1
|
Nahum-Shani I, Greer ZM, Trella AL, Zhang KW, Carpenter SM, Rünger D, Elashoff D, Murphy SA, Shetty V. Optimizing an adaptive digital oral health intervention for promoting oral self-care behaviors: Micro-randomized trial protocol. Contemp Clin Trials 2024; 139:107464. [PMID: 38307224 PMCID: PMC11007589 DOI: 10.1016/j.cct.2024.107464] [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: 08/29/2023] [Revised: 12/19/2023] [Accepted: 01/25/2024] [Indexed: 02/04/2024]
Abstract
Dental disease continues to be one of the most prevalent chronic diseases in the United States. Although oral self-care behaviors (OSCB), involving systematic twice-a-day tooth brushing, can prevent dental disease, this basic behavior is not sufficiently practiced. Recent advances in digital technology offer tremendous potential for promoting OSCB by delivering Just-In-Time Adaptive Interventions (JITAIs)- interventions that leverage dynamic information about the person's state and context to effectively prompt them to engage in a desired behavior in real-time, real-world settings. However, limited research attention has been given to systematically investigating how to best prompt individuals to engage in OSCB in daily life, and under what conditions prompting would be most beneficial. This paper describes the protocol for a Micro-Randomized Trial (MRT) to inform the development of a JITAI for promoting ideal OSCB, namely, brushing twice daily, for two minutes each time, in all four dental quadrants (i.e., 2x2x4). Sensors within an electric toothbrush (eBrush) will be used to track OSCB and a matching mobile app (Oralytics) will deliver on-demand feedback and educational information. The MRT will micro-randomize participants twice daily (morning and evening) to either (a) a prompt (push notification) containing one of several theoretically grounded engagement strategies or (b) no prompt. The goal is to investigate whether, what type of, and under what conditions prompting increases engagement in ideal OSCB. The results will build the empirical foundation necessary to develop an optimized JITAI that will be evaluated relative to a suitable control in a future randomized controlled trial.
Collapse
Affiliation(s)
- Inbal Nahum-Shani
- Institute for Social Research, University of Michigan, United States of America.
| | - Zara M Greer
- School of Dentistry, University of California, Los Angeles, United States of America
| | - Anna L Trella
- School of Engineering and Applied Sciences, Harvard University, United States of America
| | - Kelly W Zhang
- School of Engineering and Applied Sciences, Harvard University, United States of America
| | | | - Dennis Rünger
- Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, United States of America
| | - David Elashoff
- Division of General Internal Medicine and Health Services Research, Department of Biostatistics, and Department of Computational Medicine, University of California, Los Angeles, United States of America
| | - Susan A Murphy
- School of Engineering and Applied Sciences, Harvard University, United States of America
| | - Vivek Shetty
- School of Dentistry, University of California, Los Angeles, United States of America
| |
Collapse
|
2
|
Collins LM, Nahum-Shani I, Guastaferro K, Strayhorn JC, Vanness DJ, Murphy SA. Intervention Optimization: A Paradigm Shift and Its Potential Implications for Clinical Psychology. Annu Rev Clin Psychol 2024; 20. [PMID: 38316143 DOI: 10.1146/annurev-clinpsy-080822-051119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
To build a coherent knowledge base about what psychological intervention strategies work, develop interventions that have positive societal impact, and maintain and increase this impact over time, it is necessary to replace the classical treatment package research paradigm. The multiphase optimization strategy (MOST) is an alternative paradigm that integrates ideas from behavioral science, engineering, implementation science, economics, and decision science. MOST enables optimization of interventions to strategically balance effectiveness, affordability, scalability, and efficiency. In this review we provide an overview of MOST, discuss several experimental designs that can be used in intervention optimization, consider how the investigator can use experimental results to select components for inclusion in the optimized intervention, discuss the application of MOST in implementation science, and list future issues in this rapidly evolving field. We highlight the feasibility of adopting this new research paradigm as well as its potential to hasten the progress of psychological intervention science. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 20 is May 2024. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
