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Hurley NC, Dhruva SS, Desai NR, Ross JR, Ngufor CG, Masoudi F, Krumholz HM, Mortazavi BJ. Clinical Phenotyping with an Outcomes-driven Mixture of Experts for Patient Matching and Risk Estimation. ACM Trans Comput Healthc 2023; 4:1-18. [PMID: 37908872 PMCID: PMC10613929 DOI: 10.1145/3616021] [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] [Received: 05/20/2022] [Accepted: 08/02/2023] [Indexed: 11/02/2023]
Abstract
Observational medical data present unique opportunities for analysis of medical outcomes and treatment decision making. However, because these datasets do not contain the strict pairing of randomized control trials, matching techniques are to draw comparisons among patients. A key limitation to such techniques is verification that the variables used to model treatment decision making are also relevant in identifying the risk of major adverse events. This article explores a deep mixture of experts approach to jointly learn how to match patients and model the risk of major adverse events in patients. Although trained with information regarding treatment and outcomes, after training, the proposed model is decomposable into a network that clusters patients into phenotypes from information available before treatment. This model is validated on a dataset of patients with acute myocardial infarction complicated by cardiogenic shock. The mixture of experts approach can predict the outcome of mortality with an area under the receiver operating characteristic curve of 0.85 ± 0.01 while jointly discovering five potential phenotypes of interest. The technique and interpretation allow for identifying clinically relevant phenotypes that may be used both for outcomes modeling as well as potentially evaluating individualized treatment effects.
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Inselman JW, Jeffery MM, Maddux JT, Lam RW, Shah ND, Rank MA, Ngufor CG. A prediction model for asthma exacerbations after stopping asthma biologics. Ann Allergy Asthma Immunol 2023; 130:305-311. [PMID: 36509405 PMCID: PMC9992017 DOI: 10.1016/j.anai.2022.11.025] [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: 10/06/2022] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Little is known regarding the prediction of the risks of asthma exacerbation after stopping asthma biologics. OBJECTIVE To develop and validate a predictive model for the risk of asthma exacerbations after stopping asthma biologics using machine learning models. METHODS We identified 3057 people with asthma who stopped asthma biologics in the OptumLabs Database Warehouse and considered a wide range of demographic and clinical risk factors to predict subsequent outcomes. The primary outcome used to assess success after stopping was having no exacerbations in the 6 months after stopping the biologic. Elastic-net logistic regression (GLMnet), random forest, and gradient boosting machine models were used with 10-fold cross-validation within a development (80%) cohort and validation cohort (20%). RESULTS The mean age of the total cohort was 47.1 (SD, 17.1) years, 1859 (60.8%) were women, 2261 (74.0%) were White, and 1475 (48.3%) were in the Southern region of the United States. The elastic-net logistic regression model yielded an area under the curve (AUC) of 0.75 (95% confidence interval [CI], 0.71-0.78) in the development and an AUC of 0.72 in the validation cohort. The random forest model yielded an AUC of 0.75 (95% CI, 0.68-0.79) in the development cohort and an AUC of 0.72 in the validation cohort. The gradient boosting machine model yielded an AUC of 0.76 (95% CI, 0.72-0.80) in the development cohort and an AUC of 0.74 in the validation cohort. CONCLUSION Outcomes after stopping asthma biologics can be predicted with moderate accuracy using machine learning methods.
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Affiliation(s)
- Jonathan W Inselman
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Molly M Jeffery
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | | | - Regina W Lam
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona
| | - Nilay D Shah
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; OptumLabs, Cambridge, Massachusetts
| | - Matthew A Rank
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Arizona; Division of Pulmonology, Phoenix Children's Hospital, Phoenix, Arizona.
| | - Che G Ngufor
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
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Shazly SA, Borah BJ, Ngufor CG, Torbenson VE, Theiler RN, Famuyide AO. Impact of labor characteristics on maternal and neonatal outcomes of labor: A machine-learning model. PLoS One 2022; 17:e0273178. [PMID: 35994474 PMCID: PMC9394788 DOI: 10.1371/journal.pone.0273178] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 08/01/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction
Since Friedman’s seminal publication on laboring women, numerous publications have sought to define normal labor progress. However, there is paucity of data on contemporary labor cervicometry incorporating both maternal and neonatal outcomes. The objective of this study is to establish intrapartum prediction models of unfavorable labor outcomes using machine-learning algorithms.
