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Freeman NLB, Muthukkumar R, Weinstock RS, Wickerhauser MV, Kahkoska AR. Use of machine learning to identify characteristics associated with severe hypoglycemia in older adults with type 1 diabetes: a post-hoc analysis of a case-control study. BMJ Open Diabetes Res Care 2024; 12:e003748. [PMID: 38413176 PMCID: PMC10900355 DOI: 10.1136/bmjdrc-2023-003748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 01/30/2024] [Indexed: 02/29/2024] Open
Abstract
INTRODUCTION Severe hypoglycemia (SH) in older adults (OAs) with type 1 diabetes is associated with profound morbidity and mortality, yet its etiology can be complex and multifactorial. Enhanced tools to identify OAs who are at high risk for SH are needed. This study used machine learning to identify characteristics that distinguish those with and without recent SH, selecting from a range of demographic and clinical, behavioral and lifestyle, and neurocognitive characteristics, along with continuous glucose monitoring (CGM) measures. RESEARCH DESIGN AND METHODS Data from a case-control study involving OAs recruited from the T1D Exchange Clinical Network were analyzed. The random forest machine learning algorithm was used to elucidate the characteristics associated with case versus control status and their relative importance. Models with successively rich characteristic sets were examined to systematically incorporate each domain of possible risk characteristics. RESULTS Data from 191 OAs with type 1 diabetes (47.1% female, 92.1% non-Hispanic white) were analyzed. Across models, hypoglycemia unawareness was the top characteristic associated with SH history. For the model with the richest input data, the most important characteristics, in descending order, were hypoglycemia unawareness, hypoglycemia fear, coefficient of variation from CGM, % time blood glucose below 70 mg/dL, and trail making test B score. CONCLUSIONS Machine learning may augment risk stratification for OAs by identifying key characteristics associated with SH. Prospective studies are needed to identify the predictive performance of these risk characteristics.
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Affiliation(s)
- Nikki L B Freeman
- Department of Surgery, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Rashmi Muthukkumar
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ruth S Weinstock
- Department of Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
| | - M Victor Wickerhauser
- Department of Mathematics, Washington University in St Louis, St Louis, Missouri, USA
| | - Anna R Kahkoska
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Division of Endocrinology and Metabolism, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Freeman NLB, Browder SE, McGinigle KL, Kosorok MR. Individualized treatment rule characterization via a value function surrogate. Biometrics 2024; 80:ujad012. [PMID: 38372403 PMCID: PMC10875523 DOI: 10.1093/biomtc/ujad012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 10/19/2023] [Accepted: 11/14/2023] [Indexed: 02/20/2024]
Abstract
Precision medicine is a promising framework for generating evidence to improve health and health care. Yet, a gap persists between the ever-growing number of statistical precision medicine strategies for evidence generation and implementation in real-world clinical settings, and the strategies for closing this gap will likely be context-dependent. In this paper, we consider the specific context of partial compliance to wound management among patients with peripheral artery disease. Using a Gaussian process surrogate for the value function, we show the feasibility of using Bayesian optimization to learn optimal individualized treatment rules. Further, we expand beyond the common precision medicine task of learning an optimal individualized treatment rule to the characterization of classes of individualized treatment rules and show how those findings can be translated into clinical contexts.
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Affiliation(s)
- Nikki L B Freeman
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, United States
| | - Sydney E Browder
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, United States
| | - Katharine L McGinigle
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, United States
| | - Michael R Kosorok
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, United States
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Smith KW, Freeman NLB, Bir A. Assessing risk of bias in the meta-analysis of round 1 of the Health Care Innovation Awards. Syst Rev 2024; 13:36. [PMID: 38254172 PMCID: PMC10802023 DOI: 10.1186/s13643-023-02409-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 12/04/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Systematic reviews of observational studies can be affected by biases that lead to under- or over-estimates of true intervention effects. Several tools have been reported in the literature that attempt to characterize potential bias. Our objective in this study was to determine the extent to which study-specific bias may have influenced intervention impacts on total costs of care (TCOC) in round 1 of the Health Care Innovation Awards. METHODS We reviewed 82 statistical evaluations of innovation impacts on Medicare TCOC. We developed five risk-of-bias measures and assessed their influence on TCOC impacts using meta-regression. RESULTS The majority of evaluations used propensity score matching to create their comparison groups. One third of the non-randomized interventions were judged to have some risk of biased effects due largely to the way they recruited their treatment groups, and 35% had some degree of covariate imbalance remaining after propensity score adjustments. However, in the multivariable analysis of TCOC effects, none of the bias threats we examined (comparison group construction method, risk of bias, or degree of covariate imbalance) had a major impact on the magnitude of HCIA1 innovation effects. Evaluations using propensity score weighting produced larger but imprecise savings effects compared to propensity score matching. DISCUSSION Our results suggest that it is unlikely that HCIA1 TCOC effect sizes were systematically affected by the types of bias we considered. Assessing the risk of bias based on specific study design features is likely to be more useful for identifying problematic characteristics than the subjective quality ratings used by existing risk tools.
