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García-Vega D, Cinza-Sanjurjo S, Tilves-Bellas C, Eiras S, González-Juanatey JR. Sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide 1 receptor agonists and cancer mortality. A real-world registry. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024:S1885-5857(24)00235-4. [PMID: 39033874 DOI: 10.1016/j.rec.2024.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 07/01/2024] [Indexed: 07/23/2024]
Abstract
INTRODUCTION AND OBJECTIVES Sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1ra) reduce cardiovascular events through different mechanisms, but their association with cancer remains unclear. The aim of this study was to compare the effect of combined treatment (SGLT2i and GLP1ra) and monotherapy (SGLT2i or GLP1ra) on hospitalization and/or death from cancer in a general population and a subgroup of patients with cardiovascular disease (CVD). METHODS We conducted a nonconcurrent observational prospective study of patients prescribed SGLT2i, GLP1ra, or both. Multinomial propensity scores were performed in the entire population and in a subgroup of patients with CVD. A multivariate Cox regression analysis was used to determine the hazard ratio (HR) for age, sex, risk factors, and treatment for each outcome. RESULTS We included 14 709 patients (11366 with SGLT2i, 1016 with GLP1ra, and 2327 with both treatments) from treatment initiation. Diabetes was present in 97% of the patients. The subgroup with CVD included 4957 (33.7%) patients. After a median of 33 months of follow-up, the risk of adverse cancer events was similar between patients with and without CVD (3.4% or 3.7%, respectively). The main risk factors for cancer mortality were male sex and age. Combined treatment and its duration reduced the risk of cancer mortality compared with monotherapy with SGLT2i or GLP1ra in the overall population (HR, 0.2216; 95%CI, 0.1106-0.4659; P<.001; and HR, 0.1928; 95%CI, 0.071-0.5219; P=.001, respectively) and in the subgroup of patients with CVD (HR, 0.2879; 95%CI, 0.0878-0.994; P<.049; and HR, 0.1329; 95%CI, 0.024-0.6768; P=.014, respectively). CONCLUSIONS Initiation of combined therapy (SGLT2i and GLP1ra) vs monotherapy with SGLT2i or GLP1ra was associated with a lower risk of cancer mortality, mostly in diabetic patients with or without CVD. Although clinical trials are needed, these results might be explained by the complementary mechanisms of these drugs, including their antiproliferative, anti-inflammatory, and metabolic effects. Future clinical trials and mechanistic studies will clarify the possible role of these drugs in carcinogenesis.
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Affiliation(s)
- David García-Vega
- Departamento de Medicina, Universidad de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Departamento de Cardiología, Hospital Clínico Universitario de Santiago, Santiago de Compostela, A Coruña, Spain; Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Spain.
| | - Sergio Cinza-Sanjurjo
- Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Spain; Centro de Salud de Milladoiro-Ames, Área Sanitaria de Santiago de Compostela, A Coruña, Spain
| | - Carlos Tilves-Bellas
- Instituto de Investigación Sanitaria de Santiago, Santiago de Compostela, A Coruña, Spain
| | - Sonia Eiras
- Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Spain; Instituto de Investigación Sanitaria de Santiago, Santiago de Compostela, A Coruña, Spain
| | - José R González-Juanatey
- Departamento de Medicina, Universidad de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Departamento de Cardiología, Hospital Clínico Universitario de Santiago, Santiago de Compostela, A Coruña, Spain; Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Spain. https://twitter.com/@josejuanatey
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Chipayo-Gonzales D, Shabbir A, Vergara-Uzcategui C, Nombela-Franco L, Jimenez-Quevedo P, Gonzalo N, Nuñez-Gil I, Mejia-Renteria H, Macaya-Ten F, Tirado-Conte G, Perez-Vizcayno MJ, Fuentes M, Escaned J, Fernandez-Ortiz A, Salinas P. Treatment with SGLT2 Inhibitors in Patients with Diabetes Mellitus and Extensive Coronary Artery Disease: Mortality and Cardiovascular Outcomes. Diabetes Ther 2023; 14:1853-1865. [PMID: 37665429 PMCID: PMC10570247 DOI: 10.1007/s13300-023-01454-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/19/2023] [Indexed: 09/05/2023] Open
Abstract
