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McCullum LB, Karagoz A, Dede C, Garcia R, Nosrat F, Hemmati M, Hosseinian S, Schaefer AJ, Fuller CD. Markov models for clinical decision-making in radiation oncology: A systematic review. J Med Imaging Radiat Oncol 2024. [PMID: 38766899 DOI: 10.1111/1754-9485.13656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 04/03/2024] [Indexed: 05/22/2024]
Abstract
The intrinsic stochasticity of patients' response to treatment is a major consideration for clinical decision-making in radiation therapy. Markov models are powerful tools to capture this stochasticity and render effective treatment decisions. This paper provides an overview of the Markov models for clinical decision analysis in radiation oncology. A comprehensive literature search was conducted within MEDLINE using PubMed, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only studies published from 2000 to 2023 were considered. Selected publications were summarized in two categories: (i) studies that compare two (or more) fixed treatment policies using Monte Carlo simulation and (ii) studies that seek an optimal treatment policy through Markov Decision Processes (MDPs). Relevant to the scope of this study, 61 publications were selected for detailed review. The majority of these publications (n = 56) focused on comparative analysis of two or more fixed treatment policies using Monte Carlo simulation. Classifications based on cancer site, utility measures and the type of sensitivity analysis are presented. Five publications considered MDPs with the aim of computing an optimal treatment policy; a detailed statement of the analysis and results is provided for each work. As an extension of Markov model-based simulation analysis, MDP offers a flexible framework to identify an optimal treatment policy among a possibly large set of treatment policies. However, the applications of MDPs to oncological decision-making have been understudied, and the full capacity of this framework to render complex optimal treatment decisions warrants further consideration.
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Affiliation(s)
- Lucas B McCullum
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Aysenur Karagoz
- Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas, USA
| | - Cem Dede
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Raul Garcia
- Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas, USA
| | - Fatemeh Nosrat
- Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas, USA
| | - Mehdi Hemmati
- School of Industrial and Systems Engineering, The University of Oklahoma, Norman, Oklahoma, USA
| | | | - Andrew J Schaefer
- Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas, USA
| | - Clifton D Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas, USA
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Gu F, Xu J, Du L, Liang H, Zhu J, Lin L, Ma L, He B, Wei X, Zhai H. The Machine Learning Model for Predicting Inadequate Bowel Preparation Before Colonoscopy: A Multicenter Prospective Study. Clin Transl Gastroenterol 2024; 15:e00694. [PMID: 38441136 PMCID: PMC11124626 DOI: 10.14309/ctg.0000000000000694] [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: 10/12/2023] [Accepted: 02/27/2024] [Indexed: 05/26/2024] Open
Abstract
INTRODUCTION Colonoscopy is a critical diagnostic tool for colorectal diseases; however, its effectiveness depends on adequate bowel preparation (BP). This study aimed to develop a machine learning predictive model based on Chinese adults for inadequate BP. METHODS A multicenter prospective study was conducted on adult outpatients undergoing colonoscopy from January 2021 to May 2023. Data on patient characteristics, comorbidities, medication use, and BP quality were collected. Logistic regression and 4 machine learning models (support vector machines, decision trees, extreme gradient boosting, and bidirectional projection network) were used to identify risk factors and predict inadequate BP. RESULTS Of 3,217 patients, 21.14% had inadequate BP. The decision trees model demonstrated the best predictive capacity with an area under the receiver operating characteristic curve of 0.80 in the validation cohort. The risk factors at the nodes included body mass index, education grade, use of simethicone, diabetes, age, history of inadequate BP, and longer interval. DISCUSSION The decision trees model we created and the identified risk factors can be used to identify patients at higher risk of inadequate BP before colonoscopy, for whom more polyethylene glycol or auxiliary medication should be used.
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Affiliation(s)
- Feng Gu
- Department of Gastroenterology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jianing Xu
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lina Du
- Department of Gastroenterology, 731 Hospital of China Aerospace Science and Industry Group, Beijing, China
| | - Hejun Liang
- Department of Gastroenterology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jingyi Zhu
- Department of Gastroenterology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lanhui Lin
- Department of Gastroenterology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lei Ma
- Department of Gastroenterology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Boyuan He
- Department of Gastroenterology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xinxin Wei
- Henan University of Chinese Medicine, Zhengzhou, Henan, China
| | - Huihong Zhai
- Department of Gastroenterology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Maimaitituerxun R, Chen W, Xiang J, Xie Y, Xiao F, Wu XY, Chen L, Yang J, Liu A, Dai W. Predictive model for identifying mild cognitive impairment in patients with type 2 diabetes mellitus: A CHAID decision tree analysis. Brain Behav 2024; 14:e3456. [PMID: 38450963 PMCID: PMC10918605 DOI: 10.1002/brb3.3456] [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: 10/30/2023] [Revised: 02/04/2024] [Accepted: 02/10/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND As the population ages, mild cognitive impairment (MCI) and type 2 diabetes mellitus (T2DM) become common conditions that often coexist. Evidence has shown that MCI could lead to reduced treatment compliance, medication management, and self-care ability in T2DM patients. Therefore, early identification of those with increased risk of MCI is crucial from a preventive perspective. Given the growing utilization of decision trees in prediction of health-related outcomes, this study aimed to identify MCI in T2DM patients using the decision tree approach. METHODS This hospital-based case-control study was performed in the Endocrinology Department of Xiangya Hospital affiliated to Central South University between March 2021 and December 2022. MCI was defined based on the Petersen criteria. Demographic characteristics, lifestyle factors, and T2DM-related information were collected. The study sample was randomly divided into the training and validation sets in a 7:3 ratio. Univariate and multivariate analyses were performed, and a decision tree model was established using the chi-square automatic interaction detection (CHAID) algorithm to identify key predictor variables associated with MCI. The area under the curve (AUC) value was used to evaluate the performance of the established decision tree model, and the performance of multivariate regression model was also evaluated for comparison. RESULTS A total of 1001 participants (705 in the training set and 296 in the validation set) were included in this study. The mean age of participants in the training and validation sets was 60.2 ± 10.3 and 60.4 ± 9.5 years, respectively. There were no significant differences in the characteristics between the training and validation sets (p > .05). The CHAID decision tree analysis identified six key predictor variables associated with MCI, including age, educational level, household income, regular physical activity, diabetic nephropathy, and diabetic retinopathy. The established decision tree model had 15 nodes composed of 4 layers, and age is the most significant predictor variable. It performed well (AUC = .75 [95% confidence interval (CI): .71-.78] and .67 [95% CI: .61-.74] in the training and validation sets, respectively), was internally validated, and had comparable predictive value compared to the multivariate logistic regression model (AUC = .76 [95% CI: .72-.80] and .69 [95% CI: .62-.75] in the training and validation sets, respectively). CONCLUSION The established decision tree model based on age, educational level, household income, regular physical activity, diabetic nephropathy, and diabetic retinopathy performed well with comparable predictive value compared to the multivariate logistic regression model and was internally validated. Due to its superior classification accuracy and simple presentation as well as interpretation of collected data, the decision tree model is more recommended for the prediction of MCI in T2DM patients in clinical practice.
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Affiliation(s)
- Rehanguli Maimaitituerxun
- Department of Epidemiology and Health Statistics, Xiangya School of Public HealthCentral South UniversityChangshaHunanChina
| | - Wenhang Chen
- Department of NephrologyXiangya Hospital, Central South UniversityChangshaHunanChina
| | - Jingsha Xiang
- Department of Human ResourcesJinan Central Hospital Affiliated to Shandong First Medical UniversityJinanShandongChina
| | - Yu Xie
- Department of Epidemiology and Health Statistics, Xiangya School of Public HealthCentral South UniversityChangshaHunanChina
| | - Fang Xiao
- Department of Toxicology, Xiangya School of Public HealthCentral South UniversityChangshaHunanChina
| | - Xin Yin Wu
- Department of Epidemiology and Health Statistics, Xiangya School of Public HealthCentral South UniversityChangshaHunanChina
| | - Letao Chen
- Infection Control CenterXiangya Hospital, Central South UniversityChangshaHunanChina
| | - Jianzhou Yang
- Department of Preventive MedicineChangzhi Medical CollegeChangzhiShanxiChina
| | - Aizhong Liu
- Department of Epidemiology and Health Statistics, Xiangya School of Public HealthCentral South UniversityChangshaHunanChina
| | - Wenjie Dai
- Department of Epidemiology and Health Statistics, Xiangya School of Public HealthCentral South UniversityChangshaHunanChina
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Hoyos W, Aguilar J, Raciny M, Toro M. Case studies of clinical decision-making through prescriptive models based on machine learning. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 242:107829. [PMID: 37837889 DOI: 10.1016/j.cmpb.2023.107829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/11/2023] [Accepted: 09/22/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND The development of computational methodologies to support clinical decision-making is of vital importance to reduce morbidity and mortality rates. Specifically, prescriptive analytic is a promising area to support decision-making in the monitoring, treatment and prevention of diseases. These aspects remain a challenge for medical professionals and health authorities. MATERIALS AND METHODS In this study, we propose a methodology for the development of prescriptive models to support decision-making in clinical settings. The prescriptive model requires a predictive model to build the prescriptions. The predictive model is developed using fuzzy cognitive maps and the particle swarm optimization algorithm, while the prescriptive model is developed with an extension of fuzzy cognitive maps that combines them with genetic algorithms. We evaluated the proposed approach in three case studies related to monitoring (warfarin dose estimation), treatment (severe dengue) and prevention (geohelminthiasis) of diseases. RESULTS The performance of the developed prescriptive models demonstrated the ability to estimate warfarin doses in coagulated patients, prescribe treatment for severe dengue and generate actions aimed at the prevention of geohelminthiasis. Additionally, the predictive models can predict coagulation indices, severe dengue mortality and soil-transmitted helminth infections. CONCLUSIONS The developed models performed well to prescribe actions aimed to monitor, treat and prevent diseases. This type of strategy allows supporting decision-making in clinical settings. However, validations in health institutions are required for their implementation.
