédica Gregorio Marañón, Calle Doctor Esquerdo, 46, 28007, Madrid, Spain
| | - Itxarone Bilbao
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Monforte de Lemos 3-5, 28029, Madrid, Spain
- Department of Liver Transplantation, Hospital Universitario Vall d’Hebron, VHIR, Pg.de la Vall d'Hebron 119, Barcelona, Spain
| | - Carmen Alonso Martín
- Department of Hepatology and Liver Transplantation, Hospital Rio Hortega, Calle La Dulzaina, 2, 47012, Valladolid, Spain
| | - Elena Otón
- Department of Hepatology and Liver Transplantation, Hospital Virgen de la Candelaria, Carretera Del Rosario, 145, 38010, Santa Cruz de Tenerife, Spain
| | - Luisa González Diéguez
- Department of Hepatology and Liver Transplantation, Hospital Universitario Central de Asturias, Avenida de Roma, s/n, 33011, Oviedo, Spain
| | - María Dolores Espinosa
- Department of Hepatology and Liver Transplantation, Hospital Virgen de las Nieves, Avenida de las Fuerzas Armadas, 2, 18014, Granada, Spain
| | - Ana Arias Milla
- Department of Hepatology and Liver Transplantation, Hospital Universitario Puerta de Hierro, Calle Manuel de Falla, 1, 28222, Madrid, Spain
| | - Gerardo Blanco Fernández
- Department of Liver Transplantation, Hospital Universitario de Badajoz, Avenida de Elvas s/n, 06071, Badajoz, Spain
| | - Sara Lorente
- Department of Hepatology and Liver Transplantation, Hospital Universitario Lozano Blesa, Instituto de Investigaciones Sanitarias de Aragón (IIS Aragón), Avenida San Juan Bosco, 15, 50009, Zaragoza, Spain
| | - Antonio Cuadrado Lavín
- Department of Hepatology and Liver Transplantation, Hospital Universitario Marqués de Valdecilla, IDIVAL, Avenida Valdecilla, 25, 39008, Santander, Spain
| | - Amaya Redín García
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Monforte de Lemos 3-5, 28029, Madrid, Spain
- Department of Hepatology, HPB surgery and Liver Transplantation, Clínica Universidad de Navarra, IdiSNA, Avda. Pío XII, 36, 31008, Pamplona, Spain
| | - Clara Sánchez Cano
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Monforte de Lemos 3-5, 28029, Madrid, Spain
- Department of Hepatology and Liver Transplantation, Hospital La Fe e Instituto de Investigación sanitaria La Fe, Avenida de Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Carmen Cepeda-Franco
- Department of HPB surgery and Liver Transplantation, Hospital Virgen del Rocío, Av. Manuel Siurot, s/n, 41013, Sevilla, Spain
| | - José Antonio Pons
- Department of Hepatology and Liver Transplantation, Hospital Universitario Virgen Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120, Murcia, Spain
| | - Jordi Colmenero
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Monforte de Lemos 3-5, 28029, Madrid, Spain
- Department of Hepatology and Liver Transplantation, Hospital Clinic, IDIBAPS, C/ Villarroel, 170, 08036, Barcelona, Spain
| | - David Guijo-Rubio
- Department of Computer Science and Numerical Analysis, Universidad de Córdoba, Escuela Politécnica Superior de Córdoba, IMIBIC, Campus Universitario de Rabanales, Albert Einstein Building, Ctra. N-IV, Km. 396, 14071, Córdoba, Spain
- Department of Signal Processing and Communications, Universidad de Alcalá, Plaza De San Diego, S/n, 28801, Alcalá De Henares, Madrid, Spain
| | - Alejandra Otero
- Department of Hepatology and Liver Transplantation, Centro Hospitalario Universitario de A Coruña, Jubias De Arriba 82, 15006, A Coruña, Spain
| | - Alberto Amador Navarrete
- Department of Liver Transplantation, Hospital Universitario de Bellvitge, Carrer De La Feixa Llarga, S/n, 08907, Hospitalet De Llobregat, Spain
| | - Sarai Romero Moreno
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Monforte de Lemos 3-5, 28029, Madrid, Spain
- Department of Hepatology and Liver Transplantation, Hospital La Fe e Instituto de Investigación sanitaria La Fe, Avenida de Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - María Rodríguez Soler
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Monforte de Lemos 3-5, 28029, Madrid, Spain
- Department of Hepatology and Liver Transplantation, Hospital General Universitario Dr. Balmis de Alicante, ISABIAL, Av. Pintor Baeza, 12, 03010, Alicante, Spain
| | - César Hervás Martínez
- Department of Computer Science and Numerical Analysis, Universidad de Córdoba, Escuela Politécnica Superior de Córdoba, IMIBIC, Campus Universitario de Rabanales, Albert Einstein Building, Ctra. N-IV, Km. 396, 14071, Córdoba, Spain
| | - Mikel Gastaca
- Department of HPB surgery and Liver Transplantation, Hospital Universitario de Cruces, Plaza de Cruces, S/N, 48903, Barakaldo, Bilbao, Spain
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Riley RD, Snell KIE, Archer L, Ensor J, Debray TPA, van Calster B, van Smeden M, Collins GS. Evaluation of clinical prediction models (part 3): calculating the sample size required for an external validation study. BMJ 2024; 384:e074821. [PMID: 38253388 DOI: 10.1136/bmj-2023-074821] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Affiliation(s)
- Richard D Riley
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK
| | - Kym I E Snell
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK
| | - Lucinda Archer
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK
| | - Joie Ensor
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK
| | - Thomas P A Debray
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands
| | - Ben van Calster
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, Netherlands
| | - Maarten van Smeden
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Kong L, Yang M, Wan Z, Wang L. Cohort size required for prognostic genes analysis of stage II/III esophageal squamous cell carcinoma. Pathol Oncol Res 2023; 29:1610909. [PMID: 36825282 PMCID: PMC9941191 DOI: 10.3389/pore.2023.1610909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 01/26/2023] [Indexed: 02/10/2023]
Abstract
Background: Few overlaps between prognostic biomarkers are observed among different independently performed genomic studies of esophageal squamous cell carcinoma (ESCC). One of the reasons for this is the insufficient cohort size. How many cases are needed to prognostic genes analysis in ESCC? Methods: Here, based on 387 stage II/III ESCC cases analyzed by whole-genome sequencing from one single center, effects of cohort size on prognostic genes analysis were investigated. Prognostic genes analysis was performed in 100 replicates at each cohort size level using a random resampling method. Results: The number of prognostic genes followed a power-law increase with cohort size in ESCC patients with stage II and stage III, with exponents of 2.27 and 2.25, respectively. Power-law curves with increasing events number were also observed in stage II and III ESCC, respectively, and they almost overlapped. The probability of obtaining statistically significant prognostic genes shows a logistic cumulative distribution function with respect to cohort size. To achieve a 100% probability of obtaining statistically significant prognostic genes, the minimum cohort sizes required in stage II and III ESCC were approximately 95 and 60, respectively, corresponding to a number of outcome events of 33 and 36, respectively. Conclusion: In summary, the number of prognostic genes follows a power-law growth with the cohort size or events number in ESCC. The minimum events number required to achieve a 100% probability of obtaining a statistically significant prognostic gene is approximately 35.