Materials and methods
Consortium on Safe Labor is a large database consisting of pregnancy and labor characteristics from 12 medical centers in the United States. Outcomes, including maternal and neonatal outcomes, were retrospectively collected. We defined primary outcome as the composite of following unfavorable outcomes: cesarean delivery in active labor, postpartum hemorrhage, intra-amniotic infection, shoulder dystocia, neonatal morbidity, and mortality. Clinical and obstetric parameters at admission and during labor progression were used to build machine-learning risk-prediction models based on the gradient boosting algorithm.
Results
Of 228,438 delivery episodes, 66,586 were eligible for this study. Mean maternal age was 26.95 ± 6.48 years, mean parity was 0.92 ± 1.23, and mean gestational age was 39.35 ± 1.13 weeks. Unfavorable labor outcome was reported in 14,439 (21.68%) deliveries. Starting at a cervical dilation of 4 cm, the area under receiver operating characteristics curve (AUC) of prediction models increased from 0.75 (95% confidence interval, 0.75–0.75) to 0.89 (95% confidence interval, 0.89–0.90) at a dilation of 10 cm. Baseline labor risk score was above 35% in patients with unfavorable outcomes compared to women with favorable outcomes, whose score was below 25%.
Conclusion
Labor risk score is a machine-learning–based score that provides individualized and dynamic alternatives to conventional labor charts. It predicts composite of adverse birth, maternal, and neonatal outcomes as labor progresses. Therefore, it can be deployed in clinical practice to monitor labor progress in real time and support clinical decisions.
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Affiliation(s)
- Sherif A. Shazly
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota
| | - Bijan J. Borah
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Che G. Ngufor
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, Minnesota
| | | | - Regan N. Theiler
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota
| | - Abimbola O. Famuyide
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota
- * E-mail:
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Dunlay SM, Blecker S, Schulte PJ, Redfield MM, Ngufor CG, Glasgow A. Identifying Patients With Advanced Heart Failure Using Administrative Data. Mayo Clin Proc Innov Qual Outcomes 2022; 6:148-155. [PMID: 35369610 PMCID: PMC8968660 DOI: 10.1016/j.mayocpiqo.2022.02.001] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective To develop algorithms to identify patients with advanced heart failure (HF) that can be applied to administrative data. Patients and Methods In a population-based cohort of all residents of Olmsted County, Minnesota, with greater than or equal to 1 HF billing code 2007-2017 (n=8657), we identified all patients with advanced HF (n=847) by applying the gold standard European Society of Cardiology advanced HF criteria via manual medical review by an HF cardiologist. The advanced HF index date was the date the patient first met all European Society of Cardiology criteria. We subsequently developed candidate algorithms to identify advanced HF using administrative data (billing codes and prescriptions relevant to HF or comorbidities that affect HF outcomes), applied them to the HF cohort, and assessed their ability to identify patients with advanced HF on or after their advanced HF index date. Results A single hospitalization for HF or ventricular arrhythmias identified all patients with advanced HF (sensitivity, 100%); however, the positive predictive value (PPV) was low (36.4%). More stringent definitions, including additional hospitalizations and/or other signs of advanced HF (hyponatremia, acute kidney injury, hypotension, or high-dose diuretic use), decreased the sensitivity but improved the specificity and PPV. For example, 2 hospitalizations plus 1 sign of advanced HF had a sensitivity of 72.7%, specificity of 89.8%, and PPV of 60.5%. Negative predictive values were high for all algorithms evaluated. Conclusion Algorithms using administrative data can identify patients with advanced HF with reasonable performance.