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Affiliation(s)
- Kevin W Smith
- RTI International, 307 Waverley Oaks Road, Suite 101, Waltham, MA, 02452-8413, USA.
| | - Nikki L B Freeman
- RTI International, 307 Waverley Oaks Road, Suite 101, Waltham, MA, 02452-8413, USA
| | - Anupa Bir
- RTI International, 307 Waverley Oaks Road, Suite 101, Waltham, MA, 02452-8413, USA
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Freeman NLB, Browder SE, McGinigle KL. Balancing evidence-based care with patient-centered individualized care. J Vasc Surg Venous Lymphat Disord 2023; 11:1089-1094. [PMID: 37689363 PMCID: PMC10878433 DOI: 10.1016/j.jvsv.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/26/2023] [Accepted: 08/06/2023] [Indexed: 09/11/2023]
Abstract
Weak evidence, when manifested in clinical guidelines, can translate into biased vascular care. In vascular surgery, we have few randomized controlled trials with appropriate representation of females and persons of color, so generalizability of trial results can be problematic. Physicians are required to balance evidenced-based care (which is only as good as the underlying evidence) with personalized treatment recommendations that are often based on demographics, social circumstances, and/or existing therapeutic relationships. Biases, whether implicit or explicit, have an oversized effect on treatment decisions, and patient outcomes. In this commentary, we propose three principles to strengthen the vascular surgery evidence foundation and patient-centered decision-making going forward: (1) generating evidence designed for individualized care, (2) constructing clinical guidelines that are context specific and complexity aware, and (3) strengthening the training and support for surgeons to deliver patient-centered individualized care.
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Affiliation(s)
- Nikki L B Freeman
- Division of Vascular Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sydney E Browder
- Division of Vascular Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Katharine L McGinigle
- Division of Vascular Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
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Browder SE, Yohann A, Filipowicz TR, Freeman NLB, Marston WA, Heisler S, Farber MA, Patel SR, Wood JC, McGinigle KL. Differential impact of missed initial wound clinic visit on 6-month wound healing by race/ethnicity among patients with chronic limb-threatening ischemia. Wound Repair Regen 2023; 31:647-654. [PMID: 37534781 PMCID: PMC10878832 DOI: 10.1111/wrr.13116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/07/2023] [Accepted: 07/18/2023] [Indexed: 08/04/2023]
Abstract
Chronic limb-threatening ischemia (CLTI) is associated with significant morbidity, including major limb amputation, and mortality. Healing ischemic wounds is necessary to optimise vascular outcomes and can be facilitated by dedicated appointments at a wound clinic. This study aimed to estimate the association between successful wound care initiation and 6-month wound healing, with specific attention to differences by race/ethnicity. This retrospective study included 398 patients with CLTI and at least one ischaemic wound who scheduled an appointment at our wound clinic between January 2015 and July 2020. The exposure was the completion status of patients' first scheduled wound care appointment (complete/not complete) and the primary outcome was 6-month wound healing (healed/not healed). The analysis focused on how this association was modified by race/ethnicity. We used Aalen-Johansen estimators to produce cumulative incidence curves and calculated risk ratios within strata of race/ethnicity. The final adjustment set included age, revascularization, and initial wound size. Patients had a mean age of 67 ± 14 years, were 41% female, 46% non-White and had 517 total wounds. In the overall cohort, 70% of patients completed their first visit and 34% of wounds healed within 6-months. There was no significant difference in 6-month healing based on first visit completion status for White/non-Hispanic individuals (RR [95% CI] = 1.18 [0.91, 1.45]; p-value = 0.130), while non-White individuals were roughly 3 times more likely to heal their wounds if they completed their first appointment (RR [95% CI] = 2.89 [2.66, 3.11]; p-value < 0.001). In conclusion, non-White patients were approximately three times more likely to heal their wound in 6 months if they completed their first scheduled wound care appointment while White/non-Hispanic individuals' risk of healing was similar regardless of first visit completion status. Future efforts should focus on providing additional resources to ensure minority groups with wounds have the support they need to access and successfully initiate wound care.