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Affiliation(s)
- Linghong Kong
- Department of Pathology, Beijing Chuiyangliu Hospital, Beijing, China
| | - Ming Yang
- Hepato-Pancreato-Biliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Zhiyi Wan
- Department of Pathology, Beijing Chuiyangliu Hospital, Beijing, China
| | - Lining Wang
- Department of Pathology, Beijing Chuiyangliu Hospital, Beijing, China,*Correspondence: Lining Wang,
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Riley RD, Collins GS, Ensor J, Archer L, Booth S, Mozumder SI, Rutherford MJ, van Smeden M, Lambert PC, Snell KIE. Minimum sample size calculations for external validation of a clinical prediction model with a time-to-event outcome. Stat Med 2022; 41:1280-1295. [PMID: 34915593 DOI: 10.1002/sim.9275] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 11/15/2021] [Accepted: 11/16/2021] [Indexed: 12/23/2022]
Abstract
Previous articles in Statistics in Medicine describe how to calculate the sample size required for external validation of prediction models with continuous and binary outcomes. The minimum sample size criteria aim to ensure precise estimation of key measures of a model's predictive performance, including measures of calibration, discrimination, and net benefit. Here, we extend the sample size guidance to prediction models with a time-to-event (survival) outcome, to cover external validation in datasets containing censoring. A simulation-based framework is proposed, which calculates the sample size required to target a particular confidence interval width for the calibration slope measuring the agreement between predicted risks (from the model) and observed risks (derived using pseudo-observations to account for censoring) on the log cumulative hazard scale. Precise estimation of calibration curves, discrimination, and net-benefit can also be checked in this framework. The process requires assumptions about the validation population in terms of the (i) distribution of the model's linear predictor and (ii) event and censoring distributions. Existing information can inform this; in particular, the linear predictor distribution can be approximated using the C-index or Royston's D statistic from the model development article, together with the overall event risk. We demonstrate how the approach can be used to calculate the sample size required to validate a prediction model for recurrent venous thromboembolism. Ideally the sample size should ensure precise calibration across the entire range of predicted risks, but must at least ensure adequate precision in regions important for clinical decision-making. Stata and R code are provided.
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Affiliation(s)
- Richard D Riley
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Joie Ensor
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
| | - Lucinda Archer
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
| | - Sarah Booth
- Biostatistics Research Group, Department of Health Sciences, George Davies Centre, University of Leicester, Leicester, UK
| | - Sarwar I Mozumder
- Biostatistics Research Group, Department of Health Sciences, George Davies Centre, University of Leicester, Leicester, UK
| | - Mark J Rutherford
- Biostatistics Research Group, Department of Health Sciences, George Davies Centre, University of Leicester, Leicester, UK
| | - Maarten van Smeden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Paul C Lambert
- Biostatistics Research Group, Department of Health Sciences, George Davies Centre, University of Leicester, Leicester, UK
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Kym I E Snell
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
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Elhassan YS, Altieri B, Berhane S, Cosentini D, Calabrese A, Haissaguerre M, Kastelan D, Fragoso MCBV, Bertherat J, Al Ghuzlan A, Haak H, Boudina M, Canu L, Loli P, Sherlock M, Kimpel O, Laganà M, Sitch AJ, Kroiss M, Arlt W, Terzolo M, Berruti A, Deeks JJ, Libé R, Fassnacht M, Ronchi CL. S-GRAS score for prognostic classification of adrenocortical carcinoma: an international, multicenter ENSAT study. Eur J Endocrinol 2021; 186:25-36. [PMID: 34709200 PMCID: PMC8679848 DOI: 10.1530/eje-21-0510] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 10/27/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Adrenocortical carcinoma (ACC) has an aggressive but variable clinical course. Prognostic stratification based on the European Network for the Study of Adrenal Tumours stage and Ki67 index is limited. We aimed to demonstrate the prognostic role of a points-based score (S-GRAS) in a large cohort of patients with ACC. DESIGN This is a multicentre, retrospective study on ACC patients who underwent adrenalectomy. METHODS The S-GRAS score was calculated as a sum of the following points: tumour stage (1-2 = 0; 3 = 1; 4 = 2), grade (Ki67 index 0-9% = 0; 10-19% = 1; ≥20% = 2 points), resection status (R0 = 0; RX = 1; R1 = 2; R2 = 3), age (<50 years = 0; ≥50 years = 1), symptoms (no = 0; yes = 1), and categorised, generating four groups (0-1, 2-3, 4-5, and 6-9). Endpoints were progression-free survival (PFS) and disease-specific survival (DSS). The discriminative performance of S-GRAS and its components was tested by Harrell's Concordance index (C-index) and Royston-Sauerbrei's R2D statistic. RESULTS We included 942 ACC patients. The S-GRAS score showed superior prognostic performance for both PFS and DSS, with best discrimination obtained using the individual scores (0-9) (C-index = 0.73, R2D = 0.30, and C-index = 0.79, R2D = 0.45, respectively, all P < 0.01vs each component). The superiority of S-GRAS score remained when comparing patients treated or not with adjuvant mitotane (n = 481 vs 314). In particular, the risk of recurrence was significantly reduced as a result of adjuvant mitotane only in patients with S-GRAS 4-5. CONCLUSION The prognostic performance of S-GRAS is superior to tumour stage and Ki67 in operated ACC patients, independently from adjuvant mitotane. S-GRAS score provides a new important guide for personalised management of ACC (i.e. radiological surveillance and adjuvant treatment).
