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Schut MC, Dongelmans DA, de Lange DW, Brinkman S, de Keizer NF, Abu-Hanna A. Development and evaluation of regression tree models for predicting in-hospital mortality of a national registry of COVID-19 patients over six pandemic surges. BMC Med Inform Decis Mak 2024; 24:7. [PMID: 38166918 PMCID: PMC10762959 DOI: 10.1186/s12911-023-02401-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 12/11/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Objective prognostic information is essential for good clinical decision making. In case of unknown diseases, scarcity of evidence and limited tacit knowledge prevent obtaining this information. Prediction models can be useful, but need to be not only evaluated on how well they predict, but also how stable these models are under fast changing circumstances with respect to development of the disease and the corresponding clinical response. This study aims to provide interpretable and actionable insights, particularly for clinicians. We developed and evaluated two regression tree predictive models for in-hospital mortality of COVID-19 patient at admission and 24 hours (24 h) after admission, using a national registry. We performed a retrospective analysis of observational routinely collected data. METHODS Two regression tree models were developed for admission and 24 h after admission. The complexity of the trees was managed via cross validation to prevent overfitting. The predictive ability of the model was assessed via bootstrapping using the Area under the Receiver-Operating-Characteristic curve, Brier score and calibration curves. The tree models were assessed on the stability of their probabilities and predictive ability, on the selected variables, and compared to a full-fledged logistic regression model that uses variable selection and variable transformations using splines. Participants included COVID-19 patients from all ICUs participating in the Dutch National Intensive Care Evaluation (NICE) registry, who were admitted at the ICU between February 27, 2020, and November 23, 2021. From the NICE registry, we included concerned demographic data, minimum and maximum values of physiological data in the first 24 h of ICU admission and diagnoses (reason for admission as well as comorbidities) for model development. The main outcome measure was in-hospital mortality. We additionally analysed the Length-of-Stay (LoS) per patient subgroup per survival status. RESULTS A total of 13,369 confirmed COVID-19 patients from 70 ICUs were included (with mortality rate of 28%). The optimism-corrected AUROC of the admission tree (with seven paths) was 0.72 (95% CI: 0.71-0.74) and of the 24 h tree (with 11 paths) was 0.74 (0.74-0.77). Both regression trees yielded good calibration and variable selection for both trees was stable. Patient subgroups comprising the tree paths had comparable survival probabilities as the full-fledged logistic regression model, survival probabilities were stable over six COVID-19 surges, and subgroups were shown to have added predictive value over the individual patient variables. CONCLUSIONS We developed and evaluated regression trees, which operate at par with a carefully crafted logistic regression model. The trees consist of homogenous subgroups of patients that are described by simple interpretable constraints on patient characteristics thereby facilitating shared decision-making.
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Affiliation(s)
- M C Schut
- Department of Medical Informatics, Amsterdam Public Health research institute, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
- Department of Laboratory Medicine, Amsterdam UMC location Vrije Universiteit, De Boelelaan 1117, 1081, HV, Amsterdam, The Netherlands.