Collapse
Affiliation(s)
- Linda M Collins
- Department of Social and Behavioral Sciences, New York University, New York, NY, USA;
- Department of Biostatistics, New York University, New York, NY, USA
| | - Inbal Nahum-Shani
- Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Kate Guastaferro
- Department of Social and Behavioral Sciences, New York University, New York, NY, USA;
| | - Jillian C Strayhorn
- Department of Social and Behavioral Sciences, New York University, New York, NY, USA;
| | - David J Vanness
- Department of Health Policy and Administration, The Pennsylvania State University, University Park, Pennsylvania, USA
| | - Susan A Murphy
- Departments of Statistics and Computer Science, Harvard University, Cambridge, Massachusetts, USA
| |
Collapse
|
3
|
Carpenter SM, Greer ZM, Newman R, Murphy SA, Shetty V, Nahum-Shani I. Developing Message Strategies to Engage Racial and Ethnic Minority Groups in Digital Oral Self-Care Interventions: Participatory Co-Design Approach. JMIR Form Res 2023; 7:e49179. [PMID: 38079204 PMCID: PMC10750234 DOI: 10.2196/49179] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/01/2023] [Accepted: 08/25/2023] [Indexed: 12/28/2023] Open
Abstract
BACKGROUND The prevention of oral health diseases is a key public health issue and a major challenge for racial and ethnic minority groups, who often face barriers in accessing dental care. Daily toothbrushing is an important self-care behavior necessary for sustaining good oral health, yet engagement in regular brushing remains a challenge. Identifying strategies to promote engagement in regular oral self-care behaviors among populations at risk of poor oral health is critical. OBJECTIVE The formative research described here focused on creating messages for a digital oral self-care intervention targeting a racially and ethnically diverse population. Theoretically grounded strategies (reciprocity, reciprocity-by-proxy, and curiosity) were used to promote engagement in 3 aspects: oral self-care behaviors, an oral care smartphone app, and digital messages. A web-based participatory co-design approach was used to develop messages that are resource efficient, appealing, and novel; this approach involved dental experts, individuals from the general population, and individuals from the target population-dental patients from predominantly low-income racial and ethnic minority groups. Given that many individuals from racially and ethnically diverse populations face anonymity and confidentiality concerns when participating in research, we used an approach to message development that aimed to mitigate these concerns. METHODS Messages were initially developed with feedback from dental experts and Amazon Mechanical Turk workers. Dental patients were then recruited for 2 facilitator-mediated group webinar sessions held over Zoom (Zoom Video Communications; session 1: n=13; session 2: n=7), in which they provided both quantitative ratings and qualitative feedback on the messages. Participants interacted with the facilitator through Zoom polls and a chat window that was anonymous to other participants. Participants did not directly interact with each other, and the facilitator mediated sessions by verbally asking for message feedback and sharing key suggestions with the group for additional feedback. This approach plausibly enhanced participant anonymity and confidentiality during the sessions. RESULTS Participants rated messages highly in terms of liking (overall rating: mean 2.63, SD 0.58; reciprocity: mean 2.65, SD 0.52; reciprocity-by-proxy: mean 2.58, SD 0.53; curiosity involving interactive oral health questions and answers: mean 2.45, SD 0.69; curiosity involving tailored brushing feedback: mean 2.77, SD 0.48) on a scale ranging from 1 (do not like it) to 3 (like it). Qualitative feedback indicated that the participants preferred messages that were straightforward, enthusiastic, conversational, relatable, and authentic. CONCLUSIONS This formative research has the potential to guide the design of messages for future digital health behavioral interventions targeting individuals from diverse racial and ethnic populations. Insights emphasize the importance of identifying key stimuli and tasks that require engagement, gathering multiple perspectives during message development, and using new approaches for collecting both quantitative and qualitative data while mitigating anonymity and confidentiality concerns.