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Affiliation(s)
- Sydney E. Browder
- Department of Surgery—Vascular, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Avital Yohann
- Department of Surgery—Vascular, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Teresa R. Filipowicz
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Nikki L. B. Freeman
- Department of Surgery—Vascular, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - William A. Marston
- Department of Surgery—Vascular, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Stephen Heisler
- Department of Surgery—Vascular, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Mark A. Farber
- Department of Surgery—Vascular, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Shrunjay R. Patel
- Department of Surgery—Vascular, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jacob C. Wood
- Department of Surgery—Vascular, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
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Kahkoska AR, Freeman NLB, Jones EP, Shirazi D, Browder S, Page A, Sperger J, Zikry TM, Yu F, Busby-Whitehead J, Kosorok MR, Batsis JA. Individualized interventions and precision health: Lessons learned from a systematic review and implications for analytics-driven geriatric research. J Am Geriatr Soc 2023; 71:383-393. [PMID: 36524627 PMCID: PMC10037848 DOI: 10.1111/jgs.18141] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 09/16/2022] [Accepted: 10/22/2022] [Indexed: 12/23/2022]
Abstract
Older adults are characterized by profound clinical heterogeneity. When designing and delivering interventions, there exist multiple approaches to account for heterogeneity. We present the results of a systematic review of data-driven, personalized interventions in older adults, which serves as a use case to distinguish the conceptual and methodologic differences between individualized intervention delivery and precision health-derived interventions. We define individualized interventions as those where all participants received the same parent intervention, modified on a case-by-case basis and using an evidence-based protocol, supplemented by clinical judgment as appropriate, while precision health-derived interventions are those that tailor care to individuals whereby the strategy for how to tailor care was determined through data-driven, precision health analytics. We discuss how their integration may offer new opportunities for analytics-based geriatric medicine that accommodates individual heterogeneity but allows for more flexible and resource-efficient population-level scaling.
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Affiliation(s)
- Anna R. Kahkoska
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Nikki L. B. Freeman
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Emily P. Jones
- Health Sciences Library, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Daniela Shirazi
- Department of Medicine, California University of Science and Medicine, Colton, California, USA
| | - Sydney Browder
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Annie Page
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - John Sperger
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Tarek M. Zikry
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Fei Yu
- School of Information and Library Science, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jan Busby-Whitehead
- Division of Geriatric Medicine, Department of Medicine, Center for Aging and Health, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Michael R. Kosorok
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Statistics and Operations Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - John A. Batsis
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Division of Geriatric Medicine, Department of Medicine, Center for Aging and Health, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
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7
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Adu-Amankwah A, Bellad MB, Benson AM, Beyuo TK, Bhandankar M, Charanthimath U, Chisembele M, Cole SR, Dhaded SM, Enweronu-Laryea C, Freeman BL, Freeman NLB, Goudar SS, Jiang X, Kasaro MP, Kosorok MR, Luckett D, Mbewe FM, Misra S, Mutesu K, Nuamah MA, Oppong SA, Patterson JK, Peterson M, Pokaprakarn T, Price JT, Pujar YV, Rouse DJ, Sebastião YV, Spelke MB, Sperger J, Stringer JSA, Tuuli MG, Valancius M, Vwalika B. Limiting adverse birth outcomes in resource-limited settings (LABOR): protocol of a prospective intrapartum cohort study. Gates Open Res 2022; 6:115. [PMID: 36636742 PMCID: PMC9822935 DOI: 10.12688/gatesopenres.13716.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 12/23/2022] Open
Abstract
Background: Each year, nearly 300,000 women and 5 million fetuses or neonates die during childbirth or shortly thereafter, a burden concentrated disproportionately in low- and middle-income countries. Identifying women and their fetuses at risk for intrapartum-related morbidity and death could facilitate early intervention. Methods: The Limiting Adverse Birth Outcomes in Resource-Limited Settings (LABOR) Study is a multi-country, prospective, observational cohort designed to exhaustively document the course and outcomes of labor, delivery, and the immediate postpartum period in settings where adverse outcomes are frequent. The study is conducted at four hospitals across three countries in Ghana, India, and Zambia. We will enroll approximately 12,000 women at presentation to the hospital for delivery and follow them and their fetuses/newborns throughout their labor and delivery course, postpartum hospitalization, and up to 42 days thereafter. The co-primary outcomes are composites of maternal (death, hemorrhage, hypertensive disorders, infection) and fetal/neonatal adverse events (death, encephalopathy, sepsis) that may be attributed to the intrapartum period. The study collects extensive physiologic data through the use of physiologic sensors and employs medical scribes to document examination findings, diagnoses, medications, and other interventions in real time. Discussion: The goal of this research is to produce a large, sharable dataset that can be used to build statistical algorithms to prospectively stratify parturients according to their risk of adverse outcomes. We anticipate this research will inform the development of new tools to reduce peripartum morbidity and mortality in low-resource settings.