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Affiliation(s)
- Y S Elhassan
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - B Altieri
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
| | - S Berhane
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - D Cosentini
- Medical Oncology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University of Brescia, ASST-Spedali Civili, Brescia, Italy
| | - A Calabrese
- Department of Clinical and Biological Sciences, University of Turin, San Luigi Hospital, Orbassano, Italy
| | - M Haissaguerre
- Service d’Endocrinologie – Diabète et Nutrition CHU de Bordeaux, Bordeaux, France
| | - D Kastelan
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - M C B V Fragoso
- Unidade de Suprarrenal da Disciplina de Endocrinologia e Metabologia da Faculdade de Medicina do Hospital das Clinicas da Universidade de São Paulo (HCFMUSP), and Instituto do Cancer do Estado de Sao Paulo (ICESP), Sao Paulo, Brazil
| | - J Bertherat
- Reference Center for Rare Adrenal Cancer (COMETE), Cochin Hospital, Paris, France
| | - A Al Ghuzlan
- Department of Pathology, Gustave Roussy Cancer Center, Paris, France
| | - H Haak
- Department of Internal Medicine, Máxima MC, Eindhoven, Netherlands
| | - M Boudina
- Department of Endocrinology, Theagenio Cancer Hospital, Thessaloniki, Greece
| | - L Canu
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - P Loli
- Clinica Polispecialistica San Carlo, Paderno Dugnano, Milano, Italy
| | - M Sherlock
- Department of Endocrinology, Beaumont Hospital, and the Royal College of Surgeons, Dublin, Republic of Ireland
| | - O Kimpel
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
| | - M Laganà
- Medical Oncology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University of Brescia, ASST-Spedali Civili, Brescia, Italy
| | - A J Sitch
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - M Kroiss
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Würzburg, Germany
- Department for Endocrinology, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-University, Munich, Germany
| | - W Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - M Terzolo
- Department of Clinical and Biological Sciences, University of Turin, San Luigi Hospital, Orbassano, Italy
| | - A Berruti
- Medical Oncology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University of Brescia, ASST-Spedali Civili, Brescia, Italy
| | - J J Deeks
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - R Libé
- Department of Endocrinology and Metabolic Diseases, Hôpital Cochin, Paris, France
| | - M Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Würzburg, Germany
| | - C L Ronchi
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
- Correspondence should be addressed to C L Ronchi;
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Zhang Q, Zhang J, Lei L, Liang H, Li Y, Lu J, Zhou S, Li G, Zhang X, Chen Y, Pan J, Lu X, Chen Y, Lin X, Li X, An S, Xiu J. Nomogram to predict risk of incident chronic kidney disease in high-risk population of cardiovascular disease in China: community-based cohort study. BMJ Open 2021; 11:e047774. [PMID: 34772745 PMCID: PMC8593715 DOI: 10.1136/bmjopen-2020-047774] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
AIMS To develop a nomogram for incident chronic kidney disease (CKD) risk evaluation among community residents with high cardiovascular disease (CVD) risk. METHODS In this retrospective cohort study, 5730 non-CKD residents with high CVD risk participating the National Basic Public Health Service between January 2015 and December 2020 in Guangzhou were included. Endpoint was incident CKD defined as an estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m2 during the follow-up period. The entire cohorts were randomly (2:1) assigned to a development cohort and a validation cohort. Predictors of incident CKD were selected by multivariable Cox regression and stepwise approach. A nomogram based on these predictors was developed and evaluated with concordance index (C-index) and area under curve (AUC). RESULTS During the median follow-up period of 4.22 years, the incidence of CKD was 19.09% (n=1094) in the entire cohort, 19.03% (727 patients) in the development cohort and 19.21% (367 patients) in the validation cohort. Age, body mass index, eGFR 60-89 mL/min/1.73 m2, diabetes and hypertension were selected as predictors. The nomogram demonstrated a good discriminative power with C-index of 0.778 and 0.785 in the development and validation cohort. The 3-year, 4-year and 5-year AUCs were 0.817, 0.814 and 0.834 in the development cohort, and 0.830, 0.847 and 0.839 in the validation cohort. CONCLUSION Our nomogram based on five readily available predictors is a reliable tool to identify high-CVD risk patients at risk of incident CKD. This prediction model may help improving the healthcare strategies in primary care.
