Applying sequence analysis to uncover 'real-world' clinical pathways from routinely collected data: a systematic review

Exploring patterns in pediatric type 1 diabetes care and the impact of socioeconomic status

BACKGROUND

Managing pediatric type 1 diabetes is complex and requires substantial parental involvement. Adherence to clinical guidelines is often inconsistent, and lower parental socioeconomic status is associated with worse outcomes in affected children. However, few studies have examined these children's care pathways multidimensionally over time. This study aims to identify latent clusters in the care pathways of pediatric patients with type 1 diabetes mellitus, evaluate guideline adherence and disease management within these clusters, and assess the influence of socioeconomic status on cluster membership.

METHODS

We analyzed care pathways for pediatric patients with type 1 diabetes from 2017 to 2019 in the German health system, which provides universal coverage. Using state sequence analysis and clustering algorithms from the TraMineR R package, we identified patient clusters based on healthcare utilization patterns. To assess care quality within these clusters, we compared observed care patterns to clinical guideline recommendations. Our analysis was based on health insurance claims data from Techniker Krankenkasse, a statutory health insurer. From the dataset, which encompassed more than three million patients under the age of 25 years, we derived an age-homogeneous cohort of continuously insured children aged 11 to 14 years with type 1 diabetes in 2017 and extracted relevant healthcare events over a 3-year period.

RESULTS

Based on care patterns, we identified two clusters of children, which we designated as the "guideline-adherent" and "care-with-gaps" clusters. Roughly 25% of our cohort (n = 890) fell into the latter cluster, consistently receiving care that fell short of guideline recommendations. For example, these patients had less than half as many quarters with hemoglobin A1c measurement. Lower parental educational attainment and unemployment were predictors of this suboptimal care. We also found that the average number of hospitalizations per child was almost 40% higher in the cluster with less guideline-adherent care.

CONCLUSIONS

Despite universal health coverage and frequent contact with the outpatient healthcare system, a substantial proportion of pediatric type 1 diabetes patients in Germany experience suboptimal care, particularly in glycemic diagnostics and screening for complications, leading to worse health outcomes. Higher socioeconomic status is associated with care that more closely adheres to clinical guidelines.

Cluster Analysis of Palliative Care Patients' Trajectories in Primary Care: Hospitalization Yes, but Home and Nursing Home Care Above All

Background: Understanding the environment in which patients live at the end of their lives is essential to improving palliative care for these patients and their families. Objectives: We aimed to explore the different living places and trajectories of palliative care patients in the last three months of life in primary care and to identify patient characteristics associated with these trajectories. Methods: This retrospective national study was carried out among a population of adult patients who died a non-sudden death. The trajectories were modeled and classified using sequence analysis, optimal matching, and hierarchical ascendant clustering. Univariate and multivariate multinomial logistic regression compared patient characteristics associated with these trajectories. The focus was on primary care. Patients had to have spent at least one day at home or in a nursing home in the last three months before their death. The research took place between November 2020 and November 2021 in mainland France. Results: Three hundred adult patients were included in the study. Cluster analysis revealed three main trajectories during the last three months of life: "staying at home" (57%), "staying in a nursing home" (29%), and "moving from home to hospital" (14%). Dementia and having children limited hospitalization. Not having an informal caregiver and having dementia were associated with staying in a nursing home. Conclusions: Palliative care patients' living situations and transitions can be tracked using primary care practice data. This study highlights the unique needs of palliative care in home and nursing home settings. Additionally, factors such as dementia and family dynamics play a significant role in determining where patients live, which can help inform clinical practices and research strategies in palliative care.

Care trajectories for musculoskeletal disorders following a new episode of low back pain

ABSTRACT

This study explored diverse care trajectories (CTs) for low back pain (LBP) and other musculoskeletal disorders (MSDs), over a 5-year period following a first episode of LBP. Based on Quebec's administrative health data from 2007 to 2011, this longitudinal cohort study involved 12,608 adults seeking health care for LBP. Using a new multidimensional state sequence analysis, we identified 6 distinct types of CTs. The most prevalent types 1, 2, and 3 (comprising 79.2%, 18.0%, and 21.7% of the cohort, respectively) exhibit rapid recovery and similar patterns of healthcare use over 5 years but differing in initial diagnoses: nonspecific LBP in type 1, trauma-related LBP in type 2 (mostly younger men and highest initial emergency consultation), and specific LBP in type 3. Types 4 to 6, representing smaller groups, show high healthcare utilization with comparable mixed LBP diagnoses at entry but distinctive subsequent care use patterns. Patients in types 4 and 6 (mainly older age groups and women) sought care for other MSDs from general practitioners or specialists, while middle-aged patients in type 5 experienced persistent nonspecific LBP with frequent general practitioner consultations over 5 years. The CTs typology revealed several key areas for improvement in nonpharmacological interventions, including the need to address possible inappropriate medical imaging and invasive interventions for older women with MSDs and the lack of ambulatory care access for younger patients with trauma-related LBP. Finally, results clearly highlighted poor access to rehabilitation physicians and rehabilitation services for all patients suffering from LBP and MSDs.

Exploring trajectories of functional decline and recovery among older adults: a data-driven approach

Independently performing activities of daily living (ADLs) is vital for maintaining one's quality of life. Losing this ability can significantly impact an individual's overall health status, including their mental health and social well-being. Aging is an important factor contributing to the loss of ADL abilities, and our study focuses on investigating the trajectories of functional decline and recovery in older adults. Employing trajectory analytics methodologies, this research delves into the intricate dynamics of ADL pathways, unveiling their complexity, diversity, and inherent characteristics. The study leverages a substantial dataset encompassing ADL assessments of nursing home residents with diverse disability profiles in the United States. The investigation begins by transforming these assessments into sequences of disability combinations, followed by applying various statistical measures, indicators, and visual analytics. Valuable insights are gained into the typical disability states, transitions, and patterns over time. The results also indicate that while predicting the progression of ADL disabilities presents manageable challenges, the duration of these states proves more complicated. Our findings hold significant potential for improving healthcare decision-making by enabling clinicians to anticipate possible patterns, develop targeted and effective interventions that support older patients in preserving their independence, and enhance overall care quality.