| | - D A Dongelmans
- Department of Intensive Care Medicine, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - D W de Lange
- Department of Intensive Care Medicine and Dutch Poisons Information Center (DPIC), University Medical Center Utrecht, University Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands
| | - S Brinkman
- Department of Medical Informatics, Amsterdam Public Health research institute, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - N F de Keizer
- Department of Medical Informatics, Amsterdam Public Health research institute, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - A Abu-Hanna
- Department of Medical Informatics, Amsterdam Public Health research institute, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
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van Dam PMEL, Lievens S, Zelis N, van Doorn WPTM, Meex SJR, Cals JWL, Stassen PM. Head-to-head comparison of 19 prediction models for short-term outcome in medical patients in the emergency department: a retrospective study. Ann Med 2023; 55:2290211. [PMID: 38065678 PMCID: PMC10786429 DOI: 10.1080/07853890.2023.2290211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 11/04/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION Prediction models for identifying emergency department (ED) patients at high risk of poor outcome are often not externally validated. We aimed to perform a head-to-head comparison of the discriminatory performance of several prediction models in a large cohort of ED patients. METHODS In this retrospective study, we selected prediction models that aim to predict poor outcome and we included adult medical ED patients. Primary outcome was 31-day mortality, secondary outcomes were 1-day mortality, 7-day mortality, and a composite endpoint of 31-day mortality and admission to intensive care unit (ICU).The discriminatory performance of the prediction models was assessed using an area under the receiver operating characteristic curve (AUC). Finally, the prediction models with the highest performance to predict 31-day mortality were selected to further examine calibration and appropriate clinical cut-off points. RESULTS We included 19 prediction models and applied these to 2185 ED patients. Thirty-one-day mortality was 10.6% (231 patients), 1-day mortality was 1.4%, 7-day mortality was 4.4%, and 331 patients (15.1%) met the composite endpoint. The RISE UP and COPE score showed similar and very good discriminatory performance for 31-day mortality (AUC 0.86), 1-day mortality (AUC 0.87), 7-day mortality (AUC 0.86) and for the composite endpoint (AUC 0.81). Both scores were well calibrated. Almost no patients with RISE UP and COPE scores below 5% had an adverse outcome, while those with scores above 20% were at high risk of adverse outcome. Some of the other prediction models (i.e. APACHE II, NEWS, WPSS, MEWS, EWS and SOFA) showed significantly higher discriminatory performance for 1-day and 7-day mortality than for 31-day mortality. CONCLUSIONS Head-to-head validation of 19 prediction models in medical ED patients showed that the RISE UP and COPE score outperformed other models regarding 31-day mortality.
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Affiliation(s)
- Paul M. E. L. van Dam
- Department of Internal Medicine, Division of General Internal Medicine, Section Acute Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Sien Lievens
- Department of Internal Medicine, Division of General Internal Medicine, Section Acute Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Noortje Zelis
- Department of Internal Medicine, Division of General Internal Medicine, Section Acute Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - William P. T. M. van Doorn
- Central Diagnostic Laboratory, Department of Clinical Chemistry, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Steven J. R. Meex
- Central Diagnostic Laboratory, Department of Clinical Chemistry, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Jochen W. L. Cals
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, the Netherlands
| | - Patricia M. Stassen
- Department of Internal Medicine, Division of General Internal Medicine, Section Acute Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
- School for Cardiovascular Diseases (CARIM), Maastricht University, the Netherlands
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Henriksson A, Pawar Y, Hedberg P, Nauclér P. Multimodal fine-tuning of clinical language models for predicting COVID-19 outcomes. Artif Intell Med 2023; 146:102695. [PMID: 38042595 DOI: 10.1016/j.artmed.2023.102695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 10/12/2023] [Accepted: 10/29/2023] [Indexed: 12/04/2023]
Abstract
Clinical prediction models tend only to incorporate structured healthcare data, ignoring information recorded in other data modalities, including free-text clinical notes. Here, we demonstrate how multimodal models that effectively leverage both structured and unstructured data can be developed for predicting COVID-19 outcomes. The models are trained end-to-end using a technique we refer to as multimodal fine-tuning, whereby a pre-trained language model is updated based on both structured and unstructured data. The multimodal models are trained and evaluated using a multicenter cohort of COVID-19 patients encompassing all encounters at the emergency department of six hospitals. Experimental results show that multimodal models, leveraging the notion of multimodal fine-tuning and trained to predict (i) 30-day mortality, (ii) safe discharge and (iii) readmission, outperform unimodal models trained using only structured or unstructured healthcare data on all three outcomes. Sensitivity analyses are performed to better understand how well the multimodal models perform on different patient groups, while an ablation study is conducted to investigate the impact of different types of clinical notes on model performance. We argue that multimodal models that make effective use of routinely collected healthcare data to predict COVID-19 outcomes may facilitate patient management and contribute to the effective use of limited healthcare resources.