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Affiliation(s)
- William Hoyos
- Grupo de Investigaciones Microbiológicas y Biomédicas de Córdoba, Universidad de Córdoba, Montería, Colombia; Grupo de Investigación en I+D+i en TIC, Universidad EAFIT, Medellín, Colombia
| | - Jose Aguilar
- Grupo de Investigación en I+D+i en TIC, Universidad EAFIT, Medellín, Colombia; Centro de Estudios en Microelectrónica y Sistemas Distribuidos, Universidad de Los Andes, Merida, Venezuela; IMDEA Networks Institute, Madrid, Spain.
| | - Mayra Raciny
- Grupo de Investigaciones Microbiológicas y Biomédicas de Córdoba, Universidad de Córdoba, Montería, Colombia
| | - Mauricio Toro
- Grupo de Investigación en I+D+i en TIC, Universidad EAFIT, Medellín, Colombia
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León-García M, Humphries B, Morales PR, Gravholt D, Eckman MH, Bates SM, Suárez NRE, Xie F, Perestelo-Pérez L, Alonso-Coello P. Assessment of a venous thromboembolism prophylaxis shared decision-making intervention (DASH-TOP) using the decisional conflict scale: a mixed-method study. BMC Med Inform Decis Mak 2023; 23:250. [PMID: 37932759 PMCID: PMC10629184 DOI: 10.1186/s12911-023-02349-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 10/21/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) in pregnancy is a major cause of maternal morbidity and death. The use of low-molecular-weight heparin (LMWH), despite being the standard of care to prevent VTE, comes with some challenges. Shared decision-making (SDM) interventions are recommended to support patients and clinicians in making preference-sensitive decisions. The quality of the SDM process has been widely assessed with the decisional conflict scale (DCS). Our aim is to report participants' perspectives of each of the components of an SDM intervention (DASH-TOP) in relation to the different subscales of the DCS. METHODS Design: A convergent, parallel, mixed-methods design. PARTICIPANTS The sample consisted of 22 health care professionals, students of an Applied Clinical Research in Health Sciences (ICACS) master program. INTERVENTION We randomly divided the participants in three groups: Group 1 received one component (evidence -based information), Group 2 received two components (first component and value elicitation exercises), and Group 3 received all three components (the first two and a decision analysis recommendation) of the SDM intervention. ANALYSIS For the quantitative strand, we used a non-parametric test to analyze the differences in the DCS subscales between the three groups. For the qualitative strand, we conducted a content analysis using the decisional conflict domains to deductively categorize the responses. RESULTS Groups that received more intervention components experienced less conflict and better decision-making quality, although the differences between groups were not statistically significant. The decision analysis recommendation improved the efficacy with the decision-making process, however there are some challenges when implementing it in clinical practice. The uncertainty subscale showed a high decisional conflict for all three groups; contributing factors included low certainty of the evidence-based information provided and a perceived small effect of the drug to reduce the risk of a VTE event. CONCLUSIONS The DASH-TOP intervention reduced decisional conflict in the decision -making process, with decision analysis being the most effective component to improve the quality of the decision. There is a need for more implementation research to improve the delivery of SDM interventions in the clinical encounter.
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Affiliation(s)
- Montserrat León-García
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.
- Department of Pediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain.
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Brittany Humphries
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Pablo Roca Morales
- Faculty of Health Sciences, Universidad Villanueva, Madrid, Spain
- School of Health Sciences, Valencian International University, Valencia, Spain
| | - Derek Gravholt
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mark H Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shannon M Bates
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Nataly R Espinoza Suárez
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- VITAM Research Center for Sustainable Health, Quebec City, Canada
- Faculty of Medicine, Université Laval, Quebec City, Canada
| | - Feng Xie
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
| | - Lilisbeth Perestelo-Pérez
- Evaluation Unit (SESCS), Canary Islands Health Service (SCS), Tenerife, Spain
- Network for Research On Chronicity, Primary Care, and Health Promotion (RICAPPS), Tenerife, Spain
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- CIBER of Epidemiology and Public Health, CIBERESP, Madrid, Spain
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Mehrpour O, Saeedi F, Nakhaee S, Tavakkoli Khomeini F, Hadianfar A, Amirabadizadeh A, Hoyte C. Comparison of decision tree with common machine learning models for prediction of biguanide and sulfonylurea poisoning in the United States: an analysis of the National Poison Data System. BMC Med Inform Decis Mak 2023; 23:60. [PMID: 37024869 PMCID: PMC10080923 DOI: 10.1186/s12911-022-02095-y] [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: 03/30/2022] [Accepted: 12/26/2022] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND Biguanides and sulfonylurea are two classes of anti-diabetic medications that have commonly been prescribed all around the world. Diagnosis of biguanide and sulfonylurea exposures is based on history taking and physical examination; thus, physicians might misdiagnose these two different clinical settings. We aimed to conduct a study to develop a model based on decision tree analysis to help physicians better diagnose these poisoning cases. METHODS The National Poison Data System was used for this six-year retrospective cohort study.The decision tree model, common machine learning models multi layers perceptron, stochastic gradient descent (SGD), Adaboosting classiefier, linear support vector machine and ensembling methods including bagging, voting and stacking methods were used. The confusion matrix, precision, recall, specificity, f1-score, and accuracy were reported to evaluate the model's performance. RESULTS Of 6183 participants, 3336 patients (54.0%) were identified as biguanides exposures, and the remaining were those with sulfonylureas exposures. The decision tree model showed that the most important clinical findings defining biguanide and sulfonylurea exposures were hypoglycemia, abdominal pain, acidosis, diaphoresis, tremor, vomiting, diarrhea, age, and reasons for exposure. The specificity, precision, recall, f1-score, and accuracy of all models were greater than 86%, 89%, 88%, and 88%, respectively. The lowest values belong to SGD model. The decision tree model has a sensitivity (recall) of 93.3%, specificity of 92.8%, precision of 93.4%, f1_score of 93.3%, and accuracy of 93.3%. CONCLUSION Our results indicated that machine learning methods including decision tree and ensembling methods provide a precise prediction model to diagnose biguanides and sulfonylureas exposure.
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Affiliation(s)
- Omid Mehrpour
- Data Science Institute, Southern Methodist University, Dallas, TX, USA.
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Birjand, Iran.
| | - Farhad Saeedi
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Birjand, Iran
- Student Research Committee, Birjand University of Medical Sciences, Birjand, Iran
| | - Samaneh Nakhaee
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Birjand, Iran
| | | | - Ali Hadianfar
- Department of Epidemiology and Biostatistics, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Alireza Amirabadizadeh
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Iselin K, Bachmann L, Baenninger P, Sanak F, Kaufmann C. A Clinical Decision Tree to Support Keratoconus Patients Considering Corneal Cross-Linking Combined with Refractive Treatment. Klin Monbl Augenheilkd 2023; 240:379-384. [PMID: 37164397 DOI: 10.1055/a-2017-5203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
BACKGROUND To develop a fast and frugal decision tree to identify keratoconus patients most likely to benefit visually from the combination of corneal cross-linking (CXL) with topography-guided photorefractive keratectomy ("CXL plus"). PATIENTS AND METHODS The outcome of interest was an improvement in uncorrected distance visual acuity (UDVA) by at least two lines at the 12-month follow-up. Preoperative and 12-month follow-up data from patients who received CXL plus (n = 96) and CXL only (n = 96) were used in a recursive partitioning approach to construct a frugal tree with three variables (corneal thickness [>/< 430 um], patient interest in CXL plus [yes/no], and tomographic cylinder [</> 3 D]). In addition, we estimated the probability of the outcome from a multivariate logistic regression model for each combination of variables used in the decision tree. RESULTS In the complete sample, 101/192 (52.6%) patients improved by at least two lines at the 12-month follow-up. Patients affirmative in all three answers had a 75.6% (34/45) probability of gaining at least two lines of improvement in UDVA by CXL plus. The statistical model estimated a 66.0% probability for a successful outcome. CONCLUSION A fast and frugal tree consisting of three variables can be used to select a patient group with a high likelihood to benefit from CXL plus. The tree is useful in the preoperative counseling of keratoconus patients contemplating the CXL plus option, an intervention that is not fully covered by many health insurances.