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Affiliation(s)
- Qiuxia Zhang
- Department of Cardiology, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Jingyi Zhang
- Community Health Service Center, Zengjiang Avenue, Guangzhou, Guangdong, China
| | - Li Lei
- Department of Cardiology, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Hongbin Liang
- Department of Cardiology, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Yun Li
- Department of Public Health, Xintang Hospital, Guangzhou, Guangdong, China
| | - Junyan Lu
- Department of Cardiology, Zengcheng Branch of Nanfang Hospital, Guangzhou, Guangdong, China
| | - Shiyu Zhou
- Department of Biostatistics, Southern Medical University School of Public Health, Guangzhou, Guangdong, China
| | - Guodong Li
- Department of Cardiology, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Xinlu Zhang
- Department of Cardiology, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Yaode Chen
- Department of Cardiology, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Jiazhi Pan
- Department of Cardiology, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Xiangqi Lu
- Department of Cardiology, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Yejia Chen
- Department of Cardiology, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Xinxin Lin
- Department of Cardiology, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Xiaobo Li
- Department of Cardiology, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Shengli An
- Department of Biostatistics, Southern Medical University School of Public Health, Guangzhou, Guangdong, China
| | - Jiancheng Xiu
- Department of Cardiology, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
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7
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Snell KIE, Archer L, Ensor J, Bonnett LJ, Debray TPA, Phillips B, Collins GS, Riley RD. External validation of clinical prediction models: simulation-based sample size calculations were more reliable than rules-of-thumb. J Clin Epidemiol 2021; 135:79-89. [PMID: 33596458 PMCID: PMC8352630 DOI: 10.1016/j.jclinepi.2021.02.011] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 12/14/2020] [Accepted: 02/09/2021] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Sample size "rules-of-thumb" for external validation of clinical prediction models suggest at least 100 events and 100 non-events. Such blanket guidance is imprecise, and not specific to the model or validation setting. We investigate factors affecting precision of model performance estimates upon external validation, and propose a more tailored sample size approach. METHODS Simulation of logistic regression prediction models to investigate factors associated with precision of performance estimates. Then, explanation and illustration of a simulation-based approach to calculate the minimum sample size required to precisely estimate a model's calibration, discrimination and clinical utility. RESULTS Precision is affected by the model's linear predictor (LP) distribution, in addition to number of events and total sample size. Sample sizes of 100 (or even 200) events and non-events can give imprecise estimates, especially for calibration. The simulation-based calculation accounts for the LP distribution and (mis)calibration in the validation sample. Application identifies 2430 required participants (531 events) for external validation of a deep vein thrombosis diagnostic model. CONCLUSION Where researchers can anticipate the distribution of the model's LP (eg, based on development sample, or a pilot study), a simulation-based approach for calculating sample size for external validation offers more flexibility and reliability than rules-of-thumb.
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Affiliation(s)
- Kym I E Snell
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, Staffordshire, United Kingdom.
| | - Lucinda Archer
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, Staffordshire, United Kingdom
| | - Joie Ensor
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, Staffordshire, United Kingdom
| | - Laura J Bonnett
- Department of Biostatistics, University of Liverpool, Liverpool, United Kingdom
| | - Thomas P A Debray
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Bob Phillips
- Centre for Reviews and Dissemination, University of York, York, United Kingdom
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom; NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Richard D Riley
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, Staffordshire, United Kingdom
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8
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Koshiaris C, Van den Bruel A, Nicholson BD, Lay-Flurrie S, Hobbs FR, Oke JL. Clinical prediction tools to identify patients at highest risk of myeloma in primary care: a retrospective open cohort study. Br J Gen Pract 2021; 71:e347-e355. [PMID: 33824161 PMCID: PMC8049204 DOI: 10.3399/bjgp.2020.0697] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/01/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Patients with myeloma experience substantial delays in their diagnosis, which can adversely affect their prognosis. AIM To generate a clinical prediction rule to identify primary care patients who are at highest risk of myeloma. DESIGN AND SETTING Retrospective open cohort study using electronic health records data from the UK's Clinical Practice Research Datalink (CPRD) between 1 January 2000 and 1 January 2014. METHOD Patients from the CPRD were included in the study if they were aged ≥40 years, had two full blood counts within a year, and had no previous diagnosis of myeloma. Cases of myeloma were identified in the following 2 years. Derivation and external validation datasets were created based on geographical region. Prediction equations were estimated using Cox proportional hazards models including patient characteristics, symptoms, and blood test results. Calibration, discrimination, and clinical utility were evaluated in the validation set. RESULTS Of 1 281 926 eligible patients, 737 (0.06%) were diagnosed with myeloma within 2 years. Independent predictors of myeloma included: older age; male sex; back, chest and rib pain; nosebleeds; low haemoglobin, platelets, and white cell count; and raised mean corpuscular volume, calcium, and erythrocyte sedimentation rate. A model including symptoms and full blood count had an area under the curve of 0.84 (95% CI = 0.81 to 0.87) and sensitivity of 62% (95% CI = 55% to 68%) at the highest risk decile. The corresponding statistics for a second model, which also included calcium and inflammatory markers, were an area under the curve of 0.87 (95% CI = 0.84 to 0.90) and sensitivity of 72% (95% CI = 66% to 78%). CONCLUSION The implementation of these prediction rules would highlight the possibility of myeloma in patients where GPs do not suspect myeloma. Future research should focus on the prospective evaluation of further external validity and the impact on clinical practice.
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Affiliation(s)
| | | | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sarah Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jason L Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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9
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Riley RD, Van Calster B, Collins GS. A note on estimating the Cox-Snell R 2 from a reported C statistic (AUROC) to inform sample size calculations for developing a prediction model with a binary outcome. Stat Med 2021; 40:859-864. [PMID: 33283904 DOI: 10.1002/sim.8806] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 10/23/2020] [Indexed: 11/05/2022]
Abstract
In 2019 we published a pair of articles in Statistics in Medicine that describe how to calculate the minimum sample size for developing a multivariable prediction model with a continuous outcome, or with a binary or time-to-event outcome. As for any sample size calculation, the approach requires the user to specify anticipated values for key parameters. In particular, for a prediction model with a binary outcome, the outcome proportion and a conservative estimate for the overall fit of the developed model as measured by the Cox-Snell R2 (proportion of variance explained) must be specified. This proposal raises the question of how to identify a plausible value for R2 in advance of model development. Our articles suggest researchers should identify R2 from closely related models already published in their field. In this letter, we present details on how to derive R2 using the reported C statistic (AUROC) for such existing prediction models with a binary outcome. The C statistic is commonly reported, and so our approach allows researchers to obtain R2 for subsequent sample size calculations for new models. Stata and R code is provided, and a small simulation study.