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Affiliation(s)
- Aron Henriksson
- Department of Computer and Systems Sciences (DSV), Stockholm University, Kista, Sweden.
| | - Yash Pawar
- Department of Computer and Systems Sciences (DSV), Stockholm University, Kista, Sweden
| | - Pontus Hedberg
- Division of Infectious Diseases, Department of Medicine, Solna (MedS), Karolinska Institutet, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Pontus Nauclér
- Division of Infectious Diseases, Department of Medicine, Solna (MedS), Karolinska Institutet, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
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Zolotov E, Sigal A, Havrda M, Raskova M, Girsa D, Hochfeld U, Krátká K, Rychlík I. Unveiling the Unexpected: Why Doctors Should Look beyond the Lungs when Predicting COVID-19 Mortality. Kidney Blood Press Res 2023; 48:347-356. [PMID: 37166324 DOI: 10.1159/000530803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 03/27/2023] [Indexed: 05/12/2023] Open
Abstract
INTRODUCTION The main objective of this study was to identify the best combination of admission day parameters for predicting COVID-19 mortality in hospitalized patients. Furthermore, we sought to compare the predictive capacity of pulmonary parameters to that of renal parameters for mortality from COVID-19. METHODS In this retrospective study, all patients admitted to a tertiary hospital between September 1st, 2020, and December 31st, 2020, who were clinically symptomatic and tested positive for COVID-19, were included. We gathered extensive data on patient admissions, including laboratory results, comorbidities, chest X-ray (CXR) images, and SpO2 levels, to determine their role in predicting mortality. Experienced radiologists evaluated the CXR images and assigned a score from 0 to 18 based on the severity of COVID-19 pneumonia. Further, we categorized patients into two independent groups based on their renal function using the RIFLE and KDIGO criteria to define the acute kidney injury (AKI) and chronic kidney disease (CKD) groups. The first group ("AKI&CKD") was subdivided into six subgroups: normal renal function (A); CKD grade 2+3a (B); AKI-DROP (C); CKD grade 3b (D); AKI-RISE (E); and grade 4 + 5 CKD (F). The second group was based only on estimated glomerular filtration rate (eGFR) at the admission, and thus it was divided into four grades: grade 1, grade 2+3a, grade 3b, and grade 4 + 5. RESULTS The cohort comprised 619 patients. Patients who died during hospitalization had a significantly higher mean radiological score compared to those who survived, with a p value <0.01. Moreover, we observed that the risk for mortality was significantly increased as renal function deteriorated, as evidenced by the AKI&CKD and eGFR groups (p < 0.001 for each group). Regarding mortality prediction, the area under the curve (AUC) for renal parameters (AKI&CKD group, eGFR group, and age) was found to be superior to that of pulmonary parameters (age, radiological score, SpO2, CRP, and D-dimer) with an AUC of 0.8068 versus 0.7667. However, when renal and pulmonary parameters were combined, the AUC increased to 0.8813. Optimal parameter combinations for predicting mortality from COVID-19 were identified for three medical settings: Emergency Medical Service (EMS), the Emergency Department, and the Internal Medicine Floor. The AUC for these settings was 0.7874, 0.8614, and 0.8813, respectively. CONCLUSIONS Our study demonstrated that selected renal parameters are superior to pulmonary parameters in predicting COVID-19 mortality for patients requiring hospitalization. When combining both renal and pulmonary factors, the predictive ability of mortality significantly improved. Additionally, we identified the optimal combination of factors for mortality prediction in three distinct settings: EMS, Emergency Department, and Internal Medicine Floor.