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Affiliation(s)
- Shannon M Dunlay
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Saul Blecker
- Department of Population Health and Medicine, NYU Grossman School of Medicine, New York, NY
| | - Phillip J Schulte
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | | | - Che G Ngufor
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Amy Glasgow
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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Fortune E, Cloud-Biebl BA, Madansingh SI, Ngufor CG, Van Straaten MG, Goodwin BM, Murphree DH, Zhao KD, Morrow MM. Estimation of manual wheelchair-based activities in the free-living environment using a neural network model with inertial body-worn sensors. J Electromyogr Kinesiol 2022; 62:102337. [PMID: 31353200 PMCID: PMC6980511 DOI: 10.1016/j.jelekin.2019.07.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 06/24/2019] [Accepted: 07/15/2019] [Indexed: 02/03/2023] Open
Abstract
Shoulder pain is common in manual wheelchair (MWC) users. Overuse is thought to be a major cause, but little is known about exposure to activities of daily living (ADLs). The study goal was to develop a method to estimate three conditions in the field: (1) non-propulsion activity, (2) MWC propulsion, and (3) static time using an inertial measurement unit (IMU). Upper arm IMU data were collected as ten MWC users performed lab-based MWC-related ADLs. A neural network model was developed to classify data as non-propulsion activity, propulsion, or static, and validated for the lab-based data collection by video comparison. Six of the participants' free-living IMU data were collected and the lab-based model was applied to estimate daily non-propulsion activity, propulsion, and static time. The neural network model yielded lab-based validity measures ≥0.87 for differentiating non-propulsion activity, propulsion, and static time. A quasi-validation of one participant's field-based data yielded validity measures ≥0.66 for identifying propulsion. Participants' estimated mean daily non-propulsion activity, propulsion, and static time ranged from 158 to 409, 13 to 25, and 367 to 609 min, respectively. The preliminary results suggest the model may be able to accurately identify MWC users' field-based activities. The inclusion of field-based IMU data in the model could further improve field-based classification.
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Affiliation(s)
- Emma Fortune
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, 55905, USA,Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, 55905, USA
| | - Beth A. Cloud-Biebl
- Program in Physical Therapy, Mayo Clinic School of Health Sciences, Mayo Clinic, Rochester, MN, 55905, USA,Assistive and Restorative Technology Laboratory, Rehabilitation Medicine Research Center, Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, 55905, USA
| | - Stefan I. Madansingh
- Assistive and Restorative Technology Laboratory, Rehabilitation Medicine Research Center, Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, 55905, USA
| | - Che G. Ngufor
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, 55905, USA,Division of Biomedical Informatics and Statistics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, 55905, USA
| | - Meegan G. Van Straaten
- Assistive and Restorative Technology Laboratory, Rehabilitation Medicine Research Center, Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, 55905, USA
| | - Brianna M. Goodwin
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, 55905, USA,Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, 55905, USA
| | - Dennis H. Murphree
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, 55905, USA,Division of Biomedical Informatics and Statistics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, 55905, USA
| | - Kristin D. Zhao
- Assistive and Restorative Technology Laboratory, Rehabilitation Medicine Research Center, Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, 55905, USA
| | - Melissa M. Morrow
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, 55905, USA,Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, 55905, USA
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Manemann SM, St Sauver JL, Liu H, Larson NB, Moon S, Takahashi PY, Olson JE, Rocca WA, Miller VM, Therneau TM, Ngufor CG, Roger VL, Zhao Y, Decker PA, Killian JM, Bielinski SJ. Longitudinal cohorts for harnessing the electronic health record for disease prediction in a US population. BMJ Open 2021; 11:e044353. [PMID: 34103314 PMCID: PMC8190051 DOI: 10.1136/bmjopen-2020-044353] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE The depth and breadth of clinical data within electronic health record (EHR) systems paired with innovative machine learning methods can be leveraged to identify novel risk factors for complex diseases. However, analysing the EHR is challenging due to complexity and quality of the data. Therefore, we developed large electronic population-based cohorts with comprehensive harmonised and processed EHR data. PARTICIPANTS All individuals 30 years of age or older who resided in Olmsted County, Minnesota on 1 January 2006 were identified for the discovery cohort. Algorithms to define a variety of patient characteristics were developed and validated, thus building a comprehensive risk profile for each patient. Patients are followed for incident diseases and ageing-related outcomes. Using the same methods, an independent validation cohort was assembled by identifying all individuals 30 years of age or older who resided in the largely rural 26-county area of southern Minnesota and western Wisconsin on 1 January 2013. FINDINGS TO DATE For the discovery cohort, 76 255 individuals (median age 49; 53% women) were identified from which a total of 9 644 221 laboratory results; 9 513 840 diagnosis codes; 10 924 291 procedure codes; 1 277 231 outpatient drug prescriptions; 966 136 heart rate measurements and 1 159 836 blood pressure (BP) measurements were retrieved during the baseline time period. The most prevalent conditions in this cohort were hyperlipidaemia, hypertension and arthritis. For the validation cohort, 333 460 individuals (median age 54; 52% women) were identified and to date, a total of 19 926 750 diagnosis codes, 10 527 444 heart rate measurements and 7 356 344 BP measurements were retrieved during baseline. FUTURE PLANS Using advanced machine learning approaches, these electronic cohorts will be used to identify novel sex-specific risk factors for complex diseases. These approaches will allow us to address several challenges with the use of EHR.