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Affiliation(s)
- Katja Iselin
- Dept. of Ophthalmology, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | | | | | - Frantisek Sanak
- Dept. of Ophthalmology, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Claude Kaufmann
- Dept. of Ophthalmology, Lucerne Cantonal Hospital, Lucerne, Switzerland
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Moulder G, Harris E, Santhosh L. Teaching the science of uncertainty. Diagnosis (Berl) 2023; 10:13-18. [PMID: 36087299 DOI: 10.1515/dx-2022-0045] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/16/2022] [Indexed: 11/15/2022]
Abstract
As we increasingly acknowledge the ubiquitous nature of uncertainty in clinical practice (Meyer AN, Giardina TD, Khawaja L, Singh H. Patient and clinician experiences of uncertainty in the diagnostic process: current understanding and future directions. Patient Educ Counsel 2021;104:2606-15; Han PK, Klein WM, Arora NK. Varieties of uncertainty in health care: a conceptual taxonomy. Med Decis Making 2011;31:828-38) and strive to better define this entity (Lee C, Hall K, Anakin M, Pinnock R. Towards a new understanding of uncertainty in medical education. J Eval Clin Pract 2020; Bhise V, Rajan SS, Sittig DF, Morgan RO, Chaudhary P, Singh H. Defining and measuring diagnostic uncertainty in medicine: a systematic review. J Gen Intern Med 2018;33:103-15), as educators we should also design, implement, and evaluate curricula addressing clinical uncertainty. Although frequently encountered, uncertainty is often implicitly referred to rather than explicitly discussed (Gärtner J, Berberat PO, Kadmon M, Harendza S. Implicit expression of uncertainty - suggestion of an empirically derived framework. BMC Med Educ 2020;20:83). Increasing explicit discussion of - and comfort with -uncertainty has the potential to improve diagnostic reasoning and accuracy and improve patient care (Dunlop M, Schwartzstein RM. Reducing diagnostic error in the intensive care unit. Engaging. Uncertainty when teaching clinical reasoning. Scholar;1:364-71). Discussion of both diagnostic and prognostic uncertainty with patients is central to shared decision-making in many contexts as well, (Simpkin AL, Armstrong KA. Communicating uncertainty: a narrative review and framework for future research. J Gen Intern Med 2019;34:2586-91) from the outpatient setting to the inpatient setting, and from undergraduate medical education (UME) trainees to graduate medical education (GME) trainees. In this article, we will explore the current status of how the science of uncertainty is taught from the UME curriculum to the GME curriculum, and describe strategies how uncertainty can be explicitly discussed for all levels of trainees.
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Affiliation(s)
- Glenn Moulder
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Emily Harris
- Department of Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - Lekshmi Santhosh
- Department of Medicine, University of California-San Francisco, San Francisco, CA, USA
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Leidinger A, Zuckerman SL, Feng Y, He Y, Chen X, Cheserem B, Gerber LM, Lessing NL, Shabani HK, Härtl R, Mangat HS. Predictors of spinal trauma care and outcomes in a resource-constrained environment: a decision tree analysis of spinal trauma surgery and outcomes in Tanzania. J Neurosurg Spine 2023; 38:503-511. [PMID: 36640104 DOI: 10.3171/2022.11.spine22763] [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: 07/13/2022] [Accepted: 11/29/2022] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The burden of spinal trauma in low- and middle-income countries (LMICs) is immense, and its management is made complex in such resource-restricted settings. Algorithmic evidence-based management is cost-prohibitive, especially with respect to spinal implants, while perioperative care is work-intensive, making overall care dependent on multiple constraints. The objective of this study was to identify determinants of decision-making for surgical intervention, improvement in function, and in-hospital mortality among patients experiencing acute spinal trauma in resource-constrained settings. METHODS This study was a retrospective analysis of prospectively collected data in a cohort of patients with spinal trauma admitted to a tertiary referral hospital center in Dar es Salam, Tanzania. Data on demographic, clinical, and treatment characteristics were collected as part of a quality improvement neurotrauma registry. Outcome measures were surgical intervention, American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade improvement, and in-hospital mortality, based on existing treatment protocols. Univariate analyses of demographic and clinical characteristics were performed for each outcome of interest. Using the variables associated with each outcome, a machine learning algorithm-based regression nonparametric decision tree model utilizing a bootstrapping method was created and the accuracy of the three models was estimated. RESULTS Two hundred eighty-four consecutively admitted patients with acute spinal trauma were included over a period of 33 months. The median age was 34 (IQR 26-43) years, 83.8% were male, and 50.7% had experienced injury in a motor vehicle accident. The median time to hospital admission after injury was 2 (IQR 1-6) days; surgery was performed after a further median delay of 22 (IQR 13-39) days. Cervical spine injury comprised 38.4% of the injuries. Admission AIS grades were A in 48.9%, B in 16.2%, C in 8.5%, D in 9.5%, and E in 16.6%. Nearly half (45.1%) of the patients underwent surgery, 12% had at least one functional improvement in AIS grade, and 11.6% died in the hospital. Determinants of surgical intervention were age ≤ 30 years, spinal injury level, admission AIS grade, delay in arrival to the referral hospital, undergoing MRI, and type of insurance; admission AIS grade, delay to arrival to the hospital, and injury level for functional improvement; and delay to arrival, injury level, delay to surgery, and admission AIS grade for in-hospital mortality. The best accuracies for the decision tree models were 0.62, 0.34, and 0.93 for surgery, AIS grade improvement, and in-hospital mortality, respectively. CONCLUSIONS Operative intervention and functional improvement after acute spinal trauma in this tertiary referral hospital in an LMIC environment were low and inconsistent, which suggests that nonclinical factors exist within complex resource-driven decision-making frameworks. These nonclinical factors are highlighted by the authors' results showing clinical outcomes and in-hospital mortality were determined by natural history, as evidenced by the highest accuracy of the model predicting in-hospital mortality.
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Affiliation(s)
- Andreas Leidinger
- 1Department of Neurosurgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Scott L Zuckerman
- 2Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yueqi Feng
- 3Biostatistics and Data Science, Cornell University, New York, New York
| | - Yitian He
- 3Biostatistics and Data Science, Cornell University, New York, New York
| | - Xinrui Chen
- 3Biostatistics and Data Science, Cornell University, New York, New York
| | | | | | - Noah L Lessing
- 6School of Medicine, University of Maryland, Baltimore, Maryland
| | - Hamisi K Shabani
- 7Department of Neurosurgery, Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania; and
| | - Roger Härtl
- 8Neurology and Neurological Surgery, Weill Cornell Medical College, New York, New York
| | - Halinder S Mangat
- 9Department of Neurology, Division of Neurocritical Care, University of Kansas Medical Center, Kansas City, Kansas
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Blee JA, Liu X, Harland AJ, Fatania K, Currie S, Kurian KM, Hauert S. Liquid biopsies for early diagnosis of brain tumours: in silico mathematical biomarker modelling. J R Soc Interface 2022; 19:20220180. [PMID: 35919979 PMCID: PMC9346349 DOI: 10.1098/rsif.2022.0180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 07/07/2022] [Indexed: 11/12/2022] Open
Abstract
Brain tumours are the biggest cancer killer in those under 40 and reduce life expectancy more than any other cancer. Blood-based liquid biopsies may aid early diagnosis, prediction and prognosis for brain tumours. It remains unclear whether known blood-based biomarkers, such as glial fibrillary acidic protein (GFAP), have the required sensitivity and selectivity. We have developed a novel in silico model which can be used to assess and compare blood-based liquid biopsies. We focused on GFAP, a putative biomarker for astrocytic tumours and glioblastoma multi-formes (GBMs). In silico modelling was paired with experimental measurement of cell GFAP concentrations and used to predict the tumour volumes and identify key parameters which limit detection. The average GBM volumes of 449 patients at Leeds Teaching Hospitals NHS Trust were also measured and used as a benchmark. Our model predicts that the currently proposed GFAP threshold of 0.12 ng ml-1 may not be suitable for early detection of GBMs, but that lower thresholds may be used. We found that the levels of GFAP in the blood are related to tumour characteristics, such as vasculature damage and rate of necrosis, which are biological markers of tumour aggressiveness. We also demonstrate how these models could be used to provide clinical insight.