INTRODUCTION Sodium-glucose type 2 cotransporter inhibitors (SGLT2-I) have shown solid benefits in reducing cardiovascular mortality and admissions for heart failure in patients with type 2 diabetes mellitus (T2DM) and cardiovascular disease. However, no specific studies exist in patients with high-risk coronary artery disease (CAD). METHODS Single-center, retrospective, observational study including patients with T2DM and a new diagnosis of extensive CAD (defined as left main disease or three main coronary vessel disease). Patients were recruited from 2015 until 2020, with a follow-up of at least 12 months. The primary outcome was to compare all-cause mortality in patients treated with or without SGLT2-I at discharge and adjusted by inverse probability of treatment weighting (IPTW) propensity score. RESULTS A total of 420 patients were included: 104 (24.7%) were treated with SGLT2-I and 316 (75.3%) were not (non-SGLT2-I group). The presentation was acute coronary syndrome in 44.3%. The mean age was 71.2 ± 10.5 years. The mean left ventricular ejection fraction was 51.5 ± 12.5%, and the mean estimated glomerular filtration rate was 73.9 ± 22 ml/min. After a mean follow-up of 3 ± 1.6 years, all-cause mortality was 16.4%, and cardiovascular mortality was 9.5%. After IPTW, the risk of all-cause death was lower in the SGLT2-I group with a hazard ratio of 0.32 (95% confidence interval 0.12-0.81), p = 0.016. With regard to secondary outcomes, patients in the SGLT2-I group were associated with less renal function deterioration but an increase in unplanned revascularizations. CONCLUSIONS In patients with T2DM and extensive CAD, treatment with SGLT2-I after discharge was associated with a reduced risk of all-cause death.
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Affiliation(s)
- David Chipayo-Gonzales
- Department of Cardiology, Hospital Clínico San Carlos, Profesor Martin Lagos sn, 28040, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Profesor Martin Lagos sn, 28040, Madrid, Spain
| | - Asad Shabbir
- Department of Cardiology, Hospital Clínico San Carlos, Profesor Martin Lagos sn, 28040, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Profesor Martin Lagos sn, 28040, Madrid, Spain
| | - Carlos Vergara-Uzcategui
- Department of Cardiology, Hospital Clínico San Carlos, Profesor Martin Lagos sn, 28040, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Profesor Martin Lagos sn, 28040, Madrid, Spain
| | - Luis Nombela-Franco
- Department of Cardiology, Hospital Clínico San Carlos, Profesor Martin Lagos sn, 28040, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Profesor Martin Lagos sn, 28040, Madrid, Spain
| | - Pilar Jimenez-Quevedo
- Department of Cardiology, Hospital Clínico San Carlos, Profesor Martin Lagos sn, 28040, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Profesor Martin Lagos sn, 28040, Madrid, Spain
| | - Nieves Gonzalo
- Department of Cardiology, Hospital Clínico San Carlos, Profesor Martin Lagos sn, 28040, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Profesor Martin Lagos sn, 28040, Madrid, Spain
| | - Ivan Nuñez-Gil
- Department of Cardiology, Hospital Clínico San Carlos, Profesor Martin Lagos sn, 28040, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Profesor Martin Lagos sn, 28040, Madrid, Spain
| | - Hernan Mejia-Renteria
- Department of Cardiology, Hospital Clínico San Carlos, Profesor Martin Lagos sn, 28040, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Profesor Martin Lagos sn, 28040, Madrid, Spain
| | - Fernando Macaya-Ten
- Department of Cardiology, Hospital Clínico San Carlos, Profesor Martin Lagos sn, 28040, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Profesor Martin Lagos sn, 28040, Madrid, Spain
| | - Gabriela Tirado-Conte
- Department of Cardiology, Hospital Clínico San Carlos, Profesor Martin Lagos sn, 28040, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Profesor Martin Lagos sn, 28040, Madrid, Spain
| | - Maria Jose Perez-Vizcayno
- Department of Cardiology, Hospital Clínico San Carlos, Profesor Martin Lagos sn, 28040, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Profesor Martin Lagos sn, 28040, Madrid, Spain
| | - Manuel Fuentes
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Profesor Martin Lagos sn, 28040, Madrid, Spain
- Unidad de Investigación Hospital Clínico San Carlos, Madrid, Spain
- Unidad de Investigación Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Javier Escaned
- Department of Cardiology, Hospital Clínico San Carlos, Profesor Martin Lagos sn, 28040, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Profesor Martin Lagos sn, 28040, Madrid, Spain
| | - Antonio Fernandez-Ortiz
- Department of Cardiology, Hospital Clínico San Carlos, Profesor Martin Lagos sn, 28040, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Profesor Martin Lagos sn, 28040, Madrid, Spain
| | - Pablo Salinas
- Department of Cardiology, Hospital Clínico San Carlos, Profesor Martin Lagos sn, 28040, Madrid, Spain.