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Affiliation(s)
- Eli Zolotov
- Internal Medicine Department, Hackensack University Medical Center, Hackensack, New Jersey, USA,
- Third Faculty of Medicine, Charles University, Prague, Czechia,
| | - Anat Sigal
- Third Faculty of Medicine, Charles University, Prague, Czechia
- Pediatrics Department, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Martin Havrda
- Department of Internal Medicine, Faculty Hospital Královské Vinohrady, Prague, Czechia
| | - Maria Raskova
- Department of Radiology, Faculty Hospital Královské Vinohrady, Prague, Czechia
| | - David Girsa
- Third Faculty of Medicine, Charles University, Prague, Czechia
- Department of Radiology, Faculty Hospital Královské Vinohrady, Prague, Czechia
- Second Faculty of Medicine, Charles University, Prague, Czechia
| | - Uri Hochfeld
- Internal Medicine Department, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Karolína Krátká
- Department of Internal Medicine, Faculty Hospital Královské Vinohrady, Prague, Czechia
| | - Ivan Rychlík
- Third Faculty of Medicine, Charles University, Prague, Czechia
- Department of Internal Medicine, Faculty Hospital Královské Vinohrady, Prague, Czechia
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Buttia C, Llanaj E, Raeisi-Dehkordi H, Kastrati L, Amiri M, Meçani R, Taneri PE, Ochoa SAG, Raguindin PF, Wehrli F, Khatami F, Espínola OP, Rojas LZ, de Mortanges AP, Macharia-Nimietz EF, Alijla F, Minder B, Leichtle AB, Lüthi N, Ehrhard S, Que YA, Fernandes LK, Hautz W, Muka T. Prognostic models in COVID-19 infection that predict severity: a systematic review. Eur J Epidemiol 2023; 38:355-372. [PMID: 36840867 PMCID: PMC9958330 DOI: 10.1007/s10654-023-00973-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 01/28/2023] [Indexed: 02/26/2023]
Abstract
Current evidence on COVID-19 prognostic models is inconsistent and clinical applicability remains controversial. We performed a systematic review to summarize and critically appraise the available studies that have developed, assessed and/or validated prognostic models of COVID-19 predicting health outcomes. We searched six bibliographic databases to identify published articles that investigated univariable and multivariable prognostic models predicting adverse outcomes in adult COVID-19 patients, including intensive care unit (ICU) admission, intubation, high-flow nasal therapy (HFNT), extracorporeal membrane oxygenation (ECMO) and mortality. We identified and assessed 314 eligible articles from more than 40 countries, with 152 of these studies presenting mortality, 66 progression to severe or critical illness, 35 mortality and ICU admission combined, 17 ICU admission only, while the remaining 44 studies reported prediction models for mechanical ventilation (MV) or a combination of multiple outcomes. The sample size of included studies varied from 11 to 7,704,171 participants, with a mean age ranging from 18 to 93 years. There were 353 prognostic models investigated, with area under the curve (AUC) ranging from 0.44 to 0.99. A great proportion of studies (61.5%, 193 out of 314) performed internal or external validation or replication. In 312 (99.4%) studies, prognostic models were reported to be at high risk of bias due to uncertainties and challenges surrounding methodological rigor, sampling, handling of missing data, failure to deal with overfitting and heterogeneous definitions of COVID-19 and severity outcomes. While several clinical prognostic models for COVID-19 have been described in the literature, they are limited in generalizability and/or applicability due to deficiencies in addressing fundamental statistical and methodological concerns. Future large, multi-centric and well-designed prognostic prospective studies are needed to clarify remaining uncertainties.