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Affiliation(s)
- Amanda Adu-Amankwah
- Department of Obstetrics and Gynaecology, University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Mrutunjaya B. Bellad
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, India
| | - Aimee M. Benson
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - Titus K. Beyuo
- Department of Obstetrics and Gynaecology, University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Manisha Bhandankar
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, India
| | - Umesh Charanthimath
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, India
| | - Maureen Chisembele
- Women and Newborn Hospital, University Teaching Hospital of Lusaka, Lusaka, Zambia
| | - Stephen R. Cole
- Department of Epidemiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - Sangappa M. Dhaded
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, India
| | - Christabel Enweronu-Laryea
- Department of Child Health, University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Bethany L. Freeman
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - Nikki L. B. Freeman
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Shivaprasad S. Goudar
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, India
| | - Xiaotong Jiang
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Margaret P. Kasaro
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA,UNC Global Projects Zambia, LLC, Lusaka, Zambia
| | - Michael R. Kosorok
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Daniel Luckett
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | | | - Sujata Misra
- Fakir Mohan Medical College and Hospital, Balasore, India
| | - Kunda Mutesu
- Women and Newborn Hospital, University Teaching Hospital of Lusaka, Lusaka, Zambia
| | - Mercy A. Nuamah
- Department of Obstetrics and Gynaecology, University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Samuel A. Oppong
- Department of Obstetrics and Gynaecology, University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Jackie K. Patterson
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - Marc Peterson
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - Teeranan Pokaprakarn
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Joan T. Price
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA,
| | - Yeshita V. Pujar
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, India
| | - Dwight J. Rouse
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, 02903, USA
| | - Yuri V. Sebastião
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - M. Bridget Spelke
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - John Sperger
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Jeffrey S. A. Stringer
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - Methodius G. Tuuli
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, 02903, USA
| | - Michael Valancius
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Bellington Vwalika
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA,Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
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8
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Adu-Amankwah A, Bellad MB, Benson AM, Beyuo TK, Bhandankar M, Charanthimath U, Chisembele M, Cole SR, Dhaded SM, Enweronu-Laryea C, Freeman BL, Freeman NLB, Goudar SS, Jiang X, Kasaro MP, Kosorok MR, Luckett D, Mbewe FM, Misra S, Mutesu K, Nuamah MA, Oppong SA, Patterson JK, Peterson M, Pokaprakarn T, Price JT, Pujar YV, Rouse DJ, Sebastião YV, Spelke MB, Sperger J, Stringer JSA, Tuuli MG, Valancius M, Vwalika B. Limiting adverse birth outcomes in resource-limited settings (LABOR): protocol of a prospective intrapartum cohort study. Gates Open Res 2022; 6:115. [PMID: 36636742 PMCID: PMC9822935 DOI: 10.12688/gatesopenres.13716.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2022] [Indexed: 01/17/2023] Open
Abstract
Background: Each year, nearly 300,000 women and 5 million fetuses or neonates die during childbirth or shortly thereafter, a burden concentrated disproportionately in low- and middle-income countries. Identifying women and their fetuses at risk for intrapartum-related morbidity and death could facilitate early intervention. Methods: The Limiting Adverse Birth Outcomes in Resource-Limited Settings (LABOR) Study is a multi-country, prospective, observational cohort designed to exhaustively document the course and outcomes of labor, delivery, and the immediate postpartum period in settings where adverse outcomes are frequent. The study is conducted at four hospitals across three countries in Ghana, India, and Zambia. We will enroll approximately 12,000 women at presentation to the hospital for delivery and follow them and their fetuses/newborns throughout their labor and delivery course, postpartum hospitalization, and up to 42 days thereafter. The co-primary outcomes are composites of maternal (death, hemorrhage, hypertensive disorders, infection) and fetal/neonatal adverse events (death, encephalopathy, sepsis) that may be attributed to the intrapartum period. The study collects extensive physiologic data through the use of physiologic sensors and employs medical scribes to document examination findings, diagnoses, medications, and other interventions in real time. Discussion: The goal of this research is to produce a large, sharable dataset that can be used to build statistical algorithms to prospectively stratify parturients according to their risk of adverse outcomes. We anticipate this research will inform the development of new tools to reduce peripartum morbidity and mortality in low-resource settings.