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Profesor Martin Lagos sn, 28040, Madrid, Spain.
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Chung CT, Lakhani I, Chou OHI, Lee TTL, Dee EC, Ng K, Wong WT, Liu T, Lee S, Zhang Q, Cheung BMY, Tse G, Zhou J. Sodium-glucose cotransporter 2 inhibitors versus dipeptidyl peptidase 4 inhibitors on new-onset overall cancer in Type 2 diabetes mellitus: A population-based study. Cancer Med 2023; 12:12299-12315. [PMID: 37148547 PMCID: PMC10278500 DOI: 10.1002/cam4.5927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 03/07/2023] [Accepted: 03/30/2023] [Indexed: 05/08/2023] Open
Abstract
BACKGROUND Cancer is currently the second leading cause of death globally. There is much uncertainty regarding the comparative risks of new-onset overall cancer and pre-specified cancer for Type 2 diabetes mellitus (T2DM) patients on sodium-glucose cotransporter 2 inhibitors (SGLT2I) versus DPP4I. METHODS This population-based cohort study patients included patients who were diagnosed with T2DM and administered either SGLT2 or DPP4 inhibitors between 1 January 2015 and 31 December 2020 in public hospitals of Hong Kong. RESULTS This study included 60,112 T2DM patients (mean baseline age: 62.1 ± 12.4 years, male: 56.36%), of which 18,167 patients were SGLT2I users and 41,945 patients were dipeptidyl peptidase 4 inhibitor (DPP4I) users. Multivariable Cox regression found that SGLT2I use was associated with lower risks of all-cause mortality (HR: 0.92; 95% CI: 0.84-0.99; p= 0.04), cancer-related mortality (HR: 0.58; 95% CI: 0.42-0.80; p ≤ 0.001) and new diagnoses of any cancer (HR: 0.70; 95% CI: 0.59-0.84; p ≤ 0.001). SGLT2I use was associated with a lower risk of new-onset breast cancer (HR: 0.51; 95% CI: 0.32-0.80; p ≤ 0.001), but not of other malignancies. Subgroup analysis on the type of SGLT2I, dapagliflozin (HR: 0.78; 95% CI: 0.64-0.95; p = 0.01) and ertugliflozin (HR: 0.65; 95% CI: 0.43-0.98; p = 0.04) use was associated with lower risks of new cancer diagnosis. Dapagliflozin use was also linked to lower risks of breast cancer (HR: 0.48; 95% CI: 0.27-0.83; p = 0.001). CONCLUSION Sodium-glucose cotransporter 2 inhibitor use was associated with lower risks of all-cause mortality, cancer-related mortality and new-onset overall cancer compared to DPP4I use after propensity score matching and multivariable adjustment.