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Affiliation(s)
- Chepkoech Buttia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Emergency Department, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 16C, 3010 Bern, Switzerland
- Epistudia, Bern, Switzerland
| | - Erand Llanaj
- Department of Molecular Epidemiology, German Institute of Human Nutrition Potsdam-Rehbrücke, Nuthetal, Germany
- ELKH-DE Public Health Research Group of the Hungarian Academy of Sciences, Department of Public Health and Epidemiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Epistudia, Bern, Switzerland
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany
| | - Hamidreza Raeisi-Dehkordi
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Lum Kastrati
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mojgan Amiri
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Renald Meçani
- Department of Pediatrics, “Mother Teresa” University Hospital Center, Tirana, University of Medicine, Tirana, Albania
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Petek Eylul Taneri
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- HRB-Trials Methodology Research Network College of Medicine, Nursing and Health Sciences University of Galway, Galway, Ireland
| | | | - Peter Francis Raguindin
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Swiss Paraplegic Research, Nottwil, Switzerland
- Faculty of Health Sciences, University of Lucerne, Lucerne, Switzerland
| | - Faina Wehrli
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Farnaz Khatami
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
- Department of Community Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Octavio Pano Espínola
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Department of Preventive Medicine and Public Health, University of Navarre, Pamplona, Spain
- Navarra Institute for Health Research, IdiSNA, Pamplona, Spain
| | - Lyda Z. Rojas
- Research Group and Development of Nursing Knowledge (GIDCEN-FCV), Research Center, Cardiovascular Foundation of Colombia, Floridablanca, Santander, Colombia
| | | | | | - Fadi Alijla
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Beatrice Minder
- Public Health and Primary Care Library, University Library of Bern, University of Bern, Bern, Switzerland
| | - Alexander B. Leichtle
- University Institute of Clinical Chemistry, Inselspital, Bern University Hospital, and Center for Artificial Intelligence in Medicine (CAIM), University of Bern, Bern, Switzerland
| | - Nora Lüthi
- Emergency Department, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 16C, 3010 Bern, Switzerland
| | - Simone Ehrhard
- Emergency Department, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 16C, 3010 Bern, Switzerland
| | - Yok-Ai Que
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Laurenz Kopp Fernandes
- Deutsches Herzzentrum Berlin (DHZB), Berlin, Germany
- Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Wolf Hautz
- Emergency Department, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 16C, 3010 Bern, Switzerland
| | - Taulant Muka
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Epistudia, Bern, Switzerland
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Basile MJ, Helmrich IRAR, Park JG, Polo J, Rietjens JA, van Klaveren D, Zanos TP, Nelson J, Lingsma HF, Kent DM, Alsma J, Verdonschot RJCG, Hajizadeh N. US and Dutch Perspectives on the Use of COVID-19 Clinical Prediction Models: Findings from a Qualitative Analysis. Med Decis Making 2023; 43:445-460. [PMID: 36760135 PMCID: PMC9922652 DOI: 10.1177/0272989x231152852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
INTRODUCTION Clinical prediction models (CPMs) for coronavirus disease 2019 (COVID-19) may support clinical decision making, treatment, and communication. However, attitudes about using CPMs for COVID-19 decision making are unknown. METHODS Online focus groups and interviews were conducted among health care providers, survivors of COVID-19, and surrogates (i.e., loved ones/surrogate decision makers) in the United States and the Netherlands. Semistructured questions explored experiences about clinical decision making in COVID-19 care and facilitators and barriers for implementing CPMs. RESULTS In the United States, we conducted 4 online focus groups with 1) providers and 2) surrogates and survivors of COVID-19 between January 2021 and July 2021. In the Netherlands, we conducted 3 focus groups and 4 individual interviews with 1) providers and 2) surrogates and survivors of COVID-19 between May 2021 and July 2021. Providers expressed concern about CPM validity and the belief that patients may interpret CPM predictions as absolute. They described CPMs as potentially useful for resource allocation, triaging, education, and research. Several surrogates and people who had COVID-19 were not given prognostic estimates but believed this information would have supported and influenced their decision making. A limited number of participants felt the data would not have applied to them and that they or their loved ones may not have survived, as poor prognosis may have suggested withdrawal of treatment. CONCLUSIONS Many providers had reservations about using CPMs for people with COVID-19 due to concerns about CPM validity and patient-level interpretation of the outcome predictions. However, several people who survived COVID-19 and their surrogates indicated that they would have found this information useful for decision making. Therefore, information provision may be needed to improve provider-level comfort and patient and surrogate understanding of CPMs. HIGHLIGHTS While clinical prediction models (CPMs) may provide an objective means of assessing COVID-19 prognosis, provider concerns about CPM validity and the interpretation of CPM predictions may limit their clinical use.Providers felt that CPMs may be most useful for resource allocation, triage, research, or educational purposes for COVID-19.Several survivors of COVID-19 and their surrogates felt that CPMs would have been informative and may have aided them in making COVID-19 treatment decisions, while others felt the data would not have applied to them.