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Affiliation(s)
- Amanda Adu-Amankwah
- Department of Obstetrics and Gynaecology, University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Mrutunjaya B. Bellad
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, India
| | - Aimee M. Benson
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - Titus K. Beyuo
- Department of Obstetrics and Gynaecology, University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Manisha Bhandankar
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, India
| | - Umesh Charanthimath
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, India
| | - Maureen Chisembele
- Women and Newborn Hospital, University Teaching Hospital of Lusaka, Lusaka, Zambia
| | - Stephen R. Cole
- Department of Epidemiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - Sangappa M. Dhaded
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, India
| | - Christabel Enweronu-Laryea
- Department of Child Health, University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Bethany L. Freeman
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - Nikki L. B. Freeman
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Shivaprasad S. Goudar
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, India
| | - Xiaotong Jiang
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Margaret P. Kasaro
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA,UNC Global Projects Zambia, LLC, Lusaka, Zambia
| | - Michael R. Kosorok
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Daniel Luckett
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | | | - Sujata Misra
- Fakir Mohan Medical College and Hospital, Balasore, India
| | - Kunda Mutesu
- Women and Newborn Hospital, University Teaching Hospital of Lusaka, Lusaka, Zambia
| | - Mercy A. Nuamah
- Department of Obstetrics and Gynaecology, University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Samuel A. Oppong
- Department of Obstetrics and Gynaecology, University of Ghana Medical School, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Jackie K. Patterson
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - Marc Peterson
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - Teeranan Pokaprakarn
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Joan T. Price
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA,
| | - Yeshita V. Pujar
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, India
| | - Dwight J. Rouse
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, 02903, USA
| | - Yuri V. Sebastião
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - M. Bridget Spelke
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - John Sperger
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Jeffrey S. A. Stringer
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA
| | - Methodius G. Tuuli
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, 02903, USA
| | - Michael Valancius
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Bellington Vwalika
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599, USA,Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
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9
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Affiliation(s)
- Anna R Kahkoska
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Nikki L B Freeman
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
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10
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Chung J, Freeman NLB, Kosorok MR, Marston WA, Conte MS, McGinigle KL. Analysis of a Machine Learning-Based Risk Stratification Scheme for Chronic Limb-Threatening Ischemia. JAMA Netw Open 2022; 5:e223424. [PMID: 35315918 PMCID: PMC8941356 DOI: 10.1001/jamanetworkopen.2022.3424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
IMPORTANCE Valid risk stratification schemes are key to performing comparative effectiveness research; however, for chronic limb-threatening ischemia (CLTI), risk stratification schemes have limited efficacy. Improved, accurate, comprehensive, and reproducible risk stratification models for CLTI are needed. OBJECTIVE To evaluate the use of topic model cluster analysis to generate an accurate risk prediction model for CLTI. DESIGN, SETTING, AND PARTICIPANTS This multicenter, nested cohort study of existing Project of Ex Vivo Vein Graft Engineering via Transfection (PREVENT) III clinical trial data assessed data from patients undergoing infrainguinal vein bypass for the treatment of ischemic rest pain or