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Affiliation(s)
- Cheuk To Chung
- Diabetes Research UnitCardiovascular Analytics Group, China‐UK CollaborationHong KongChina
| | - Ishan Lakhani
- Diabetes Research UnitCardiovascular Analytics Group, China‐UK CollaborationHong KongChina
| | - Oscar Hou In Chou
- Diabetes Research UnitCardiovascular Analytics Group, China‐UK CollaborationHong KongChina
- Division of Clinical Pharmacology and Therapeutics, Department of Medicine, LKS Faculty of MedicineThe University of Hong KongHong KongChina
| | - Teddy Tai Loy Lee
- Diabetes Research UnitCardiovascular Analytics Group, China‐UK CollaborationHong KongChina
| | - Edward Christopher Dee
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Kenrick Ng
- Department of Medical OncologyUniversity College London Hospitals NHS Foundation TrustLondonUK
| | - Wing Tak Wong
- School of Life SciencesChinese University of Hong KongHong KongChina
| | - Tong Liu
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of CardiologySecond Hospital of Tianjin Medical UniversityTianjinChina
| | - Sharen Lee
- Diabetes Research UnitCardiovascular Analytics Group, China‐UK CollaborationHong KongChina
| | - Qingpeng Zhang
- School of Data ScienceCity University of Hong KongHong KongChina
| | - Bernard Man Yung Cheung
- Division of Clinical Pharmacology and Therapeutics, Department of Medicine, LKS Faculty of MedicineThe University of Hong KongHong KongChina
| | - Gary Tse
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of CardiologySecond Hospital of Tianjin Medical UniversityTianjinChina
- Kent and Medway Medical SchoolUniversity of Kent and Canterbury Christ Church UniversityCanterburyUK
- School of Nursing and Health StudiesHong Kong Metropolitan UniversityHong KongChina
| | - Jiandong Zhou
- Diabetes Research UnitCardiovascular Analytics Group, China‐UK CollaborationHong KongChina
- Nuffield Department of MedicineUniversity of OxfordOxfordUK
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Spiazzi BF, Naibo RA, Wayerbacher LF, Piccoli GF, Farenzena LP, Londero TM, da Natividade GR, Zoldan M, Degobi NAH, Niches M, Lopes G, Boyko EJ, Utzschneider KM, Colpani V, Gerchman F. Sodium-glucose cotransporter-2 inhibitors and cancer outcomes: A systematic review and meta-analysis of randomized controlled trials. Diabetes Res Clin Pract 2023; 198:110621. [PMID: 36921905 DOI: 10.1016/j.diabres.2023.110621] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/21/2023] [Accepted: 03/07/2023] [Indexed: 03/16/2023]
Abstract
AIMS Concerns regarding breast and bladder cancer risk with Sodium-glucose cotransporter-2 (SGLT2) inhibitors remain controversial and its effect on cancer mortality is unknown. We aim to evaluate the association between SGLT2 inhibitors and the risk of cancer outcomes. METHODS We searched PubMed, Embase and CENTRAL up to June 20th, 2022, for randomized controlled trials of SGLT2 inhibitors in adults, with a minimum follow-up of 48 weeks. Researchers extracted study-level data and assessed within-study risk of bias with the RoB 2.0 tool and quality of evidence with GRADE. We performed meta-analyses summarizing the relative risks (RRs) of cancer outcomes. RESULTS Seventy-six trials encompassing 116,375 participants were selected. Overall risk of bias was low. SGLT2 inhibitors did not reduce/increase the overall risk of cancer (RR, 1.03; 95% confidence interval [CI], 0.96-1.10) and cancer mortality (RR, 0.99; 95% CI, 0.85-1.16). SGLT2 inhibitors likely result in little to no difference in the risk of breast (RR, 1.01; 95% CI 0.77-1.32) and bladder cancers (RR, 0.93; 95% CI 0.71-1.21). Trial sequential analysis provided evidence that the sample size was sufficient to avoid missing alternative results. CONCLUSIONS SGLT2 inhibitors are not associated with an increased risk of cancer outcomes, providing reassuring data regarding previous safety concerns.