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Affiliation(s)
- Melissa J. Basile
- Melissa J. Basile, Institute of Health
System Science, Feinstein Institutes for Medical Research, Northwell Health, 600
Community Drive, Manhasset, NY 11030, USA;
()
| | | | - Jinny G. Park
- Institute of Health System Science, Feinstein
Institutes for Medical Research, Northwell Health, Manhasset, NY, USA,Predictive Analytics and Comparative
Effectiveness (PACE) Center at the Institute for Clinical Research and
Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | | | - Judith A.C. Rietjens
- Department of Public Health, Erasmus University
Medical Center, Rotterdam, the Netherlands
| | - David van Klaveren
- Predictive Analytics and Comparative
Effectiveness (PACE) Center at the Institute for Clinical Research and
Health Policy Studies, Tufts Medical Center, Boston, MA, USA,Predictive Analytics and Comparative
Effectiveness (PACE) Center at the Institute for Clinical Research and
Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Theodoros P. Zanos
- Institute of Health System Science, Feinstein
Institutes for Medical Research, Northwell Health, Manhasset, NY, USA,Institute of Bioelectronic Medicine, Feinstein
Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Jason Nelson
- Predictive Analytics and Comparative
Effectiveness (PACE) Center at the Institute for Clinical Research and
Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Hester F. Lingsma
- Department of Public Health, Erasmus
University Medical Center, Rotterdam, the Netherlands
| | - David M. Kent
- Department of Public Health, Erasmus
University Medical Center, Rotterdam, the Netherlands
| | - Jelmer Alsma
- Department of Public Health, Erasmus
University Medical Center, Rotterdam, the Netherlands
| | | | - Negin Hajizadeh
- Institute of Health System Science, Feinstein
Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
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7
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Starting Home Telemonitoring and Oxygen Therapy Directly after Emergency Department Assessment Appears to Be Safe in COVID-19 Patients. J Clin Med 2022; 11:jcm11237236. [PMID: 36498810 PMCID: PMC9736754 DOI: 10.3390/jcm11237236] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/24/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Since data on the safety and effectiveness of home telemonitoring and oxygen therapy started directly after Emergency Department (ED) assessment in COVID-19 patients are sparse but could have many advantages, we evaluated these parameters in this study. METHODS All COVID-19 patients ≥18 years eligible for receiving home telemonitoring (November 2020-February 2022, Albert Schweitzer hospital, the Netherlands) were included: patients started directly after ED assessment (ED group) or after hospital admission (admission group). Safety (number of ED reassessments and hospital readmissions) and effectiveness (number of phone calls, duration of oxygen usage and home telemonitoring) were described in both groups. RESULTS 278 patients were included (n = 65 ED group, n = 213 admission group). ED group: 23.8% (n = 15) was reassessed, 15.9% (n = 10) was admitted and 7.7% (n = 5) ICU admitted. Admission group: 15.8% (n = 37) was reassessed, 6.5% (n = 14) was readmitted and 2.4% (n = 5) ICU (re)admitted. Ten patients died, of whom 7 due to COVID-19 (1 in ED group; 6 in the admission group). ED group: median duration of oxygen therapy was 9 (IQR 7-13) days; the total duration of home telemonitoring was 14 (IQR 9-18) days. Admission group: duration of oxygen therapy was 10 (IQR 6-16) days; total duration of home telemonitoring was 14 (IQR 10-20) days. CONCLUSION it appears to be safe to start home telemonitoring and oxygen therapy directly after ED assessment.