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Affiliation(s)
- Richard D Riley
- Centre for Prognosis Research, School of Medicine, Keele University, Staffordshire, UK
| | - Ben Van Calster
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
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10
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Archer L, Snell KIE, Ensor J, Hudda MT, Collins GS, Riley RD. Minimum sample size for external validation of a clinical prediction model with a continuous outcome. Stat Med 2021; 40:133-146. [PMID: 33150684 DOI: 10.1002/sim.8766] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 08/06/2020] [Accepted: 09/11/2020] [Indexed: 01/12/2023]
Abstract
Clinical prediction models provide individualized outcome predictions to inform patient counseling and clinical decision making. External validation is the process of examining a prediction model's performance in data independent to that used for model development. Current external validation studies often suffer from small sample sizes, and subsequently imprecise estimates of a model's predictive performance. To address this, we propose how to determine the minimum sample size needed for external validation of a clinical prediction model with a continuous outcome. Four criteria are proposed, that target precise estimates of (i) R2 (the proportion of variance explained), (ii) calibration-in-the-large (agreement between predicted and observed outcome values on average), (iii) calibration slope (agreement between predicted and observed values across the range of predicted values), and (iv) the variance of observed outcome values. Closed-form sample size solutions are derived for each criterion, which require the user to specify anticipated values of the model's performance (in particular R2 ) and the outcome variance in the external validation dataset. A sensible starting point is to base values on those for the model development study, as obtained from the publication or study authors. The largest sample size required to meet all four criteria is the recommended minimum sample size needed in the external validation dataset. The calculations can also be applied to estimate expected precision when an existing dataset with a fixed sample size is available, to help gauge if it is adequate. We illustrate the proposed methods on a case-study predicting fat-free mass in children.
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Affiliation(s)
- Lucinda Archer
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
| | - Kym I E Snell
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
| | - Joie Ensor
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
| | - Mohammed T Hudda
- Population Health Research Institute, St George's, University of London, London, UK
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Richard D Riley
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
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11
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Collins SD, Peek N, Riley RD, Martin GP. Sample sizes of prediction model studies in prostate cancer were rarely justified and often insufficient. J Clin Epidemiol 2020; 133:53-60. [PMID: 33383128 DOI: 10.1016/j.jclinepi.2020.12.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 12/02/2020] [Accepted: 12/08/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Developing clinical prediction models (CPMs) on data of sufficient sample size is critical to help minimize overfitting. Using prostate cancer as a clinical exemplar, we aimed to investigate to what extent existing CPMs adhere to recent formal sample size criteria, or historic rules of thumb of events per predictor parameter (EPP)≥10. STUDY DESIGN AND SETTING A systematic review to identify CPMs related to prostate cancer, which provided enough information to calculate minimum sample size. We compared the reported sample size of each CPM against the traditional 10 EPP rule of thumb and formal sample size criteria. RESULTS About 211 CPMs were included. Three of the studies justified the sample size used, mostly using EPP rules of thumb. Overall, 69% of the CPMs were derived on sample sizes that surpassed the traditional EPP≥10 rule of thumb, but only 48% surpassed recent formal sample size criteria. For most CPMs, the required sample size based on formal criteria was higher than the sample sizes to surpass 10 EPP. CONCLUSION Few of the CPMs included in this study justified their sample size, with most justifications being based on EPP. This study shows that, in real-world data sets, adhering to the classic EPP rules of thumb is insufficient to adhere to recent formal sample size criteria.
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Affiliation(s)
- Shane D Collins
- Research Department of Oncology, Cancer Institute, Faculty of Medical Sciences, School of Life & Medical Sciences, University College London, London, UK; Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Niels Peek
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Richard D Riley
- Centre for Prognosis Research, School of Primary, Community and Social Care, Keele University, Staffordshire, UK
| | - Glen P Martin
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
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12
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Riley RD, Ensor J, Snell KIE, Harrell FE, Martin GP, Reitsma JB, Moons KGM, Collins G, van Smeden M. Calculating the sample size required for developing a clinical prediction model. BMJ 2020; 368:m441. [PMID: 32188600 DOI: 10.1136/bmj.m441] [Citation(s) in RCA: 820] [Impact Index Per Article: 205.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Richard D Riley
- Centre for Prognosis Research, School of Primary, Community and Social Care, Keele University, Staffordshire ST5 5BG, UK
| | - Joie Ensor
- Centre for Prognosis Research, School of Primary, Community and Social Care, Keele University, Staffordshire ST5 5BG, UK
| | - Kym I E Snell
- Centre for Prognosis Research, School of Primary, Community and Social Care, Keele University, Staffordshire ST5 5BG, UK
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville TN, USA
| | - Glen P Martin
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Johannes B Reitsma
- Julius Center for Health Sciences, University Medical Center Utrecht, Utrecht, Netherlands
| | - Karel G M Moons
- Julius Center for Health Sciences, University Medical Center Utrecht, Utrecht, Netherlands
| | - Gary Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Maarten van Smeden