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Affiliation(s)
- Johanna A. Blee
- Department of Engineering Mathematics, University of Bristol, Ada Lovelace Building, Bristol BS8 1TW, UK
| | - Xia Liu
- Brain Tumour Research Centre, Bristol Medical School, Bristol BS2 8DZ, UK
| | - Abigail J. Harland
- Brain Tumour Research Centre, Bristol Medical School, Bristol BS2 8DZ, UK
| | - Kavi Fatania
- Department of Radiology, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
| | - Stuart Currie
- Department of Radiology, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
| | | | - Sabine Hauert
- Department of Engineering Mathematics, University of Bristol, Ada Lovelace Building, Bristol BS8 1TW, UK
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11
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Abineza C, Balas VE, Nsengiyumva P. A machine-learning-based prediction method for easy COPD classification based on pulse oximetry clinical use. JOURNAL OF INTELLIGENT & FUZZY SYSTEMS 2022. [DOI: 10.3233/jifs-219270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Chronic Obstructive Pulmonary Disease (COPD) is a progressive, obstructive lung disease that restricts airflow from the lungs. COPD patients are at risk of sudden and acute worsening of symptoms called exacerbations. Early identification and classification of COPD exacerbation can reduce COPD risks and improve patient’s healthcare and management. Pulse oximetry is a non-invasive technique used to assess patients with acutely worsening symptoms. As part of manual diagnosis based on pulse oximetry, clinicians examine three warning signs to classify COPD patients. This may lack high sensitivity and specificity which requires a blood test. However, laboratory tests require time, further delayed treatment and additional costs. This research proposes a prediction method for COPD patients’ classification based on pulse oximetry three manual warning signs and the resulting derived few key features that can be obtained in a short time. The model was developed on a robust physician labeled dataset with clinically diverse patient cases. Five classification algorithms were applied on the mentioned dataset and the results showed that the best algorithm is XGBoost with the accuracy of 91.04%, precision of 99.86%, recall of 82.19%, F1 measure value of 90.05% with an AUC value of 95.8%. Age, current and baseline heart rate, current and baseline pulse ox. (SPO2) were found the top most important predictors. These findings suggest the strength of XGBoost model together with the availability and the simplicity of input variables in classifying COPD daily living using a (wearable) pulse oximeter.
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Affiliation(s)
- Claudia Abineza
- African Center of Excellence in Internet of Things, University of Rwanda, Kigali, Rwanda
| | - Valentina E. Balas
- Department of Automatics and Applied Software, “Aurel Vlaicu” University, Arad, Romania
| | - Philibert Nsengiyumva
- African Center of Excellence in Internet of Things, University of Rwanda, Kigali, Rwanda
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12
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Heldner MR, Chalfine C, Houot M, Umarova RM, Rosner J, Lippert J, Gallucci L, Leger A, Baronnet F, Samson Y, Rosso C. Cognitive Status Predicts Return to Functional Independence After Minor Stroke: A Decision Tree Analysis. Front Neurol 2022; 13:833020. [PMID: 35250835 PMCID: PMC8891604 DOI: 10.3389/fneur.2022.833020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/10/2022] [Indexed: 11/13/2022] Open
Abstract
About two-thirds of patients with minor strokes are discharged home. However, these patients may have difficulties returning to their usual living activities. To investigate the factors associated with successful home discharge, our aim was to provide a decision tree (based on clinical data) that could identify if a patient discharged home could return to pre-stroke activities and to perform an external validation of this decision tree on an independent cohort. Two cohorts of patients with minor strokes gathered from stroke registries at the Hôpital Pitié-Salpêtrière and University Hospital Bern were included in this study (n = 105 for the construction cohort coming from France; n = 100 for the second cohort coming from Switzerland). The decision tree was built using the classification and regression tree (CART) analysis on the construction cohort. It was then applied to the validation cohort. Accuracy, sensitivity, specificity, false positive, and false-negative rates were reported for both cohorts. In the construction cohort, 60 patients (57%) returned to their usual, pre-stroke level of independence. The CART analysis produced a decision tree with the Montreal Cognitive Assessment (MoCA) as the first decision point, followed by discharge NIHSS score or age, and then by the occupational status. The overall prediction accuracy to the favorable outcome was 80% in the construction cohort and reached 72% accuracy in the validation cohort. This decision tree highlighted the role of cognitive function as a crucial factor for patients to return to their usual activities after a minor stroke. The algorithm may help clinicians to tailor planning of patients' discharge.
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Affiliation(s)
- Mirjam R. Heldner
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Caroline Chalfine
- Assistance Publique – Hôpitaux de Paris (APHP) Service de Soins de Suite et Réadaptation, Hôpital Pitié-Salpêtrière, Paris, France
| | - Marion Houot
- Assistance Publique – Hôpitaux de Paris (APHP) Centre d'Investigations Cliniques de Neurosciences, Hôpital Pitié-Salpêtrière, Paris, France
- Inserm U 1127, CNRS UMR 7225, Sorbonne Université, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinière (ICM), Paris, France
| | - Roza M. Umarova
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Jan Rosner
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Julian Lippert
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Laura Gallucci
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Anne Leger
- STARE Team, iCRIN, Institut du Cerveau et de la Moelle épinière (ICM), Paris, France
- APHP-Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
| | - Flore Baronnet
- STARE Team, iCRIN, Institut du Cerveau et de la Moelle épinière (ICM), Paris, France
- APHP-Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
| | - Yves Samson
- STARE Team, iCRIN, Institut du Cerveau et de la Moelle épinière (ICM), Paris, France
- APHP-Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
| | - Charlotte Rosso
- Inserm U 1127, CNRS UMR 7225, Sorbonne Université, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinière (ICM), Paris, France
- STARE Team, iCRIN, Institut du Cerveau et de la Moelle épinière (ICM), Paris, France
- APHP-Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
- *Correspondence: Charlotte Rosso
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13
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Li R, Ellington SR, Galang RR, Grosse SD, Mendoza Z, Hurst S, Vale Y, Lathrop E, Romero L. Economic evaluation of Zika Contraception Access Network in Puerto Rico during the 2016-17 Zika virus outbreak. Contraception 2021; 107:68-73. [PMID: 34748752 DOI: 10.1016/j.contraception.2021.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 10/04/2021] [Accepted: 10/23/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE During the 2016-2017 Zika virus (ZIKV) outbreak, the prevention of unintended pregnancies was identified as a primary strategy to prevent birth defects. This study estimated the cost-effectiveness of the Zika Contraception Access Network (Z-CAN), an emergency response intervention that provided women in Puerto Rico with access to the full range of reversible contraception at no cost and compared results with a pre-implementation hypothetical cost-effectiveness analysis (CEA). STUDY DESIGN We evaluated costs and outcomes of Z-CAN from a health sector perspective compared to no intervention using a decision tree model. Number of people served, contraception methods mix, and costs under Z-CAN were from actual program data and other input parameters were from the literature. Health outcome measures included the number of Zika-associated microcephaly (ZAM) cases and unintended pregnancies. The economic benefits of the Z-CAN intervention were ZIKV-associated direct costs avoided, including lifetime medical and supportive costs associated with ZAM cases, costs of monitoring ZIKV-exposed pregnancies and infants born from Zika-virus infected mothers, and the costs of unintended pregnancies prevented during the outbreak as a result of increased contraception use through the Z-CAN intervention. RESULTS The Z-CAN intervention cost a total of $26.1 million, including costs for the full range of reversible contraceptive methods, contraception related services, and programmatic activities. The program is estimated to have prevented 85% of cases of estimated ZAM cases and unintended pregnancies in the absence of Z-CAN. The intervention cost was projected to have been more than offset by $79.9 million in ZIKV-associated costs avoided, 96% of which were lifetime ZAM-associated costs, as well as $137.0 million from avoided unintended pregnancies, with total net savings in one year of $216.9 million. The results were consistent with the previous CEA study. CONCLUSION Z-CAN was likely cost-saving in the context of a public health emergency response setting.
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Affiliation(s)
- Rui Li
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA.
| | - Sascha R Ellington
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Romeo R Galang
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Scott D Grosse
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Zipatly Mendoza
- National Foundation for the Centers for Disease Control and Prevention, 600 Peachtree Street NE, Suite 1000, Atlanta, GA, 30308
| | - Stacey Hurst
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Yari Vale
- University of Puerto Rico, Department of Gynecology and Obstetrics
| | - Eva Lathrop
- Department of Obstetrics and Gynecology, Emory University School of Medicine, Atlanta, GA
| | - Lisa Romero
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
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14
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Decherchi S, Pedrini E, Mordenti M, Cavalli A, Sangiorgi L. Opportunities and Challenges for Machine Learning in Rare Diseases. Front Med (Lausanne) 2021; 8:747612. [PMID: 34676229 PMCID: PMC8523988 DOI: 10.3389/fmed.2021.747612] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/31/2021] [Indexed: 12/16/2022] Open
Abstract
Rare diseases (RDs) are complicated health conditions that are difficult to be managed at several levels. The scarcity of available data chiefly determines an intricate scenario even for experts and specialized clinicians, which in turn leads to the so called “diagnostic odyssey” for the patient. This situation calls for innovative solutions to support the decision process via quantitative and automated tools. Machine learning brings to the stage a wealth of powerful inference methods; however, matching the health conditions with advanced statistical techniques raises methodological, technological, and even ethical issues. In this contribution, we critically point to the specificities of the dialog of rare diseases with machine learning techniques concentrating on the key steps and challenges that may hamper or create actionable knowledge and value for the patient together with some on-field methodological suggestions and considerations.