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8
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van Klaveren D, Zanos TP, Nelson J, Levy TJ, Park JG, Retel Helmrich IRA, Rietjens JAC, Basile MJ, Hajizadeh N, Lingsma HF, Kent DM. Prognostic models for COVID-19 needed updating to warrant transportability over time and space. BMC Med 2022; 20:456. [PMID: 36424619 PMCID: PMC9686462 DOI: 10.1186/s12916-022-02651-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 11/04/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Supporting decisions for patients who present to the emergency department (ED) with COVID-19 requires accurate prognostication. We aimed to evaluate prognostic models for predicting outcomes in hospitalized patients with COVID-19, in different locations and across time. METHODS We included patients who presented to the ED with suspected COVID-19 and were admitted to 12 hospitals in the New York City (NYC) area and 4 large Dutch hospitals. We used second-wave patients who presented between September and December 2020 (2137 and 3252 in NYC and the Netherlands, respectively) to evaluate models that were developed on first-wave patients who presented between March and August 2020 (12,163 and 5831). We evaluated two prognostic models for in-hospital death: The Northwell COVID-19 Survival (NOCOS) model was developed on NYC data and the COVID Outcome Prediction in the Emergency Department (COPE) model was developed on Dutch data. These models were validated on subsequent second-wave data at the same site (temporal validation) and at the other site (geographic validation). We assessed model performance by the Area Under the receiver operating characteristic Curve (AUC), by the E-statistic, and by net benefit. RESULTS Twenty-eight-day mortality was considerably higher in the NYC first-wave data (21.0%), compared to the second-wave (10.1%) and the Dutch data (first wave 10.8%; second wave 10.0%). COPE discriminated well at temporal validation (AUC 0.82), with excellent calibration (E-statistic 0.8%). At geographic validation, discrimination was satisfactory (AUC 0.78), but with moderate over-prediction of mortality risk, particularly in higher-risk patients (E-statistic 2.9%). While discrimination was adequate when NOCOS was tested on second-wave NYC data (AUC 0.77), NOCOS systematically overestimated the mortality risk (E-statistic 5.1%). Discrimination in the Dutch data was good (AUC 0.81), but with over-prediction of risk, particularly in lower-risk patients (E-statistic 4.0%). Recalibration of COPE and NOCOS led to limited net benefit improvement in Dutch data, but to substantial net benefit improvement in NYC data. CONCLUSIONS NOCOS performed moderately worse than COPE, probably reflecting unique aspects of the early pandemic in NYC. Frequent updating of prognostic models is likely to be required for transportability over time and space during a dynamic pandemic.
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Affiliation(s)
- David van Klaveren
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Dr. Molewaterplein 50, 3015 GE, Rotterdam, The Netherlands. .,Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, USA.