- Julius Center for Health Sciences, University Medical Center Utrecht, Utrecht, Netherlands
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Clinical Epidemiology, Leiden University Medical Center Leiden, Netherlands
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13
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Fermont JM, Bolton CE, Fisk M, Mohan D, Macnee W, Cockcroft JR, McEniery C, Fuld J, Cheriyan J, Tal-Singer R, Wilkinson IB, Wood AM, Polkey MI, Müllerova H. Risk assessment for hospital admission in patients with COPD; a multi-centre UK prospective observational study. PLoS One 2020; 15:e0228940. [PMID: 32040531 PMCID: PMC7010290 DOI: 10.1371/journal.pone.0228940] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/27/2020] [Indexed: 11/25/2022] Open
Abstract
In chronic obstructive pulmonary disease (COPD), acute exacerbation of COPD requiring hospital admission is associated with mortality and healthcare costs. The ERICA study assessed multiple clinical measures in people with COPD, including the short physical performance battery (SPPB), a simple test of physical function with 3 components (gait speed, balance and sit-to-stand). We tested the hypothesis that SPPB score would relate to risk of hospital admissions and length of hospital stay. Data were analysed from 714 of the total 729 participants (434 men and 280 women) with COPD. Data from this prospective observational longitudinal study were obtained from 4 secondary and 1 tertiary centres from England, Scotland, and Wales. The main outcome measures were to estimate the risk of hospitalisation with acute exacerbation of COPD (AECOPD and length of hospital stay derived from hospital episode statistics (HES). In total, 291 of 714 individuals experienced 762 hospitalised AECOPD during five-year follow up. Poorer performance of SPPB was associated with both higher rate (IRR 1.08 per 1 point decrease, 95% CI 1.01 to 1.14) and increased length of stay (IRR 1.18 per 1 point decrease, 95% CI 1.10 to 1.27) for hospitalised AECOPD. For the individual sit-to-stand component of the SPPB, the association was even stronger (IRR 1.14, 95% CI 1.02 to 1.26 for rate and IRR 1.32, 95% CI 1.16 to 1.49 for length of stay for hospitalised AECOPD). The SPPB, and in particular the sit-to-stand component can both evaluate the risk of H-AECOPD and length of hospital stay in COPD. The SPPB can aid in clinical decision making and when prioritising healthcare resources.
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Affiliation(s)
- Jilles M. Fermont
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, England, United Kingdom
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, England, United Kingdom
- * E-mail:
| | - Charlotte E. Bolton
- Division of Respiratory Medicine and NIHR Nottingham BRC Respiratory Theme, School of Medicine, University of Nottingham, Nottingham, England, United Kingdom
| | - Marie Fisk
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, England, United Kingdom
| | - Divya Mohan
- Medical Innovation, Value Evidence and Outcomes GSK, Collegeville, PA, United States
| | - William Macnee
- Centre for Inflammation Research, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - John R. Cockcroft
- Department of Cardiology, Columbia University Medical Centre, New York, New York, United States
| | - Carmel McEniery
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, England, United Kingdom
| | - Jonathan Fuld
- Department of Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England, United Kingdom
| | - Joseph Cheriyan
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, England, United Kingdom
| | - Ruth Tal-Singer
- Medical Innovation, Value Evidence and Outcomes GSK, Collegeville, PA, United States
| | - Ian B. Wilkinson
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, England, United Kingdom
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, England, United Kingdom
| | - Angela M. Wood
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, England, United Kingdom
- British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, England, United Kingdom
- National Institute for Health Research Blood and Transplant Research Unit in Donor Health and Genomics, University of Cambridge, Cambridge, England, United Kingdom
- National Institute for Health Research Cambridge Biomedical Research Centre, University of Cambridge and Cambridge University Hospitals, Cambridge, England, United Kingdom
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, England, United Kingdom
| | - Michael I. Polkey
- Department of Respiratory Medicine, Royal Brompton Hospital, London, England, United Kingdom
| | - Hana Müllerova
- Epidemiology, Value Evidence and Outcomes GSK, Uxbridge, England, United Kingdom
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14
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Debray TPA, Damen JAAG, Riley RD, Snell K, Reitsma JB, Hooft L, Collins GS, Moons KGM. A framework for meta-analysis of prediction model studies with binary and time-to-event outcomes. Stat Methods Med Res 2019; 28:2768-2786. [PMID: 30032705 PMCID: PMC6728752 DOI: 10.1177/0962280218785504] [Citation(s) in RCA: 117] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
It is widely recommended that any developed-diagnostic or prognostic-prediction model is externally validated in terms of its predictive performance measured by calibration and discrimination. When multiple validations have been performed, a systematic review followed by a formal meta-analysis helps to summarize overall performance across multiple settings, and reveals under which circumstances the model performs suboptimal (alternative poorer) and may need adjustment. We discuss how to undertake meta-analysis of the performance of prediction models with either a binary or a time-to-event outcome. We address how to deal with incomplete availability of study-specific results (performance estimates and their precision), and how to produce summary estimates of the c-statistic, the observed:expected ratio and the calibration slope. Furthermore, we discuss the implementation of frequentist and Bayesian meta-analysis methods, and propose novel empirically-based prior distributions to improve estimation of between-study heterogeneity in small samples. Finally, we illustrate all methods using two examples: meta-analysis of the predictive performance of EuroSCORE II and of the Framingham Risk Score. All examples and meta-analysis models have been implemented in our newly developed R package "metamisc".