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Affiliation(s)
- Bernardo F Spiazzi
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Rafaella A Naibo
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Laura F Wayerbacher
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Giovana F Piccoli
- Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Laura P Farenzena
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Thizá M Londero
- Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Gabriella R da Natividade
- Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Maira Zoldan
- Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Nathália A H Degobi
- Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Matheus Niches
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Gilberto Lopes
- Sylvester Comprehensive Cancer Center, Global Oncology Program, Miami, FL, United States
| | - Edward J Boyko
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle WA, 98195, United States; Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States
| | - Kristina M Utzschneider
- Research and Development, VA Puget Sound Health Care System, Seattle, WA, 98108, United States; Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, Seattle WA, 98195, United States
| | - Verônica Colpani
- Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Fernando Gerchman
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; Division of Endocrinology and Metabolism, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.
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5
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Ben-Assuli O, Ramon-Gonen R, Heart T, Jacobi A, Klempfner R. Utilizing shared frailty with the Cox proportional hazards regression: Post discharge survival analysis of CHF patients. J Biomed Inform 2023; 140:104340. [PMID: 36935013 DOI: 10.1016/j.jbi.2023.104340] [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: 04/17/2022] [Revised: 02/02/2023] [Accepted: 03/13/2023] [Indexed: 03/19/2023]
Abstract
Understanding patients' survival probability as well as the factors affecting it constitute a significant concern for researchers and practitioners, in particular for patients with severe chronic illnesses such as congestive heart failure (CHF). CHF is a clinical syndrome characterized by comorbidities and adverse medical events. Risk stratification to identify patients most likely to die shortly after hospital discharge can improve the quality of care by better allocating organizational resources and personalized interventions. Probability assessment improves clinical decision-making, contributes to personalized care, and saves costs. Although one of the most informative indices is the time to an adverse event for each patient, commonly analyzed using survival analysis methods, these are often challenging to implement due to the complexity of the medical data. Numerous studies have used the Cox proportional hazards (PH) regression method to generate the survival distribution pattern and factors affecting survival. This model, although advantageous for survival analysis, assumes the homogeneity of the hazard ratio across patients and independence of the observations in terms of survival time. These assumptions are often violated in real-world data, especially when the dataset is composed of readmission data for chronically ill patients, since these recurring observations are inherently dependent. This study ran the Cox PH regression on a feature set selected by machine learning algorithms from a rich hospital dataset. The event modeled here was patient mortality within 90 days post-hospital discharge. The sample was composed of medical records of patients hospitalized in the Israeli Sheba Medical Center more than once, with CHF as the primary diagnosis. We modeled the survival of CHF patients using the Cox PH regression with and without the shared frailty correction that addresses the shortcomings of the Cox Model. The results of the two models of the Cox PH regression - with and without the shared frailty correction were compared. The results demonstrate that the shared frailty correction, which was statistically significant in our analysis, improved the performance of the basic Cox PH model. While this is the main contribution, we also show that this model outperforms two commonly used measures (ADHERE and EFFECT) for predicting early mortality of CHF patients. Thus, the results illustrate how applying advanced analytics can outperform traditional methods. An additional contribution is the feature set selected using machine-learning methods that is different from those used in the extant literature.
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Affiliation(s)
- Ofir Ben-Assuli
- Faculty of Business Administration, Ono Academic College, 104 Zahal Street, Kiryat Ono 55000, Israel.
| | - Roni Ramon-Gonen
- The Graduate School of Business Administration, Bar-Ilan University, Ramat-Gan, Israel.
| | - Tsipi Heart
- Faculty of Business Administration, Ono Academic College, 104 Zahal Street, Kiryat Ono 55000, Israel.
| | - Arie Jacobi
- Faculty of Business Administration, Ono Academic College, 104 Zahal Street, Kiryat Ono 55000, Israel; Peres Academic Center, 10 Shimon Peres Street, Rehovot, Israel.
| | - Robert Klempfner
- The Leviev Heart Center, Sheba Medical Center, Ramat-Gan, Israel.
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