| | - Theodoros P Zanos
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Jason Nelson
- Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, USA
| | - Todd J Levy
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Jinny G Park
- Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, USA
| | - Isabel R A Retel Helmrich
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Dr. Molewaterplein 50, 3015 GE, Rotterdam, The Netherlands
| | - Judith A C Rietjens
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Dr. Molewaterplein 50, 3015 GE, Rotterdam, The Netherlands
| | - Melissa J Basile
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY, USA
| | - Negin Hajizadeh
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY, USA
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Dr. Molewaterplein 50, 3015 GE, Rotterdam, The Netherlands
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, USA
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Levy TJ, Coppa K, Cang J, Barnaby DP, Paradis MD, Cohen SL, Makhnevich A, van Klaveren D, Kent DM, Davidson KW, Hirsch JS, Zanos TP. Development and validation of self-monitoring auto-updating prognostic models of survival for hospitalized COVID-19 patients. Nat Commun 2022; 13:6812. [PMID: 36357420 PMCID: PMC9648888 DOI: 10.1038/s41467-022-34646-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 11/02/2022] [Indexed: 11/12/2022] Open
Abstract
Clinical prognostic models can assist patient care decisions. However, their performance can drift over time and location, necessitating model monitoring and updating. Despite rapid and significant changes during the pandemic, prognostic models for COVID-19 patients do not currently account for these drifts. We develop a framework for continuously monitoring and updating prognostic models and apply it to predict 28-day survival in COVID-19 patients. We use demographic, laboratory, and clinical data from electronic health records of 34912 hospitalized COVID-19 patients from March 2020 until May 2022 and compare three modeling methods. Model calibration performance drift is immediately detected with minor fluctuations in discrimination. The overall calibration on the prospective validation cohort is significantly improved when comparing the dynamically updated models against their static counterparts. Our findings suggest that, using this framework, models remain accurate and well-calibrated across various waves, variants, race and sex and yield positive net-benefits.
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Affiliation(s)
- Todd J Levy
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, 11030, USA
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, 11030, USA
| | - Kevin Coppa
- Clinical Digital Solutions, Northwell Health, New Hyde Park, NY, 11042, USA
| | - Jinxuan Cang
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, 11030, USA
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, 11030, USA
| | - Douglas P Barnaby
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, 11030, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, 11549, USA
| | - Marc D Paradis
- Northwell Holdings, Northwell Health, Manhasset, NY, 11030, USA
| | - Stuart L Cohen
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, 11030, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, 11549, USA
| | - Alex Makhnevich
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, 11030, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, 11549, USA
| | - David van Klaveren
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center, Boston, MA, USA
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center, Boston, MA, USA
| | - Karina W Davidson
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, 11030, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, 11549, USA
| | - Jamie S Hirsch
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, 11030, USA
- Clinical Digital Solutions, Northwell Health, New Hyde Park, NY, 11042, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, 11549, USA
| | - Theodoros P Zanos
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, 11030, USA.
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, 11030, USA.
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, 11549, USA.
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10
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Tredinnick-Rowe J, Symonds R. Rapid systematic review of respiratory rate as a vital sign of clinical deterioration in COVID-19. Expert Rev Respir Med 2022; 16:1227-1236. [PMID: 36644851 DOI: 10.1080/17476348.2023.2169138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 01/12/2023] [Indexed: 01/17/2023]
Abstract
OBJECTIVES This meta-analysis aimed to establish a clinical evidence base for respiratory rate (RR) as a single predictor of early-onset COVID-19. The review also looked to determine the practical implementation of mobile respiratory rate measuring devices where information was available. METHODS We focused on domestic settings with older adults. Relevant studies were identified through MEDLINE, Embase, and CENTRAL databases. A snowballing method was also used. Articles published from the beginning of the COVID-19 pandemic (2019) until Feb 2022 were selected. Databases were searched for terms related to COVID-19 and respiratory rate measurements in domestic patients. RESULTS A total of 2,889 articles were screened for relevant content, of which 60 full-text publications were included. We compared the Odds Ratios and statistically significant results of both vital signs. CONCLUSION Multinational studies across dozens of countries have shown respiratory rate to have predictive accuracy in detecting COVID-19 deterioration. However, considerable variability is present in the data, making it harder to be sure about the effects. There is no meaningful difference in data quality in terms of variability (95% CI intervals) between vital signs as predictors of decline in COVID-19 patients. Contextual and economic factors will likely determine the choice of measurement used.
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11
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Zhao X, Lai JW, Wah Ho AF, Liu N, Hock Ong ME, Cheong KH. Predicting hospital emergency department visits with deep learning approaches. Biocybern Biomed Eng 2022. [DOI: 10.1016/j.bbe.2022.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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