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Affiliation(s)
- Thomas PA Debray
- Julius Center for Health Sciences and
Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Cochrane Netherlands, University Medical
Center Utrecht, Utrecht, The Netherlands
| | - Johanna AAG Damen
- Julius Center for Health Sciences and
Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Cochrane Netherlands, University Medical
Center Utrecht, Utrecht, The Netherlands
| | - Richard D Riley
- Research Institute for Primary Care and
Health Sciences, Keele University, Staffordshire, UK
| | - Kym Snell
- Research Institute for Primary Care and
Health Sciences, Keele University, Staffordshire, UK
| | - Johannes B Reitsma
- Julius Center for Health Sciences and
Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Cochrane Netherlands, University Medical
Center Utrecht, Utrecht, The Netherlands
| | - Lotty Hooft
- Julius Center for Health Sciences and
Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Cochrane Netherlands, University Medical
Center Utrecht, Utrecht, The Netherlands
| | - Gary S Collins
- Centre for Statistics in Medicine,
University of Oxford, Oxford, UK
| | - Karel GM Moons
- Julius Center for Health Sciences and
Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Cochrane Netherlands, University Medical
Center Utrecht, Utrecht, The Netherlands
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15
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Riley RD, Snell KIE, Ensor J, Burke DL, Harrell Jr FE, Moons KGM, Collins GS. Minimum sample size for developing a multivariable prediction model: PART II - binary and time-to-event outcomes. Stat Med 2019; 38:1276-1296. [PMID: 30357870 PMCID: PMC6519266 DOI: 10.1002/sim.7992] [Citation(s) in RCA: 478] [Impact Index Per Article: 95.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 09/13/2018] [Accepted: 09/13/2018] [Indexed: 12/23/2022]
Abstract
When designing a study to develop a new prediction model with binary or time-to-event outcomes, researchers should ensure their sample size is adequate in terms of the number of participants (n) and outcome events (E) relative to the number of predictor parameters (p) considered for inclusion. We propose that the minimum values of n and E (and subsequently the minimum number of events per predictor parameter, EPP) should be calculated to meet the following three criteria: (i) small optimism in predictor effect estimates as defined by a global shrinkage factor of ≥0.9, (ii) small absolute difference of ≤ 0.05 in the model's apparent and adjusted Nagelkerke's R2 , and (iii) precise estimation of the overall risk in the population. Criteria (i) and (ii) aim to reduce overfitting conditional on a chosen p, and require prespecification of the model's anticipated Cox-Snell R2 , which we show can be obtained from previous studies. The values of n and E that meet all three criteria provides the minimum sample size required for model development. Upon application of our approach, a new diagnostic model for Chagas disease requires an EPP of at least 4.8 and a new prognostic model for recurrent venous thromboembolism requires an EPP of at least 23. This reinforces why rules of thumb (eg, 10 EPP) should be avoided. Researchers might additionally ensure the sample size gives precise estimates of key predictor effects; this is especially important when key categorical predictors have few events in some categories, as this may substantially increase the numbers required.
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Affiliation(s)
- Richard D Riley
- Centre for Prognosis Research, Research Institute for Primary Care and Health SciencesKeele UniversityStaffordshireUK
| | - Kym IE Snell
- Centre for Prognosis Research, Research Institute for Primary Care and Health SciencesKeele UniversityStaffordshireUK
| | - Joie Ensor
- Centre for Prognosis Research, Research Institute for Primary Care and Health SciencesKeele UniversityStaffordshireUK
| | - Danielle L Burke
- Centre for Prognosis Research, Research Institute for Primary Care and Health SciencesKeele UniversityStaffordshireUK
| | - Frank E Harrell Jr
- Department of BiostatisticsVanderbilt University School of MedicineNashvilleTennessee
| | - Karel GM Moons
- Julius Centre for Health Sciences and Primary CareUniversity Medical Centre UtrechtUtrechtThe Netherlands
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal SciencesUniversity of OxfordOxfordUK
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Elwood JM, Tawfiq E, TinTin S, Marshall RJ, Phung TM, Campbell I, Harvey V, Lawrenson R. Development and validation of a new predictive model for breast cancer survival in New Zealand and comparison to the Nottingham prognostic index. BMC Cancer 2018; 18:897. [PMID: 30223800 PMCID: PMC6142675 DOI: 10.1186/s12885-018-4791-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 09/03/2018] [Indexed: 01/21/2023] Open
Abstract
Background The only available predictive models for the outcome of breast cancer patients in New Zealand (NZ) are based on data in other countries. We aimed to develop and validate a predictive model using NZ data for this population, and compare its performance to a widely used overseas model, the Nottingham Prognostic Index (NPI). Methods We developed a model to predict 10-year breast cancer-specific survival, using data collected prospectively in the largest population-based regional breast cancer registry in NZ (Auckland, 9182 patients), and assessed its performance in this data set (internal validation) and in an independent NZ population-based series of 2625 patients in Waikato (external validation). The data included all women with primary invasive breast cancer diagnosed from 1 June 2000 to 30 June 2014, with follow up to death or Dec 31, 2014. We used multivariate Cox proportional hazards regression to assess predictors and to calculate predicted 10-year breast cancer mortality, and therefore survival, probability for each patient. We assessed observed survival by the Kaplan Meier method. We assessed discrimination by the C statistic, and calibration by comparing predicted and observed survival rates for patients in 10 groups ordered by predicted 10-year survival. We compared this NZ model with the Nottingham Prognostic Index (NPI) in this validation data set. Results Discrimination was good: C statistics were 0.84 for internal validity and 0.83 for an independent external validity. For calibration, for both internal and external validity the predicted 10-year survival probabilities in all groups of patients, ordered by predicted survival, were within the 95% confidence intervals (CI) of the observed Kaplan-Meier survival probabilities. The NZ model showed good discrimination even within the prognostic groups defined by the NPI. Conclusions These results for the New Zealand model show good internal and external validity, transportability, and potential clinical value of the model, and its clear superiority over the NPI. Further research is needed to assess other potential predictors, to assess the model’s performance in specific subgroups of patients, and to compare it to other models, which have been developed in other countries and have not yet been tested in NZ. Electronic supplementary material The online version of this article (10.1186/s12885-018-4791-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- J Mark Elwood
- Epidemiology and Biostatistics, School of Population Health, University of Auckland, 261 Morrin Road, Private Bag 92019, Auckland Mail Centre, Auckland, 1142, New Zealand.