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Affiliation(s)
- Sergio Decherchi
- Computational and Chemical Biology, Fondazione Istituto Italiano di Tecnologia, Genoa, Italy
| | - Elena Pedrini
- Department of Rare Skeletal Disorders, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marina Mordenti
- Department of Rare Skeletal Disorders, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Andrea Cavalli
- Computational and Chemical Biology, Fondazione Istituto Italiano di Tecnologia, Genoa, Italy.,Department of Pharmacy and Biotechnology (FaBiT), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Luca Sangiorgi
- Department of Rare Skeletal Disorders, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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15
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Lee C, Hall K, Anakin M, Pinnock R. Towards a new understanding of uncertainty in medical education. J Eval Clin Pract 2021; 27:1194-1204. [PMID: 33089607 DOI: 10.1111/jep.13503] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/27/2020] [Accepted: 09/28/2020] [Indexed: 12/21/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Uncertainty is a complex and constant phenomenon in clinical practice. How medical students recognize and respond to uncertainty impacts on their well-being, career choices, and attitudes towards patients. It has been suggested that curricula should do more to prepare medical students for an uncertain world. In order to teach medical students about uncertainty, we need to understand how uncertainty has been conceptualized in the literature to date. The aim of this article is to explore existing models of uncertainty and to develop a framework of clinical uncertainty to aid medical education. METHOD A scoping literature review was performed to identify conceptual models of uncertainty in healthcare. Content and inductive analyses were performed to explore three dimensions of clinical uncertainty: sources of uncertainty, subjective influencers and responses to uncertainty. RESULTS Nine hundred one references were identified using our search strategy, of which, 24 met our inclusion criteria. It was possible to classify these conceptual models using one or more of three dimensions of uncertainty; sources, subjective influencers, and responses. Exploration and further classification of these dimensions led to the development of a framework of uncertainty for medical education. CONCLUSION The developed framework of clinical uncertainty highlights sources, subjective influencers, responses to uncertainty, and the dynamic relationship among these elements. Our framework illustrates the different aspects of knowledge as a source of uncertainty and how to distinguish between those aspects. Our framework highlights the complexity of sources of uncertainty, especially when including uncertainty arising from relationships and systems. These sources can occur in combination. Our framework is also novel in how it describes the impact of influencers such as personal characteristics, experience, and affect on perceptions of and responses to uncertainty. This framework can be used by educators and curricula developers to help understand and teach about clinical uncertainty.
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Affiliation(s)
- Ciara Lee
- Department of General Practice and Rural Health, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Katherine Hall
- Department of General Practice and Rural Health, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Megan Anakin
- Education Unit, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Ralph Pinnock
- Education Unit, Otago Medical School, University of Otago, Dunedin, New Zealand
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16
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Toth EG, Gibbs D, Moczygemba J, McLeod A. Decision tree modeling in R software to aid clinical decision making. HEALTH AND TECHNOLOGY 2021. [DOI: 10.1007/s12553-021-00542-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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17
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Si T, Sun L, Zhang Y, Zhang L. Dose Adjustment Model of Paliperidone in Patients With Acute Schizophrenia: A post hoc Analysis of an Open-Label, Single-Arm Multicenter Study. Front Psychiatry 2021; 12:723245. [PMID: 34497547 PMCID: PMC8419303 DOI: 10.3389/fpsyt.2021.723245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 07/28/2021] [Indexed: 12/01/2022] Open
Abstract
This study aimed to investigate the factors that influenced the clinicians to adjust the paliperidone dose in the acute phase of schizophrenia. This was a post hoc study of an 8-week, open-label, single-arm multicenter trial which evaluated the efficacy, safety, and tolerability of flexible doses of paliperidone ER (3-12 mg/day) in patients with acutely exacerbated schizophrenia. Patients were divided into groups according to the dose at week 8 (3, 6, and 9-12 mg). The responder was defined as the reduction percentage in the Positive and Negative Syndrome Scale (PANSS) total score of ≥30%. According to the chi-squared automatic interaction detection algorithm, decision tree models predicting an increase in the dose of paliperidone ER were established. A decision tree, based on 4-week Marder positive factor, Clinical Global Impression (CGI), and BMI, was established to guide the dose adjustments of paliperidone ER in the acute phase of schizophrenia. The multivariable logistic regression analysis showed that lower age at onset, higher baseline PANSS positive subscale score, and lower baseline Personal and Social Performance Scale (PSP) score were significant predictors of increased dose in responders. Patients with young-onset age, severe baseline symptoms, and poor function are more likely to benefit from high dosage.
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Affiliation(s)
- Tianmei Si
- Peking University Sixth Hospital (Institute of Mental Health), Beijing, China.,NHC Key Laboratory of Mental Health (Peking University) & National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China
| | - Ling Sun
- Tianjin Anding Hospital, Tianjin, China
| | | | - Lili Zhang
- Xian Janssen Pharmaceuticals, Beijing, China
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18
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de la Espriella R. Decision Making in Psychiatric Patients: A Qualitative Study with Focus Groups. ACTA ACUST UNITED AC 2020; 49:231-238. [PMID: 33328015 DOI: 10.1016/j.rcp.2019.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 03/15/2019] [Accepted: 06/04/2019] [Indexed: 12/01/2022]
Abstract
INTRODUCTION It has been said that mental illnesses are characterised by poor decision making; there is some neuroscientific evidence of specific alterations in performance in decision making tests, but little is known about how patients make choices about their own treatments. METHODS Focus groups with patients from two psychiatric clinics, with discourse analysis. RESULTS Five deductive categories (tools, capacity, therapeutic relationship, method and family and network), plus one additional category from the analysis (stigma), and 35 inductive (posterior) categories were considered. The categories are analysed and the findings presented. CONCLUSIONS Patients express a need for greater participation in decisions about their treatment, and a more symmetrical psychiatrist-patient relationship, involving families. Decisions may be changed due to stigma, barriers to treatment access, and previous experiences.
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Affiliation(s)
- Ricardo de la Espriella
- Departamento de Psiquiatría y Salud Mental, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia.
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19
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Boggs D, Kuper H, Mactaggart I, Murthy G, Oye J, Polack S. Estimating assistive product need in Cameroon and India: results of population-based surveys and comparison of self-report and clinical impairment assessment approaches. Trop Med Int Health 2020; 26:146-158. [PMID: 33166008 DOI: 10.1111/tmi.13523] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To estimate population need and coverage for distance glasses, hearing aids and wheelchairs in India and Cameroon, and to explore the relationship between assistive product (AP) need measured through self-report and clinical impairment assessment. METHODS Population-based surveys of approximately 4000 people each were conducted in Mahabubnagar district, India and Fundong district, Cameroon. Participants underwent standardised vision, hearing and musculoskeletal impairment assessment to assess need for distance glasses, hearing aids, wheelchairs. Participants with moderate or worse impairment and/or self-reported difficulties in functioning were also asked about their self-reported AP need. RESULTS 6.5% (95% CI 5.4-7.9) in India and 1.9% (95% CI 1.5-2.4) in Cameroon of the population needed at least one of the three APs based on moderate or worse impairments. Total need was highest for distance glasses [3.7% (95% CI 2.8-4.7) India; 0.8% (95% CI 0.5-1.1), Cameroon] and lowest for wheelchairs (0.1% both settings; 95% CI 0.03-0.3 India, 95% CI 0.04-0.3 Cameroon). Coverage for each AP was below 40%, except for distance glasses in India, where it was 87% (95% CI 77.1-93.0). The agreement between self-report and clinical impairment assessment of AP need was poor. For instance, in India, 60% of people identified through clinical assessment as needing distance glasses did not self-report a need. Conversely, in India, 75% of people who self-reported needing distance glasses did not require one based on clinical impairment assessment. CONCLUSIONS There is high need and low coverage of three APs in two low-and middle-income settings. Methodological shortcomings highlight the need for improved survey methods compatible with the international classification of functioning, disability and health to estimate population-level need for AP and related services to inform advocacy and planning.
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Affiliation(s)
- Dorothy Boggs
- International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, London, UK
| | - Hannah Kuper
- International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, London, UK
| | - Islay Mactaggart
- International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, London, UK
| | - Gvs Murthy
- International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, London, UK.,Indian Institute of Public Health, Hyderabad, India
| | | | - Sarah Polack
- International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, London, UK
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20
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Abstract
Engaging patients in shared decision making (SDM) is a professional requirement since the Montgomery ruling in 2015. Endodontic treatments present a specific challenge to achieving SDM, both for the clinician and the patient. The treatments are often perceived as more challenging to complete by the clinician, and the assessment of risk and likely outcome requires a deep understanding of the (limited) evidence base. For the patient, decisions can be required at a time of acute symptoms and prolonged treatments. There are health literacy demands in comparison to some less complex dental treatments. Treatment decisions may be based more on inherent biases and prior experiences than objective probabilities. This article discusses options and supports effective shared decision making in endodontic treatment.