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Affiliation(s)
- Sheila M Manemann
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Jennifer L St Sauver
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Hongfang Liu
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicholas B Larson
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Sungrim Moon
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul Y Takahashi
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Janet E Olson
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Walter A Rocca
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Women's Health Research Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Virginia M Miller
- Mayo Clinic Women's Health Research Center, Mayo Clinic, Rochester, Minnesota, USA
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Specialized Center of Research Excellence, Mayo Clinic Rochester, Minnesota, USA, Mayo Clinic, Rochester, Minnesota, USA
| | - Terry M Therneau
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Che G Ngufor
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Veronique L Roger
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Epidemiology and Community Health Branch National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Yiqing Zhao
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul A Decker
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Jill M Killian
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Suzette J Bielinski
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
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Dhruva SS, Ross JS, Mortazavi BJ, Hurley NC, Krumholz HM, Curtis JP, Berkowitz AP, Masoudi FA, Messenger JC, Parzynski CS, Ngufor CG, Girotra S, Amin AP, Shah ND, Desai NR. Use of Mechanical Circulatory Support Devices Among Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock. JAMA Netw Open 2021; 4:e2037748. [PMID: 33616664 PMCID: PMC7900859 DOI: 10.1001/jamanetworkopen.2020.37748] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [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: 01/17/2023] Open
Abstract
IMPORTANCE Mechanical circulatory support (MCS) devices, including intravascular microaxial left ventricular assist devices (LVADs) and intra-aortic balloon pumps (IABPs), are used in patients who undergo percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) complicated by cardiogenic shock despite limited evidence of their clinical benefit. OBJECTIVE To examine trends in the use of MCS devices among patients who underwent PCI for AMI with cardiogenic shock, hospital-level use variation, and factors associated with use. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used the CathPCI and Chest Pain-MI Registries of the American College of Cardiology National Cardiovascular Data Registry. Patients who underwent PCI for AMI complicated by cardiogenic shock between October 1, 2015, and December 31, 2017, were identified from both registries. Data were analyzed from October 2018 to August 2020. EXPOSURES Therapies to provide hemodynamic support were categorized as intravascular microaxial LVAD, IABP, TandemHeart, extracorporeal membrane oxygenation, LVAD, other devices, combined IABP and intravascular microaxial LVAD, combined IABP and other device (defined as TandemHeart, extracorporeal membrane oxygenation, LVAD, or another MCS device), or medical therapy only. MAIN OUTCOMES AND MEASURES Use of MCS devices overall and specific MCS devices, including intravascular microaxial LVAD, at both patient and hospital levels and variables associated with use. RESULTS Among the 28 304 patients included in the study, the mean (SD) age was 65.4 (12.6) years and 18 968 were men (67.0%). The overall MCS device use was constant from the fourth quarter of 2015 to the fourth quarter of 2017, although use of intravascular microaxial LVADs significantly increased (from 4.1% to 9.8%; P < .001), whereas use of IABPs significantly decreased (from 34.8% to 30.0%; P < .001). A significant hospital-level variation in MCS device use was found. The median (interquartile range [IQR]) proportion of patients who received MCS devices was 42% (30%-54%), and the median proportion of patients who received intravascular microaxial LVADs was 1% (0%-10%). In multivariable analyses, cardiac arrest at first medical contact or during hospitalization (odds ratio [OR], 1.82; 95% CI, 1.58-2.09) and severe left main and/or proximal left anterior descending coronary artery stenosis (OR, 1.36; 95% CI, 1.20-1.54) were patient characteristics that were associated with higher odds of receiving intravascular microaxial LVADs only compared with IABPs only. CONCLUSIONS AND RELEVANCE This study found that, among patients who underwent PCI for AMI complicated by cardiogenic shock, overall use of MCS devices was constant, and a 2.5-fold increase in intravascular microaxial LVAD use was found along with a corresponding decrease in IABP use and a significant hospital-level variation in MCS device use. These trends were observed despite limited clinical trial evidence of improved outcomes associated with device use.