| | - Essa Tawfiq
- Epidemiology and Biostatistics, School of Population Health, University of Auckland, 261 Morrin Road, Private Bag 92019, Auckland Mail Centre, Auckland, 1142, New Zealand
| | - Sandar TinTin
- Epidemiology and Biostatistics, School of Population Health, University of Auckland, 261 Morrin Road, Private Bag 92019, Auckland Mail Centre, Auckland, 1142, New Zealand
| | - Roger J Marshall
- Epidemiology and Biostatistics, School of Population Health, University of Auckland, 261 Morrin Road, Private Bag 92019, Auckland Mail Centre, Auckland, 1142, New Zealand
| | - Tung M Phung
- Epidemiology and Biostatistics, School of Population Health, University of Auckland, 261 Morrin Road, Private Bag 92019, Auckland Mail Centre, Auckland, 1142, New Zealand
| | - Ian Campbell
- Waikato Clinical Campus, Department of Surgery, University of Auckland, Hamilton, New Zealand.,Waikato District Health Board, Hamilton, New Zealand
| | - Vernon Harvey
- Regional Cancer and Blood Centre, Auckland City Hospital, Auckland, New Zealand
| | - Ross Lawrenson
- Waikato Clinical Campus, Department of Surgery, University of Auckland, Hamilton, New Zealand.,The University of Waikato, Hamilton, 3240, New Zealand.,Waikato District Health Board, Hamilton, New Zealand
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17
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Mehta S, Jackson R, Pylypchuk R, Poppe K, Wells S, Kerr AJ. Development and validation of alternative cardiovascular risk prediction equations for population health planning: a routine health data linkage study of 1.7 million New Zealanders. Int J Epidemiol 2018; 47:1571-1584. [DOI: 10.1093/ije/dyy137] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Suneela Mehta
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Rod Jackson
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Romana Pylypchuk
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Katrina Poppe
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Sue Wells
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Andrew J Kerr
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
- Cardiology Department, Middlemore Hospital, Auckland, New Zealand
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Schulz A, Zöller D, Nickels S, Beutel ME, Blettner M, Wild PS, Binder H. Simulation of complex data structures for planning of studies with focus on biomarker comparison. BMC Med Res Methodol 2017; 17:90. [PMID: 28610631 PMCID: PMC5470184 DOI: 10.1186/s12874-017-0364-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 05/24/2017] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND There are a growing number of observational studies that do not only focus on single biomarkers for predicting an outcome event, but address questions in a multivariable setting. For example, when quantifying the added value of new biomarkers in addition to established risk factors, the aim might be to rank several new markers with respect to their prediction performance. This makes it important to consider the marker correlation structure for planning such a study. Because of the complexity, a simulation approach may be required to adequately assess sample size or other aspects, such as the choice of a performance measure. METHODS In a simulation study based on real data, we investigated how to generate covariates with realistic distributions and what generating model should be used for the outcome, aiming to determine the least amount of information and complexity needed to obtain realistic results. As a basis for the simulation a large epidemiological cohort study, the Gutenberg Health Study was used. The added value of markers was quantified and ranked in subsampling data sets of this population data, and simulation approaches were judged by the quality of the ranking. One of the evaluated approaches, the random forest, requires original data at the individual level. Therefore, also the effect of the size of a pilot study for random forest based simulation was investigated. RESULTS We found that simple logistic regression models failed to adequately generate realistic data, even with extensions such as interaction terms or non-linear effects. The random forest approach was seen to be more appropriate for simulation of complex data structures. Pilot studies starting at about 250 observations were seen to provide a reasonable level of information for this approach. CONCLUSIONS We advise to avoid oversimplified regression models for simulation, in particular when focusing on multivariable research questions. More generally, a simulation should be based on real data for adequately reflecting complex observational data structures, such as found in epidemiological cohort studies.
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Affiliation(s)
- Andreas Schulz
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, Mainz, 55131, Germany.
- Center for Translational Vascular Biology (CTVB), University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, Mainz, 55131, Germany.
| | - Daniela Zöller
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg-University Mainz, Obere Zahlbacher Str. 69, Mainz, 55131, Germany
| | - Stefan Nickels
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, Mainz, 55131, Germany
| | - Manfred E Beutel
- Clinic for Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, Mainz, 55131, Germany
| | - Maria Blettner
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg-University Mainz, Obere Zahlbacher Str. 69, Mainz, 55131, Germany
| | - Philipp S Wild
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, Mainz, 55131, Germany
- Center for Translational Vascular Biology (CTVB), University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, Mainz, 55131, Germany
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, Mainz, 55131, Germany
- DZHK (German Center for Cardiovascular Research), partner site RhineMain, Mainz, Langenbeckstraße 1, Mainz, 55131, Germany
| | - Harald Binder
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Stefan-Meier-Str. 26, Freiburg, 79104, Germany
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19
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Four hundred or more participants needed for stable contingency table estimates of clinical prediction rule performance. J Clin Epidemiol 2017; 82:137-148. [DOI: 10.1016/j.jclinepi.2016.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 10/05/2016] [Accepted: 10/11/2016] [Indexed: 12/18/2022]
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Riley RD, Ensor J, Snell KIE, Debray TPA, Altman DG, Moons KGM, Collins GS. External validation of clinical prediction models using big datasets from e-health records or IPD meta-analysis: opportunities and challenges. BMJ 2016; 353:i3140. [PMID: 27334381 PMCID: PMC4916924 DOI: 10.1136/bmj.i3140] [Citation(s) in RCA: 295] [Impact Index Per Article: 36.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2016] [Indexed: 12/18/2022]
Affiliation(s)
- Richard D Riley
- Research Institute for Primary Care and Health Sciences, Keele University, Keele ST5 5BG, Staffordshire, UK
| | - Joie Ensor
- Research Institute for Primary Care and Health Sciences, Keele University, Keele ST5 5BG, Staffordshire, UK
| | - Kym I E Snell
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Thomas P A Debray
- Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands Cochrane Netherlands, University Medical Center Utrecht, Utrecht, Netherlands
| | - Doug G Altman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Karel G M Moons
- Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands Cochrane Netherlands, University Medical Center Utrecht, Utrecht, Netherlands
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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