ischemic tissue loss. Original data were collected from January 1, 2001, to December 31, 2003, and were analyzed in September 2021. All patients had 1 year of follow-up. EXPOSURES Supervised topic model cluster analysis was applied to nested cohort data from the PREVENT III randomized clinical trial. Given a fixed number of clusters, the data were used to examine the probability that a patient belonged to each of the clusters and the distribution of the features within each cluster. MAIN OUTCOMES AND MEASURES The primary outcome was 1-year CLTI-free survival, a composite of survival with remission of ischemic rest pain, wound healing, and freedom from major lower-extremity amputation without recurrent CLTI. RESULTS Of the original 1404 patients, 166 were excluded because of a lack of sufficient feature and/or outcome data, leaving 1238 patients for analysis (mean [SD] age, 68.4 [11.2] years; 800 [64.6%] male; 894 [72.2%] White). The Society for Vascular Surgery Wound, Ischemia, and Foot Infection grade 2 wounds were present in 543 patients (43.8%), with rest pain present in 645 (52.1%). Three distinct clusters were identified within the cohort (130 patients in stage 1, 578 in stage 2, and 530 in stage 3), with 1-year CLTI-free survival rates of 82.3% (107 of 130 patients) for stage 1, 61.1% (353 of 578 patients) for stage 2, and 53.4% (283 of 530 patients) for stage 3. Stratified by stage, 1-year mortality was 10.0% (13 of 130 observed deaths in stage 1) for stage 1, 13.5% (78 of 578 patients) for stage 2, and 20.2% (105 of 521 patients) for stage 3. Similarly, stratifying by stage revealed major limb amputation rates of 4.2% (5 of 119 observed major limb amputations in stage 1) for stage 1, 10.8% (55 of 509 patients) for stage 2, and 18.4% (81 of 440 patients) for stage 3. Among survivors without a major amputation, the rates of CLTI recurrence were 9.2% (11 of 119 observed recurrences in stage 1) for stage 1, 24.9% (130 of 523 patients) for stage 2, and 29.6% (132 of 446 patients) for stage 3. CONCLUSIONS AND RELEVANCE The topic model cluster analysis in this cohort study identified 3 distinct stages within CLTI. Findings suggest that CLTI-free survival is an end point that can be accurately and reproducibly quantified and may be used as a patient-centric outcome.
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Affiliation(s)
- Jayer Chung
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Nikki L. B. Freeman
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill
| | - Michael R. Kosorok
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill
| | - William A. Marston
- Division of Vascular Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill
| | - Michael S. Conte
- Department of Surgery, University of California at San Francisco, San Francisco
| | - Katharine L. McGinigle
- Division of Vascular Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill
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11
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Bergey M, Chiri G, Freeman NLB, Mackie TI. Mapping mental health inequalities: The intersecting effects of gender, race, class, and ethnicity on ADHD diagnosis. Sociol Health Illn 2022; 44:604-623. [PMID: 35147240 DOI: 10.1111/1467-9566.13443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 01/04/2022] [Accepted: 01/17/2022] [Indexed: 06/14/2023]
Abstract
While the effects of social stratification by gender, race, class, and ethnicity on health inequalities are well-documented, our understanding of the intersecting consequences of these social dimensions on diagnosis remains limited. This is particularly the case in studies of mental health, where "paradoxical" patterns of stratification have been identified. Using a Bayesian multi-level random-effects Poisson model and a nationally representative random sample of 138,009 households from the National Survey of Children's Health, this study updates and extends the literature on mental health inequalities through an intersectional investigation of one of the most commonly diagnosed psychiatric conditions of childhood/adolescence: attention-deficit hyperactivity disorder (ADHD). Findings indicate that gender, race, class, and ethnicity combine in mutually constitutive ways to explain between-group variation in ADHD diagnosis. Observed effects underscore the importance and feasibility of an intersectional, multi-level modelling approach and data mapping technique to advance our understanding of social subgroups more/less likely to be diagnosed with mental health conditions.