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Affiliation(s)
- Sanket S. Dhruva
- University of California, San Francisco School of Medicine, San Francisco
- Section of Cardiology, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Joseph S. Ross
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Bobak J. Mortazavi
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Department of Computer Science and Engineering, Texas A&M University, College Station
- Center for Remote Health Technologies and Systems, Texas A&M University, College Station
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Nathan C. Hurley
- Department of Computer Science and Engineering, Texas A&M University, College Station
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jeptha P. Curtis
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alyssa P. Berkowitz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Frederick A. Masoudi
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - John C. Messenger
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - Craig S. Parzynski
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Che G. Ngufor
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Digital Health Sciences, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Saket Girotra
- Division of Cardiovascular Diseases, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
| | - Amit P. Amin
- Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri
| | - Nilay D. Shah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Policy Research, Mayo Clinic, Rochester, Minnesota
| | - Nihar R. Desai
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Yao X, Inselman JW, Ross JS, Izem R, Graham DJ, Martin DB, Thompson AM, Ross Southworth M, Siontis KC, Ngufor CG, Nath KA, Desai NR, Nallamothu BK, Saran R, Shah ND, Noseworthy PA. Comparative Effectiveness and Safety of Oral Anticoagulants Across Kidney Function in Patients With Atrial Fibrillation. Circ Cardiovasc Qual Outcomes 2020; 13:e006515. [PMID: 33012172 DOI: 10.1161/circoutcomes.120.006515] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [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] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients with atrial fibrillation and severely decreased kidney function were excluded from the pivotal non-vitamin K antagonist oral anticoagulants (NOAC) trials, thereby raising questions about comparative safety and effectiveness in patients with reduced kidney function. The study aimed to compare oral anticoagulants across the range of kidney function in patients with atrial fibrillation. METHODS AND RESULTS Using a US administrative claims database with linked laboratory data, 34 569 new users of oral anticoagulants with atrial fibrillation and estimated glomerular filtration rate ≥15 mL/(min·1.73 m2) were identified between October 1, 2010 to November 29, 2017. The proportion of patients using NOACs declined with decreasing kidney function-73.5%, 69.6%, 65.4%, 59.5%, and 45.0% of the patients were prescribed a NOAC in estimated glomerular filtration rate ≥90, 60 to 90, 45 to 60, 30 to 45, 15 to 30 mL/min per 1.73 m2 groups, respectively. Stabilized inverse probability of treatment weighting was used to balance 4 treatment groups (apixaban, dabigatran, rivaroxaban, and warfarin) on 66 baseline characteristics. In comparison to warfarin, apixaban was associated with a lower risk of stroke (hazard ratio [HR], 0.57 [0.43-0.75]; P<0.001), major bleeding (HR, 0.51 [0.44-0.61]; P<0.001), and mortality (HR, 0.68 [0.56-0.83]; P<0.001); dabigatran was associated with a similar risk of stroke but a lower risk of major bleeding (HR, 0.57 [0.43-0.75]; P<0.001) and mortality (HR, 0.68 [0.48-0.98]; P=0.04); rivaroxaban was associated with a lower risk of stroke (HR, 0.69 [0.51-0.94]; P=0.02), major bleeding (HR, 0.84 [0.72-0.99]; P=0.04), and mortality (HR, 0.73 [0.58-0.91]; P=0.006). There was no significant interaction between treatment and estimated glomerular filtration rate categories for any outcome. When comparing one NOAC to another NOAC, there was no significant difference in mortality, but some differences existed for stroke or major bleeding. No relationship between treatments and falsification end points was found, suggesting no evidence for substantial residual confounding. CONCLUSIONS Relative to warfarin, NOACs are used less frequently as kidney function declines. However, NOACs appears to have similar or better comparative effectiveness and safety across the range of kidney function.
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Affiliation(s)
- Xiaoxi Yao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (X.Y., J.W.I., C.G.N., N.D.S., P.A.N.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN.,Division of Health Care Policy and Research, Department of Health Sciences Research (X.Y., J.W.I., N.D.S.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN.,Department of Cardiovascular Medicine (X.Y., K.C.S., P.A.N.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Jonathan W Inselman
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (X.Y., J.W.I., C.G.N., N.D.S., P.A.N.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN.,Division of Health Care Policy and Research, Department of Health Sciences Research (X.Y., J.W.I., N.D.S.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Joseph S Ross
- Department of Internal Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT (J.S.R.).,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (J.S.R., N.R.D.)
| | - Rima Izem
- Division of Biometrics and Epidemiology, Children's National Research Institute, Washington, D.C. (R.I.)