Collapse
Affiliation(s)
- Stephanie M Carpenter
- College of Health Solutions, Arizona State University, Phoenix, AZ, United States
- Department of Psychology, University of Wisconsin-Madison, Madison, WI, United States
| | - Zara M Greer
- Oral and Maxillofacial Surgery, School of Dentistry, University of California, Los Angeles, Los Angeles, CA, United States
| | - Rebecca Newman
- Oral and Maxillofacial Surgery, School of Dentistry, University of California, Los Angeles, Los Angeles, CA, United States
| | - Susan A Murphy
- Department of Statistics, Harvard University, Cambridge, MA, United States
- Department of Computer Science, Harvard University, Cambridge, MA, United States
| | - Vivek Shetty
- Oral and Maxillofacial Surgery, School of Dentistry, University of California, Los Angeles, Los Angeles, CA, United States
| | - Inbal Nahum-Shani
- Institute for Social Research, University of Michigan, Ann Arbor, MI, United States
| |
Collapse
|
4
|
Lipschitz JM, Pike CK, Hogan TP, Murphy SA, Burdick KE. The engagement problem: A review of engagement with digital mental health interventions and recommendations for a path forward. Curr Treat Options Psychiatry 2023; 10:119-135. [PMID: 38390026 PMCID: PMC10883589 DOI: 10.1007/s40501-023-00297-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 02/24/2024]
Abstract
Purpose of the review Digital mental health interventions (DMHIs) are an effective and accessible means of addressing the unprecedented levels of mental illness worldwide. Currently, however, patient engagement with DMHIs in real-world settings is often insufficient to see clinical benefit. In order to realize the potential of DMHIs, there is a need to better understand what drives patient engagement. Recent findings We discuss takeaways from the existing literature related to patient engagement with DMHIs and highlight gaps to be addressed through further research. Findings suggest that engagement is influenced by patient-, intervention- and systems-level factors. At the patient-level, variables such as sex, education, personality traits, race, ethnicity, age and symptom severity appear to be associated with engagement. At the intervention-level, integrating human support, gamification, financial incentives and persuasive technology features may improve engagement. Finally, although systems-level factors have not been widely explored, the existing evidence suggests that achieving engagement will require addressing organizational and social barriers and drawing on the field of implementation science. Summary Future research clarifying the patient-, intervention- and systems-level factors that drive engagement will be essential. Additionally, to facilitate improved understanding of DMHI engagement, we propose the following: (a) widespread adoption of a minimum necessary 5-element engagement reporting framework; (b) broader application of alternative clinical trial designs; and (c) directed efforts to build upon an initial parsimonious conceptual model of DMHI engagement.
Collapse
Affiliation(s)
- Jessica M Lipschitz
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA
- Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Chelsea K Pike
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA
| | - Timothy P Hogan
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA
- Peter O'Donnell School of Public Health, UT Southwestern Medical Center, Dallas, TX
| | | | - Katherine E Burdick
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA
- Department of Psychiatry, Harvard Medical School, Boston, MA
| |
Collapse
|
5
|
Burton S, Landers T, Wilson M, Ortiz-Gumina C, Persaud A, McNeill Ransom M, Fox L, Murphy SA. Public health infection prevention: An analysis of existing training during the COVID-19 pandemic. Public Health 2023; 222:7-12. [PMID: 37494870 DOI: 10.1016/j.puhe.2023.06.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 06/12/2023] [Accepted: 06/19/2023] [Indexed: 07/28/2023]
Abstract
OBJECTIVES In response to the COVID-19 pandemic, agencies and organizations required trainings to support the needs of the public health workforce. To better understand the training resources available, this study identified, organized, and classified infection prevention and control (IPC) training and educational opportunities. STUDY DESIGN Environmental scan. METHODS A total of 306 IPC training resources were compiled between January and April 2021. Key themes and topics were identified and compared to the Healthcare Infection Control Practices Advisory Committee's (HICPAC) core IPC practices. RESULTS Three hundred and six training resources, including webinars, fact sheets, module-based learning activities, infographics, and professional practice guidance materials, were identified. Common themes included proper use of personal protective equipment (e.g., masks, gloves), community reopening guidance, and mass vaccination resources. A large proportion (74.9%) of trainings were under 60 min. Using the HICPAC framework, the most frequently addressed content included standard precautions (40%), leadership support (31.6%), and transmission-based precautions (25.8%). Few trainings addressed performance monitoring and feedback (17.1%). CONCLUSIONS A wide range of organizations developed IPC-specific content during the pandemic. However, these resources did not address the breadth of knowledge required to implement IPC concepts effectively. The creation of universally applicable IPC core competencies and the development of high-quality IPC education and trainings for public health and the overall responder workforces should be prioritized. Accessible high-quality online and just-in-time trainings are critical for future pandemic and disaster preparedness.