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Affiliation(s)
- Meredith Bergey
- Department of Sociology and Criminology, Villanova University, Villanova, Pennsylvania, USA
| | - Giuseppina Chiri
- RTI International, Center for the Health of Populations, Waltham, Massachusetts, USA
| | - Nikki L B Freeman
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Thomas I Mackie
- Department of Health Policy and Management, School of Public Health, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, New York, USA
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12
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McGinigle KL, Freeman NLB, Marston WA, Farber A, Conte MS, Kosorok MR, Kalbaugh CA. Precision Medicine Enables More TNM-Like Staging in Patients With Chronic Limb Threatening Ischemia. Front Cardiovasc Med 2021; 8:709904. [PMID: 34336963 PMCID: PMC8322654 DOI: 10.3389/fcvm.2021.709904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 06/24/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: In cancer, there are survival-based staging systems and tailored, stage-based treatments. There is little personalized treatment in vascular disease. The 2019 Global Vascular Guidelines on the Management of CLTI proposed successful treatment hinges upon Patient risk, Limb severity, and ANatomic complexity (PLAN). We sought to confirm a three axis approach and define how increasing severity affects mortality, not just limb loss. Methods: Patients revascularized for incident CLTI at our institution from 2013 to 2017 were included. Outcomes were mortality, limb loss, the composite endpoint of amputation-free survival. Using Bayesian machine learning, specifically supervised topic modeling, clusters of patient features associated with mortality were formed after controlling for revascularization type. Patients were assigned to the cluster they belonged to with highest probability; clusters were characterized by analyzing the characteristics of patients within them. Patient outcomes were used to order the clusters into stages with increasing mortality. Results: We defined three distinct clusters as the basis for patient- and limb-centered stages. Across stages, rates of 1-year mortality were 7.6, 13.8, 18.9% and rates of amputation-free survival were 84.8, 79.3, and 63.2%. Stage one had patients with rest pain and previous revascularization who were less likely to have wounds, diabetes, and renal disease. Stage two had doubled mortality, likely related to diabetes prevalence. Stage three is characterized by high rates of complicated comorbidities, particularly end stage renal disease, and significantly higher rate of limb loss (22.6 vs. 8% in stages one and two). Conclusion: Using precision medicine, we have demonstrated clustering of CLTI patients that can be used toward a robust staging system. We provide empiric evidence for PLAN and detail about how changes in each variable affect survival and amputation-free survival.
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Affiliation(s)
- Katharine L McGinigle
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Nikki L B Freeman
- Department of Biostatistics, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - William A Marston
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Alik Farber
- Department of Surgery, Boston University School of Medicine, Boston, MA, United States
| | - Michael S Conte
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Michael R Kosorok
- Department of Biostatistics, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Corey A Kalbaugh
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States.,Department of Bioengineering, Clemson University, Clemson, SC, United States
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13
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Freeman NLB, Sperger J, El-Zaatari H, Kahkoska AR, Lu M, Valancius M, Virkud AV, Zikry TM, Kosorok MR. Beyond Two Cultures: Cultural Infrastructure for Data-driven Decision Support. Obs Stud 2021; 7:77-94. [PMID: 35106520 PMCID: PMC8802367 DOI: 10.1353/obs.2021.0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
In the twenty years since Dr. Leo Breiman's incendiary paper Statistical Modeling: The Two Cultures was first published, algorithmic modeling techniques have gone from controversial to commonplace in the statistical community. While the widespread adoption of these methods as part of the contemporary statistician's toolkit is a testament to Dr. Breiman's vision, the number of high-profile failures of algorithmic models suggests that Dr. Breiman's final remark that "the emphasis needs to be on the problem and the data" has been less widely heeded. In the spirit of Dr. Breiman, we detail an emerging research community in statistics - data-driven decision support. We assert that to realize the full potential of decision support, broadly and in the context of precision health, will require a culture of social awareness and accountability, in addition to ongoing attention towards complex technical challenges.
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Affiliation(s)
- Nikki L B Freeman
- Department of Biostatistics, University of North Carolina at Chapel Hill
| | - John Sperger
- Department of Biostatistics, University of North Carolina at Chapel Hill
| | - Helal El-Zaatari
- Department of Biostatistics, University of North Carolina at Chapel Hill
| | - Anna R Kahkoska
- Department of Nutrition, University of North Carolina School of Medicine
| | - Minxin Lu
- Department of Biostatistics, University of North Carolina at Chapel Hill
| | - Michael Valancius
- Department of Biostatistics, University of North Carolina at Chapel Hill
| | - Arti V Virkud
- Department of Epidemiology, University of North Carolina at Chapel Hill
| | - Tarek M Zikry
- Department of Biostatistics, University of North Carolina at Chapel Hill
| | - Michael R Kosorok
- Department of Biostatistics, University of North Carolina at Chapel Hill
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14
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Affiliation(s)
- John Sperger
- Department of Biostatistics University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Nikki L. B. Freeman
- Department of Biostatistics University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Xiaotong Jiang
- Department of Biostatistics University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - David Bang
- Department of Biostatistics University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Daniel Marchi
- Department of Biostatistics University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Michael R. Kosorok
- Department of Biostatistics University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
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15
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Freeman NLB, Jiang X, Leete OE, Luckett DJ, Pokaprakarn TB, Kosorok MR. Comment: Models as Approximations. Stat Sci 2019; 34:572-574. [PMID: 34526734 DOI: 10.1214/19-sts724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Nikki L B Freeman
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Xiaotong Jiang
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Owen E Leete
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Daniel J Luckett
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Teeranan Ben Pokaprakarn
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michael R Kosorok
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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16
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Abstract
Using delivery system innovations to advance health care reform continues to be of widespread interest. However, it is difficult to generalize about the success of specific types of innovations, since they have been examined in only a few studies. To gain a broader perspective, we analyzed the results of forty-three ambulatory care programs funded by the first round of the Center for Medicare and Medicaid Innovation's Health Care Innovations Awards. The innovations' impacts on total cost of care were estimated by independent evaluators using multivariable difference-in-differences models. Through the first two years, most of the innovations did not show a significant effect on total cost of care. Using meta-regression, we assessed the effects on costs of five common components of these innovations. Innovations that used health information technology or community health workers achieved the greatest cost savings. Savings were also relatively large in programs that targeted clinically fragile patients-clinically complex populations at risk for disease progression. While the magnitude of these effects was often substantial, none achieved conventional levels of significance in our analyses. Meta-analyses of a larger number of delivery system innovations are needed to more clearly establish their potential for patient care cost savings.