| | - David J Graham
- Office of Surveillance and Epidemiology (D.J.G.), Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - David B Martin
- Office of Medical Policy (D.B.M.), Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - Aliza M Thompson
- Division of Cardiovascular and Renal Products (A.M.T, M.R.S.), Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - Mary Ross Southworth
- Division of Cardiovascular and Renal Products (A.M.T, M.R.S.), Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - Konstantinos C Siontis
- Department of Cardiovascular Medicine (X.Y., K.C.S., P.A.N.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Che G Ngufor
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (X.Y., J.W.I., C.G.N., N.D.S., P.A.N.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN.,Division of Biomedical Statistics and Informatics, Department of Health Sciences Research (C.G.N.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Karl A Nath
- Division of Nephrology and Hypertension (K.A.N.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Nihar R Desai
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (J.S.R., N.R.D.)
| | - Brahmajee K Nallamothu
- Division of Cardiovascular Medicine, Department of Internal Medicine (B.K.N.), University of Michigan, Ann Arbor
| | - Rajiv Saran
- Department of Internal Medicine (R.S.), University of Michigan, Ann Arbor
| | - Nilay D Shah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (X.Y., J.W.I., C.G.N., N.D.S., P.A.N.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN.,Division of Health Care Policy and Research, Department of Health Sciences Research (X.Y., J.W.I., N.D.S.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN.,OptumLabs, Cambridge, MA (N.D.S.)
| | - Peter A Noseworthy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (X.Y., J.W.I., C.G.N., N.D.S., P.A.N.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN.,Department of Cardiovascular Medicine (X.Y., K.C.S., P.A.N.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN
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Chen D, Goyal G, Go RS, Parikh SA, Ngufor CG. Improved Interpretability of Machine Learning Model Using Unsupervised Clustering: Predicting Time to First Treatment in Chronic Lymphocytic Leukemia. JCO Clin Cancer Inform 2019; 3:1-11. [DOI: 10.1200/cci.18.00137] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Time to event is an important aspect of clinical decision making. This is particularly true when diseases have highly heterogeneous presentations and prognoses, as in chronic lymphocytic lymphoma (CLL). Although machine learning methods can readily learn complex nonlinear relationships, many methods are criticized as inadequate because of limited interpretability. We propose using unsupervised clustering of the continuous output of machine learning models to provide discrete risk stratification for predicting time to first treatment in a cohort of patients with CLL. PATIENTS AND METHODS A total of 737 treatment-naïve patients with CLL diagnosed at Mayo Clinic were included in this study. We compared predictive abilities for two survival models (Cox proportional hazards and random survival forest) and four classification methods (logistic regression, support vector machines, random forest, and gradient boosting machine). Probability of treatment was then stratified. RESULTS Machine learning methods did not yield significantly more accurate predictions of time to first treatment. However, automated risk stratification provided by clustering was able to better differentiate patients who were at risk for treatment within 1 year than models developed using standard survival analysis techniques. CONCLUSION Clustering the posterior probabilities of machine learning models provides a way to better interpret machine learning models.
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Yao X, Inselman JW, Shah ND, Ross JS, Izem R, Graham D, Martin D, Thompson A, Southworth MR, Siontis KC, Ngufor CG, Nath K, Desai NR, Nallamothu B, Saran R, Noseworthy PA. Abstract 11: Comparative Effectiveness and Safety of Oral Anticoagulants across Baseline Kidney Function. Circ Cardiovasc Qual Outcomes 2019. [DOI: 10.1161/hcq.12.suppl_1.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Stroke prevention using warfarin is challenging in AF patients with CKD, due to high bleeding risk and difficulties in the INR control. NOACs provide alternative options, but all have greater degrees of renal clearance. This study aimed to compare the outcomes of apixaban, dabigatran, rivaroxaban, and warfarin across the range of kidney function in patients with AF.
Methods:
Using a US administrative database including private insurance or Medicare Advantage patients with linked claims and laboratory data, we identified 34,569 new users of oral anticoagulants with AF and eGFR ≥15 between 10/1/2010-11/29/2017. Stabilized IPTW balanced four treatment groups on 66 baseline characteristics. The primary outcomes included stroke, major bleeding, and mortality. Weighted Cox proportional hazards models compared treatments in the overall population and in each eGFR subgroup, with mortality as a competing risk for stroke and major bleeding.