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Affiliation(s)
| | - Aengus Kelly
- Clinical Lecturer in Dental Education, Peninsula Dental School, Plymouth University
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21
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Girard CI, Warren CE, Romanchuk NJ, Del Bel MJ, Carsen S, Chan ADC, Benoit DL. Decision Tree Learning Algorithm for Classifying Knee Injury Status Using Return-to-Activity Criteria. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2020:5494-5497. [PMID: 33019223 DOI: 10.1109/embc44109.2020.9176010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Anterior cruciate ligament (ACL) injury rates in female adolescents are increasing. Irrespective of treatment options, approximately 1/3 will suffer secondary ACL injuries following their return to activity (RTA). Despite this, there are no evidence-informed RTA guidelines to aid clinicians in deciding when this should occur. The first step towards these guidelines is to identify relevant and feasible measures to assess the functional status of these patients. The purpose of this study was therefore to evaluate tests frequently used to assess functional capacity following surgery using a Reduced Error Pruning Tree (REPT). Thirty-six healthy and forty-two ACLinjured adolescent females performed a series of functional tasks. Motion analysis along with spatiotemporal measures were used to extract thirty clinically relevant variables. The REPT reduced these variables down to two limb symmetry measures (maximum anterior hop and maximum lateral hop), capable of classifying injury status between the healthy and ACL injured participants with a 69% sensitivity, 78% specificity and kappa statistic of 0.464. We, therefore, conclude that the REPT model was able to evaluate functional capacity as it relates to injury status in adolescent females. We also recommend considering these variables when developing RTA assessments and guidelines.Clinical Relevance- Our results indicate that spatiotemporal measures may differentiate ACL-injured and healthy female adolescents with moderate confidence using a REPT. The identified tests may reasonably be added to the clinical evaluation process when evaluating functional capacity and readiness to return to activity.
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22
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Aydin E, Türkmen İU, Namli G, Öztürk Ç, Esen AB, Eray YN, Eroğlu E, Akova F. A novel and simple machine learning algorithm for preoperative diagnosis of acute appendicitis in children. Pediatr Surg Int 2020; 36:735-742. [PMID: 32314055 DOI: 10.1007/s00383-020-04655-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION There is a tendency toward nonoperative management of appendicitis resulting in an increasing need for preoperative diagnosis and classification. For medical purposes, simple conceptual decision-making models that can learn are widely used. Decision trees are reliable and effective techniques which provide high classification accuracy. We tested if we could detect appendicitis and differentiate uncomplicated from complicated cases using machine learning algorithms. MATERIALS AND METHODS We analyzed all cases admitted between 2010 and 2016 that fell into the following categories: healthy controls (Group 1); sham controls (Group 2); sham disease (Group 3), and acute abdomen (Group 4). The latter group was further divided into four groups: false laparotomy; uncomplicated appendicitis; complicated appendicitis without abscess, and complicated appendicitis with abscess. Patients with comorbidities and whose complete blood count and/or pathology results were lacking were excluded. Data were collected for demographics, preoperative blood analysis, and postoperative diagnosis. Various machine learning algorithms were applied to detect appendicitis patients. RESULTS There were 7244 patients with a mean age of 6.84 ± 5.31 years, of whom 82.3% (5960/7244) were male. Most algorithms tested, especially linear methods, provided similar performance measures. We preferred the decision tree model due to its easier interpretability. With this algorithm, we detected appendicitis patients with 93.97% area under the curve (AUC), 94.69% accuracy, 93.55% sensitivity, and 96.55% specificity, and uncomplicated appendicitis with 79.47% AUC, 70.83% accuracy, 66.81% sensitivity, and 81.88% specificity. CONCLUSIONS Machine learning is a novel approach to prevent unnecessary operations and decrease the burden of appendicitis both for patients and health systems. LEVELS OF EVIDENCE III.
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Affiliation(s)
- Emrah Aydin
- Department of Pediatric Surgery, Koç University School of Medicine, Istanbul, Turkey. .,Department of Pediatric Surgery, Bahcelievler State Hospital, Istanbul, Turkey. .,Department of Pediatric Surgery, Bagcilar Training and Research Hospital, Istanbul, Turkey. .,Maltepe Mah Topkapi, Cad No:4, 34010, Zeytinburnu, Istanbul, Turkey.
| | | | - Gözde Namli
- Department of Pediatric Surgery, Bahcelievler State Hospital, Istanbul, Turkey
| | - Çiğdem Öztürk
- Department of Pathology, Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Ayşe B Esen
- Department of Microbiology, Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Y Nur Eray
- Department of Pediatric Surgery, Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Egemen Eroğlu
- Department of Pediatric Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Fatih Akova
- Department of Pediatric Surgery, Bagcilar Training and Research Hospital, Istanbul, Turkey.,Department of Pediatric Surgery, Biruni University, Istanbul, Turkey
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23
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Use of Decision Analysis and Economic Evaluation in Breast Reconstruction: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2786. [PMID: 32440446 PMCID: PMC7209866 DOI: 10.1097/gox.0000000000002786] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 02/26/2020] [Indexed: 11/26/2022]
Abstract
Background: Decision analysis allows clinicians to compare different strategies in the context of uncertainty, through explicit and quantitative measures such as quality of life outcomes and costing data. This is especially important in breast reconstruction, where multiple strategies can be offered to patients. This systematic review aims to appraise and review the different decision analytic models used in breast reconstruction. Methods: A search of English articles in PubMed, Ovid, and Embase databases was performed. All articles regardless of date of publishing were considered. Two reviewers independently assessed each article, based on strict inclusion criteria. Results: Out of 442 articles identified, 27 fit within the inclusion criteria. These were then grouped according to aspects of breast reconstruction, with implant-based reconstruction (n = 13) being the most commonly reported. Decision analysis (n = 19) and/or economic analyses (n = 27) were employed to discuss reconstructive options. The most common outcome was cost (n = 27). The decision analysis models compared and contrasted surgical strategies, management options, and novel adjuncts. Conclusions: Decision analysis in breast reconstruction is growing exponentially.The most common model used was a simple decision tree. Models published were of high quality but could be improved with a more in-depth sensitivity analysis. It is essential for surgeons to familiarize themselves with the concept of decision analysis to better tackle complicated decisions, due to its intrinsic advantage of being able to weigh risks and benefits of multiple strategies while using probabilistic models.
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24
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Ahmed Z, Mohamed K, Zeeshan S, Dong X. Artificial intelligence with multi-functional machine learning platform development for better healthcare and precision medicine. Database (Oxford) 2020; 2020:baaa010. [PMID: 32185396 PMCID: PMC7078068 DOI: 10.1093/database/baaa010] [Citation(s) in RCA: 167] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 01/05/2020] [Accepted: 01/21/2020] [Indexed: 02/06/2023]
Abstract
Precision medicine is one of the recent and powerful developments in medical care, which has the potential to improve the traditional symptom-driven practice of medicine, allowing earlier interventions using advanced diagnostics and tailoring better and economically personalized treatments. Identifying the best pathway to personalized and population medicine involves the ability to analyze comprehensive patient information together with broader aspects to monitor and distinguish between sick and relatively healthy people, which will lead to a better understanding of biological indicators that can signal shifts in health. While the complexities of disease at the individual level have made it difficult to utilize healthcare information in clinical decision-making, some of the existing constraints have been greatly minimized by technological advancements. To implement effective precision medicine with enhanced ability to positively impact patient outcomes and provide real-time decision support, it is important to harness the power of electronic health records by integrating disparate data sources and discovering patient-specific patterns of disease progression. Useful analytic tools, technologies, databases, and approaches are required to augment networking and interoperability of clinical, laboratory and public health systems, as well as addressing ethical and social issues related to the privacy and protection of healthcare data with effective balance. Developing multifunctional machine learning platforms for clinical data extraction, aggregation, management and analysis can support clinicians by efficiently stratifying subjects to understand specific scenarios and optimize decision-making. Implementation of artificial intelligence in healthcare is a compelling vision that has the potential in leading to the significant improvements for achieving the goals of providing real-time, better personalized and population medicine at lower costs. In this study, we focused on analyzing and discussing various published artificial intelligence and machine learning solutions, approaches and perspectives, aiming to advance academic solutions in paving the way for a new data-centric era of discovery in healthcare.
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Affiliation(s)
- Zeeshan Ahmed
- Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, 112 Paterson Street, New Brunswick, NJ, USA
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences, 125 Paterson Street, New Brunswick, NJ, USA
- Department of Genetics and Genome Sciences, School of Medicine, University of Connecticut Health Center, 263 Farmington Ave., Farmington, CT, USA
- Institute for Systems Genomics, University of Connecticut, 67 North Eagleville Road, Storrs, CT, USA
| | - Khalid Mohamed
- Department of Genetics and Genome Sciences, School of Medicine, University of Connecticut Health Center, 263 Farmington Ave., Farmington, CT, USA
| | - Saman Zeeshan
- The Jackson Laboratory for Genomic Medicine, 10 Discovery Drive, Farmington, CT, USA
| | - XinQi Dong
- Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, 112 Paterson Street, New Brunswick, NJ, USA
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences, 125 Paterson Street, New Brunswick, NJ, USA
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25
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Assessing the Impact of Ozone and Particulate Matter on Mortality Rate from Respiratory Disease in Seoul, Korea. ATMOSPHERE 2019. [DOI: 10.3390/atmos10110685] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The evidence linking ozone and particulate matter with adverse health impacts is increasing. The goal of this study was to assess the impact of air pollution on the mortality rate from respiratory disease in Seoul, Korea, between 2008 and 2017. The analysis was conducted using a decision tree model in two ways: using 24-hour average concentrations and using 1-hour maximum values to compare any health impacts from the different times of exposure to pollution. Results show that in spring an elevated level of ozone is one of the most important factors, but in summer temperature has a greater impact than air pollution. Nitrogen dioxide is one of the most important factors in fall, while high levels of particles less than 2.5 μm (PM2.5) and 10 μm in size (PM10) and cooler temperatures are key factors in winter. We checked the accuracy of our results through a 10-fold cross validation method. Error rates using 24-hour average and 1-hour maximum concentrations were in the ranges of 24.9%–42% and 27.6%–42%, respectively, indicating that 24-hour average concentrations are slightly more directly related with mortality rate. These results could be useful for policy makers in determining the temporal scale of predicted pollutant concentrations for an air quality warning system to help minimize the adverse impacts of air pollution.