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Affiliation(s)
- Kevin W Smith
- Kevin W. Smith is a senior public health scientist at the Center for Advanced Methods Development at RTI International in Waltham, Massachusetts
| | - Anupa Bir
- Anupa Bir is director of the Center for Advanced Methods Development at RTI International
| | - Nikki L B Freeman
- Nikki L. B. Freeman is a research associate in the Center for Advanced Methods Development at RTI International
| | - Benjamin C Koethe
- Benjamin C. Koethe is a research analyst at the Center for Advanced Methods Development at RTI International
| | - Julia Cohen
- Julia Cohen is a research associate at the Center for Advanced Methods Development at RTI International
| | - Timothy J Day
- Timothy J. Day is a social science research analyst at the Center for Medicare and Medicaid Innovation, in Baltimore, Maryland
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17
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Chang SH, Freeman NLB, Lee JA, Stoll CRT, Calhoun AJ, Eagon JC, Colditz GA. Early major complications after bariatric surgery in the USA, 2003-2014: a systematic review and meta-analysis. Obes Rev 2018; 19:529-537. [PMID: 29266740 PMCID: PMC5880318 DOI: 10.1111/obr.12647] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 10/05/2017] [Accepted: 10/23/2017] [Indexed: 01/06/2023]
Abstract
The effectiveness of bariatric surgery has been well-studied. However, complications after bariatric surgery have been understudied. This review assesses <30-d major complications associated with bariatric procedures, including anastomotic leak, myocardial infarction and pulmonary embolism. This review included 71 studies conducted in the USA between 2003 and 2014 and 107,874 patients undergoing either gastric bypass, adjustable gastric banding or sleeve gastrectomy, with mean age of 44 years and pre-surgery body mass index of 46.5 kg m-2 . Less than 30-d anastomotic leak rate was 1.15%; myocardial infarction rate was 0.37%; pulmonary embolism rate was 1.17%. Among all patients, mortality rate following anastomotic leak, myocardial infarction and pulmonary embolism was 0.12%, 0.37% and 0.18%, respectively. Among surgical procedures, <30-d after surgery, sleeve gastrectomy (1.21% [95% confidence interval, 0.23-2.19%]) had higher anastomotic leak rate than gastric bypass (1.14% [95% confidence interval, 0.84-1.43%]); gastric bypass had higher rates of myocardial infarction and pulmonary embolism than adjustable gastric banding or sleeve gastrectomy. During the review, we found that the quality of complication reporting is lower than the reporting of other outcomes. In summary, <30-d rates of the three major complications after either one of the procedures range from 0% to 1.55%. Mortality following these complications ranges from 0% to 0.64%. Future studies reporting complications after bariatric surgery should improve their reporting quality.
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Affiliation(s)
- S-H Chang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - N L B Freeman
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.,Center for Advanced Methods Development, RTI International, NC, USA
| | - J A Lee
- Agricultural Statistics Laboratory, University of Arkansas, Fayetteville, AR, USA
| | - C R T Stoll
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - A J Calhoun
- Saint Louis University School of Medicine, St. Louis, MO, USA
| | - J C Eagon
- Minimally Invasive and Bariatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - G A Colditz
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
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