Results:
The proportion of patients using warfarin increased as the kidney function declined - 26.5%, 30.4%, 34.6%, 40.5%, and 55.0% of patients were prescribed warfarin in eGFR ≥90, 60-90, 45-60, 30-45, 15-30 groups, respectively. In comparison to warfarin, apixaban was associated with a lower risk of stroke, major bleeding, and mortality; dabigatran was associated with a similar risk of stroke, and a lower risk of major bleeding and mortality; rivaroxaban was associated with a lower risk of stroke, major bleeding, and mortality (Figure). When comparing one NOAC to another NOAC, apixaban and dabigatran were associated with a lower risk of major bleeding than rivaroxaban (HR 0.61 [0.51-0.73], p<0.001 for apixaban versus rivaroxaban; HR 0.67 [0.50-0.90], p=0.007 for dabigatran versus rivaroxaban); dabigatran was associated with a higher risk of stroke than apixaban (HR 1.65 [1.11-2.46], p=0.01); there was no difference in mortality. There was no significant interaction between treatment and eGFR categories for any outcome, but the number of patients with low eGFR was small.
Conclusions:
In practice, relative to warfarin, NOACs are progressively less commonly used with increasing degree of renal dysfunction. However, each NOAC was consistently associated with at least equivalent effectiveness and safety compared with warfarin across the range of kidney function.
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Affiliation(s)
| | | | | | | | - Rima Izem
- Children’s National Hosp, Washington DC, DC
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11
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Upadhyaya SG, Murphree DH, Ngufor CG, Knight AM, Cronk DJ, Cima RR, Curry TB, Pathak J, Carter RE, Kor DJ. Automated Diabetes Case Identification Using Electronic Health Record Data at a Tertiary Care Facility. Mayo Clin Proc Innov Qual Outcomes 2017; 1:100-110. [PMID: 30225406 PMCID: PMC6135013 DOI: 10.1016/j.mayocpiqo.2017.04.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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] [Indexed: 12/05/2022] Open
Abstract
Objective To develop and validate a phenotyping algorithm for the identification of patients with type 1 and type 2 diabetes mellitus (DM) preoperatively using routinely available clinical data from electronic health records. Patients and Methods We used first-order logic rules (if-then-else rules) to imply the presence or absence of DM types 1 and 2. The “if” clause of each rule is a conjunction of logical and, or predicates that provides evidence toward or against the presence of DM. The rule includes International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes, outpatient prescription information, laboratory values, and positive annotation of DM in patients’ clinical notes. This study was conducted from March 2, 2015, through February 10, 2016. The performance of our rule-based approach and similar approaches proposed by other institutions was evaluated with a reference standard created by an expert reviewer and implemented for routine clinical care at an academic medical center. Results A total of 4208 surgical patients (mean age, 52 years; males, 48%) were analyzed to develop the phenotyping algorithm. Expert review identified 685 patients (16.28% of the full cohort) as having DM. Our proposed method identified 684 patients (16.25%) as having DM. The algorithm performed well—99.70% sensitivity, 99.97% specificity—and compared favorably with previous approaches. Conclusion Among patients undergoing surgery, determination of DM can be made with high accuracy using simple, computationally efficient rules. Knowledge of patients’ DM status before surgery may alter physicians’ care plan and reduce postsurgical complications. Nevertheless, future efforts are necessary to determine the effect of first-order logic rules on clinical processes and patient outcomes.
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Key Words
- CCW, Chronic Condition Data Warehouse
- DDC, Durham Diabetes Coalition
- DM, diabetes mellitus
- EHR, electronic health record
- HbA1c of NYC, Hemoglobin A1c of New York City
- HbA1c, hemoglobin A1c
- ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification
- MICS, Mayo Integrated Clinical Systems
- NLP, natural language processing
- SUPREME-DM, Surveillance, Prevention, and Management of Diabetes Mellitus
- T1DM, type 1 diabetes mellitus
- T2DM, type 2 diabetes mellitus
- eMERGE, Electronic Medical Records and Genomics
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Affiliation(s)
| | | | - Che G Ngufor
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Alison M Knight
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Daniel J Cronk
- Department of Information Technology, Mayo Clinic, Rochester, MN
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.,Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Timothy B Curry
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN
| | | | - Rickey E Carter
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Daryl J Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
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Rank MA, Jeffery MM, Ngufor CG, Shah ND. Omalizumab Utilization Trends for Asthma in the US from 2003-2015. J Allergy Clin Immunol 2017. [DOI: 10.1016/j.jaci.2016.12.244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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