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26
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Use of Decision Analysis and Economic Evaluation in Upper Extremity Surgery: A Systematic Review. Plast Reconstr Surg 2019; 144:395-407. [PMID: 31348350 DOI: 10.1097/prs.0000000000005830] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Decision analysis allows clinicians to apply evidence-based medicine to guide objective decisions in uncertain scenarios. There is no comprehensive review summarizing the various decision analysis tools used. The authors aimed to appraise and review the decision analytic models used in hand surgery. METHODS A search of English articles on the PubMed, Ovid, and Embase databases was performed. All articles, regardless of date of publishing, were considered. Two reviewers, based on strict inclusion criteria, independently assessed each article. RESULTS The search resulted in 5525 abstracts, which yielded 30 studies that met inclusion criteria. Included studies were grouped according to medical indications, with scaphoid fractures (n = 6) and carpal tunnel syndrome (n = 5) being the most commonly reported. Included articles used decision analysis (n = 15) and/or economic analyses (n = 23) to discuss diagnostic strategies or compare treatments. The three most common outcomes reported were utility (n = 12), cost per quality-adjusted life-year (n = 16), and quality-adjusted life-years (n = 16). The decision analysis models compared diagnostic strategies, management options, and novel treatments. CONCLUSIONS Decision analysis is increasingly popular in hand surgery. It is useful for comparing surgical strategies through evaluation of quality-of-life outcomes and costing data. The most common model was a simple decision tree. The quality of decision analysis models can be improved with the addition of sensitivity analysis. Surgeons should be familiar with the principles of decision analysis, so that complex decisions can be evaluated using rigorous probabilistic models that combine risks and benefits of multiple strategies.
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27
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Krismer F, Seppi K, Göbel G, Steiger R, Zucal I, Boesch S, Gizewski ER, Wenning GK, Poewe W, Scherfler C. Morphometric MRI profiles of multiple system atrophy variants and implications for differential diagnosis. Mov Disord 2019; 34:1041-1048. [PMID: 30919495 PMCID: PMC6767501 DOI: 10.1002/mds.27669] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 02/07/2019] [Accepted: 02/12/2019] [Indexed: 12/14/2022] Open
Abstract
Background Manual width measurements of the middle cerebellar peduncle on MRI were shown to improve the accuracy of an imaging‐guided diagnosis of multiple system atrophy (MSA). Recently, automated volume segmentation algorithms were able to reliably differentiate patients with Parkinson's disease (PD) and the parkinsonian variant of MSA. The objective of the current study was to integrate probabilistic information of the middle cerebellar peduncle into an existing MRI atlas for automated subcortical segmentation and to evaluate the diagnostic properties of the novel atlas for the differential diagnosis of MSA (parkinsonian and cerebellar variant) versus PD. Methods Three Tesla MRI scans of 48 healthy individuals were used to establish an automated whole‐brain segmentation procedure that includes the volumes of the putamen, cerebellar gray and white matter, and the middle cerebellar peduncles. Classification accuracy of segmented volumes were tested in early‐stage MSA patients (18 MSA‐parkinsonism, 13 MSA‐cerebellar) and 19 PD patients using a C4.5 classifier. Results Putaminal and infratentorial atrophy were present in 77.8% and 61.1% of MSA‐parkinsonian patients, respectively. Four of 18 MSA‐parkinsonian patients (22.2%) had infratentorial atrophy without evidence of putaminal atrophy. Infratentorial atrophy was present in all MSA‐cerebellar patients, with concomitant putaminal atrophy in 46.2% of these cases. The diagnostic algorithm using putaminal and infratentorial volumetric information correctly classified all PD patients and 96.8% of MSA patients. Conclusions The middle cerebellar peduncle was successfully integrated into a subcortical segmentation atlas, and its excellent diagnostic accuracy outperformed existing volumetric MRI processing strategies in differentiating MSA patients with variable atrophy patterns from PD patients. © 2019 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Florian Krismer
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria.,Neuroimaging Research Core Facility, Medical University Innsbruck, Innsbruck, Austria
| | - Klaus Seppi
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria.,Neuroimaging Research Core Facility, Medical University Innsbruck, Innsbruck, Austria
| | - Georg Göbel
- Medical Statistics, Informatics and Health Economics, Medical University Innsbruck, Innsbruck, Austria
| | - Ruth Steiger
- Neuroimaging Research Core Facility, Medical University Innsbruck, Innsbruck, Austria.,Department of Neuroradiology, Medical University Innsbruck, Innsbruck, Austria
| | - Isabel Zucal
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Sylvia Boesch
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Elke R Gizewski
- Neuroimaging Research Core Facility, Medical University Innsbruck, Innsbruck, Austria.,Department of Neuroradiology, Medical University Innsbruck, Innsbruck, Austria
| | - Gregor K Wenning
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Werner Poewe
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria.,Neuroimaging Research Core Facility, Medical University Innsbruck, Innsbruck, Austria
| | - Christoph Scherfler
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria.,Neuroimaging Research Core Facility, Medical University Innsbruck, Innsbruck, Austria
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28
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Boggenpoel B, Madasa V, Jeftha T, Joseph C. Systematic scoping review protocol for clinical prediction rules (CPRs) in the management of patients with spinal cord injuries. BMJ Open 2019; 9:e025076. [PMID: 30782748 PMCID: PMC6361323 DOI: 10.1136/bmjopen-2018-025076] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION The upsurge in the use of clinical prediction models in general medical practice is a result of evidence-based practice. However, the total number of clinical prediction rules (CPRs) currently being used or undergoing impact analysis in the management of patients who have sustained spinal cord injuries (SCIs) is unknown. This scoping review protocol will describe the current CPRs being used and highlight their possible strengths and weaknesses in SCI management. METHODS AND ANALYSIS Arksey and O'Malley's scoping review framework will be used. The following databases will be searched to identify relevant literature relating to the use of CPRs in the management of patients who have sustained an SCI: PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), ScienceDirect, EBSCOhost, Medline, OvidMedline and Google Scholar. Grey literature as well as reference lists of included studies will be searched. All studies relating to the use of CPRs in the management of patients with SCIs will be included. Literature searches and data extraction will be performed independently by two groups of reviewers. ETHICS AND DISSEMINATION Ethical clearance is not required for this scoping review study since only secondary data sources will be used. The findings of this review will be disseminated by means of peer-reviewed publication and conference proceedings. The final paper will be submitted for publication. Results of this review will also be presented at relevant conferences and disseminated to important stakeholders such as practicing physicians within specialised spinal care facilities within South Africa.
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Affiliation(s)
- Blake Boggenpoel
- Department of Physiotherapy, The University of the Western Cape, Cape Town, South Africa
| | - Vuyolwethu Madasa
- Department of Physiotherapy, The University of the Western Cape, Cape Town, South Africa
| | - Tarryn Jeftha
- Department of Physiotherapy, The University of the Western Cape, Cape Town, South Africa
| | - Conran Joseph
- Department of Physiotherapy, The University of the Western Cape, Cape Town, South Africa
- Department of Neurobiology, Care Sciences and Society, Physiotherapy Division, Karolinska Institutet, Stockholm, Sweden
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29
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Romanowski K, Campbell JR, Oxlade O, Fregonese F, Menzies D, Johnston JC. The impact of improved detection and treatment of isoniazid resistant tuberculosis on prevalence of multi-drug resistant tuberculosis: A modelling study. PLoS One 2019; 14:e0211355. [PMID: 30677101 PMCID: PMC6345486 DOI: 10.1371/journal.pone.0211355] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/13/2019] [Indexed: 11/27/2022] Open
Abstract
Introduction Isoniazid-resistant, rifampin susceptible tuberculosis (INHR-TB) is the most common form of drug resistant TB globally. Treatment of INHR-TB with standard first-line therapy is associated with high rates of multidrug resistant TB (MDR-TB). We modelled the potential impact of INHR-TB detection and appropriate treatment on MDR-TB prevalence. Methods A decision analysis model was developed to compare three different strategies for the detection of TB (AFB smear, Xpert MTB/RIF, and Line-Probe Assays (LPA)), combined with appropriate treatment. The population evaluated were patients with a globally representative prevalence of newly diagnosed, drug-susceptible (88.6%), isoniazid-resistant (7.3%), and multidrug resistant (4.1%) pulmonary TB. Our primary outcome was the proportion of patients with MDR-TB after initial attempt at diagnosis and treatment within a 2-year period. Secondary outcomes were the proportion of i) individuals with detected TB who acquired MDR-TB ii) individuals who died after initial attempt at diagnosis and treatment. Results After initial attempt at diagnosis and treatment, LPA combined with appropriate INHR-TB therapy resulted in a lower proportion of prevalent MDR-TB (1.61%; 95% Uncertainty Range (UR: 2.5th and 97.5th percentiles generated from 10 000 Monte Carlo simulation trials) 1.61–1.65), when compared to Xpert (1.84%; 95% UR 1.82–1.85) and AFB smear (3.21%; 95% UR 3.19–3.26). LPA also resulted in fewer cases of acquired MDR-TB in those with detected TB (0.35%; 95% UR 0.34–0.35), when compared to Xpert (0.67%; 95% UR 0.65–0.67) and AFB smear (0.68%; 95% UR 0.67–0.69). The majority of acquired MDR-TB arose from the treatment of INHR-TB in all strategies. Xpert-based strategies resulted in a lower proportion of death (2.89%; 95% UR 2.87–2.90) compared to LPA (2.93%; 95% UR 2.91–2.94) and AFB smear (3.21%; 95% UR 3.19–3.23). Conclusion Accurate diagnosis and tailored treatment of INHR-TB with LPA led to an almost 50% relative decrease in acquired MDR-TB when compared with an Xpert MTB/RIF strategy. Continued reliance on diagnostic and treatment protocols that ignore INHR-TB will likely result in further generation of MDR-TB.
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Affiliation(s)
- Kamila Romanowski
- TB Services, BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | | | - Olivia Oxlade
- McGill International TB Centre, Montreal, Quebec, Canada
| | | | - Dick Menzies
- McGill International TB Centre, Montreal, Quebec, Canada
- Division of Respiratory Medicine, Department of Medicine, McGill University, Quebec, Canada
| | - James C. Johnston
- TB Services, BC Centre for Disease Control, Vancouver, British Columbia, Canada
- McGill International TB Centre, Montreal, Quebec, Canada
- Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Canada
- * E-mail:
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30
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Tai YM, Tsai GF, Guu SM. Risk factors of psychiatric hospitalization of military service persons in Taiwan: Preliminary results from unsupervised clustering techniques. TAIWANESE JOURNAL OF PSYCHIATRY 2019. [DOI: 10.4103/tpsy.tpsy_19_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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31
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Min L, Zhao Y, Xing J, Zhang S. Letter: NICE referral criteria for lower gastrointestinal alarm features - not ideal but not poor either. Aliment Pharmacol Ther 2017; 45:1175. [PMID: 28326582 DOI: 10.1111/apt.13989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- L Min
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing, China
| | - Y Zhao
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing, China
| | - J Xing
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing, China
| | - S Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing, China
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32
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An ethical evaluation index system for clinical approval of medical technology in China: A structural equation model study. Chin J Integr Med 2016; 23:474-480. [DOI: 10.1007/s11655-016-2628-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Indexed: 10/20/2022]
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Mohebian MR, Marateb HR, Mansourian M, Mañanas MA, Mokarian F. A Hybrid Computer-aided-diagnosis System for Prediction of Breast Cancer Recurrence (HPBCR) Using Optimized Ensemble Learning. Comput Struct Biotechnol J 2016; 15:75-85. [PMID: 28018557 PMCID: PMC5173316 DOI: 10.1016/j.csbj.2016.11.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 11/24/2016] [Accepted: 11/26/2016] [Indexed: 02/07/2023] Open
Abstract
Cancer is a collection of diseases that involves growing abnormal cells with the potential to invade or spread to the body. Breast cancer is the second leading cause of cancer death among women. A method for 5-year breast cancer recurrence prediction is presented in this manuscript. Clinicopathologic characteristics of 579 breast cancer patients (recurrence prevalence of 19.3%) were analyzed and discriminative features were selected using statistical feature selection methods. They were further refined by Particle Swarm Optimization (PSO) as the inputs of the classification system with ensemble learning (Bagged Decision Tree: BDT). The proper combination of selected categorical features and also the weight (importance) of the selected interval-measurement-scale features were identified by the PSO algorithm. The performance of HPBCR (hybrid predictor of breast cancer recurrence) was assessed using the holdout and 4-fold cross-validation. Three other classifiers namely as supported vector machines, DT, and multilayer perceptron neural network were used for comparison. The selected features were diagnosis age, tumor size, lymph node involvement ratio, number of involved axillary lymph nodes, progesterone receptor expression, having hormone therapy and type of surgery. The minimum sensitivity, specificity, precision and accuracy of HPBCR were 77%, 93%, 95% and 85%, respectively in the entire cross-validation folds and the hold-out test fold. HPBCR outperformed the other tested classifiers. It showed excellent agreement with the gold standard (i.e. the oncologist opinion after blood tumor marker and imaging tests, and tissue biopsy). This algorithm is thus a promising online tool for the prediction of breast cancer recurrence.
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Key Words
- Breast cancer
- CAD, computer-aided diagnosis
- Cancer recurrence
- Computer-assisted diagnosis
- DT, decision tree
- FH, family history of cancer
- HPBCR, the proposed hybrid predictor of breast cancer recurrence
- HRT, hormone therapy
- I. Node, number of involved axillary lymph nodes
- Machine learning
- NR, lymph node involvement ratio
- Prognosis
- T. Node, number of dissected axillary lymph nodes
- TS, tumor size
- XRT, radiotherapy
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Affiliation(s)
- Mohammad R. Mohebian
- Biomedical Engineering Department, Engineering Faculty, University of Isfahan, Hezar Jerib St., 81746-73441, Isfahan, Iran
| | - Hamid R. Marateb
- Biomedical Engineering Department, Engineering Faculty, University of Isfahan, Hezar Jerib St., 81746-73441, Isfahan, Iran
- Department of Automatic Control, Biomedical Engineering Research Center, Universitat Politècnica de Catalunya, BarcelonaTech (UPC), C. Pau Gargallo, 5, 08028 Barcelona, Spain
| | - Marjan Mansourian
- Department of Biostatistics and Epidemiology, School of Public Health, Isfahan University of Medical Sciences, Hezar Jerib St., 81745 Isfahan, Iran
- Corresponding author.
| | - Miguel Angel Mañanas
- Department of Automatic Control, Biomedical Engineering Research Center, Universitat Politècnica de Catalunya, BarcelonaTech (UPC), C. Pau Gargallo, 5, 08028 Barcelona, Spain
| | - Fariborz Mokarian
- Cancer Prevention Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Internal Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Bamber JH, Evans SA. The value of decision tree analysis in planning anaesthetic care in obstetrics. Int J Obstet Anesth 2016; 27:55-61. [PMID: 27026589 DOI: 10.1016/j.ijoa.2016.02.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 02/23/2016] [Indexed: 11/19/2022]
Abstract
The use of decision tree analysis is discussed in the context of the anaesthetic and obstetric management of a young pregnant woman with joint hypermobility syndrome with a history of insensitivity to local anaesthesia and a previous difficult intubation due to a tongue tumour. The multidisciplinary clinical decision process resulted in the woman being delivered without complication by elective caesarean section under general anaesthesia after an awake fibreoptic intubation. The decision process used is reviewed and compared retrospectively to a decision tree analytical approach. The benefits and limitations of using decision tree analysis are reviewed and its application in obstetric anaesthesia is discussed.
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Affiliation(s)
- J H Bamber
- Department of Anaesthesia, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | - S A Evans
- Public Health England, The West Wing, Victoria House, Capital Park, Fulbourn, Cambridge, UK
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35
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Bae JM. Development and application of patient decision aids. Epidemiol Health 2015; 37:e2015018. [PMID: 25868639 PMCID: PMC4430759 DOI: 10.4178/epih/e2015018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 04/02/2015] [Indexed: 11/29/2022] Open
Abstract
With the current overdiagnosis of thyroid cancer resulting from routine screening in Korea, it is necessary to educate the public that not all cancers are malignant. The exposure to patient decision aids (PtDAs) compared to usual care reduced the number of people choosing to undergo prostate-specific antigen screening. This article introduces the definition, usefulness, and developmental processes of PtDAs and suggests the urgent need for a Korean PtDA related to thyroid cancer screening.
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Affiliation(s)
- Jong-Myon Bae
- Department of Preventive Medicine, Jeju National University School of Medicine, Jeju, Korea
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36
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Bae JM. Value-based medicine: concepts and application. Epidemiol Health 2015; 37:e2015014. [PMID: 25773441 PMCID: PMC4398974 DOI: 10.4178/epih/e2015014] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 03/04/2015] [Indexed: 11/22/2022] Open
Abstract
Global healthcare in the 21st century is characterized by evidence-based medicine (EBM), patient-centered care, and cost effectiveness. EBM involves clinical decisions being made by integrating patient preference with medical treatment evidence and physician experiences. The Center for Value-Based Medicine suggested value-based medicine (VBM) as the practice of medicine based upon the patient-perceived value conferred by an intervention. VBM starts with the best evidence-based data and converts it to patient value-based data, so that it allows clinicians to deliver higher quality patient care than EBM alone. The final goals of VBM are improving quality of healthcare and using healthcare resources efficiently. This paper introduces the concepts and application of VBM and suggests some strategies for promoting related research.
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Affiliation(s)
- Jong-Myon Bae
- Department of Preventive Medicine, Jeju National University School of Medicine, Jeju, Korea
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