Collapse
Affiliation(s)
- S Burton
- Tulane University, New Orleans, LA, USA
| | - T Landers
- Nationwide Children's Hospital, Columbus, OH, USA
| | - M Wilson
- Tulane University, New Orleans, LA, USA
| | | | | | - M McNeill Ransom
- National Coordinating Center for Public Health Training, NNPHI, USA
| | - L Fox
- National Network of Public Health Institutes, New Orleans, LA, USA
| | - S A Murphy
- Tulane University, New Orleans, LA, USA.
| |
Collapse
|
6
|
Baker EL, Murphy SA. Setting Priorities and Managing Time: Core Leadership Skills. J Public Health Manag Pract 2023; 29:745-747. [PMID: 37478095 DOI: 10.1097/phh.0000000000001795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
Affiliation(s)
- Edward L Baker
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (Dr Baker); Harvard T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts (Dr Baker); and Business Consultants Group, Inc, Rancho Mirage, California (Dr Murphy)
| | | |
Collapse
|
7
|
Karine K, Klasnja P, Murphy SA, Marlin BM. Assessing the Impact of Context Inference Error and Partial Observability on RL Methods for Just-In-Time Adaptive Interventions. Proc Mach Learn Res 2023; 216:1047-1057. [PMID: 37724310 PMCID: PMC10506656] [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] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
Just-in-Time Adaptive Interventions (JITAIs) are a class of personalized health interventions developed within the behavioral science community. JITAIs aim to provide the right type and amount of support by iteratively selecting a sequence of intervention options from a pre-defined set of components in response to each individual's time varying state. In this work, we explore the application of reinforcement learning methods to the problem of learning intervention option selection policies. We study the effect of context inference error and partial observability on the ability to learn effective policies. Our results show that the propagation of uncertainty from context inferences is critical to improving intervention efficacy as context uncertainty increases, while policy gradient algorithms can provide remarkable robustness to partially observed behavioral state information.
Collapse
|
8
|
Cohn ER, Qian T, Murphy SA. Sample size considerations for micro-randomized trials with binary proximal outcomes. Stat Med 2023; 42:2777-2796. [PMID: 37094566 PMCID: PMC10314739 DOI: 10.1002/sim.9748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 04/04/2023] [Accepted: 04/11/2023] [Indexed: 04/26/2023]
Abstract
Micro-randomized trials (MRTs) are a novel experimental design for developing mobile health interventions. Participants are repeatedly randomized in an MRT, resulting in longitudinal data with time-varying treatments. Causal excursion effects are the main quantities of interest in MRT primary and secondary analyses. We consider MRTs where the proximal outcome is binary and the randomization probability is constant or time-varying but not data-dependent. We develop a sample size formula for detecting a nonzero marginal excursion effect. We prove that the formula guarantees power under a set of working assumptions. We demonstrate via simulation that violations of certain working assumptions do not affect the power, and for those that do, we point out the direction in which the power changes. We then propose practical guidelines for using the sample size formula. As an illustration, the formula is used to size an MRT on interventions for excessive drinking. The sample size calculator is implemented in R package MRTSampleSizeBinary and an interactive R Shiny app. This work can be used in trial planning for a wide range of MRTs with binary proximal outcomes.
Collapse
Affiliation(s)
| | - Tianchen Qian
- Department of Statistics, University of California, Irvine
| | | |
Collapse
|
9
|
Rathnam S, Parbhoo S, Pan W, Murphy SA, Doshi-Velez F. The Unintended Consequences of Discount Regularization: Improving Regularization in Certainty Equivalence Reinforcement Learning. Proc Mach Learn Res 2023; 202:28746-28767. [PMID: 37662875 PMCID: PMC10472113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Discount regularization, using a shorter planning horizon when calculating the optimal policy, is a popular choice to restrict planning to a less complex set of policies when estimating an MDP from sparse or noisy data (Jiang et al., 2015). It is commonly understood that discount regularization functions by de-emphasizing or ignoring delayed effects. In this paper, we reveal an alternate view of discount regularization that exposes unintended consequences. We demonstrate that planning under a lower discount factor produces an identical optimal policy to planning using any prior on the transition matrix that has the same distribution for all states and actions. In fact, it functions like a prior with stronger regularization on state-action pairs with more transition data. This leads to poor performance when the transition matrix is estimated from data sets with uneven amounts of data across state-action pairs. Our equivalence theorem leads to an explicit formula to set regularization parameters locally for individual state-action pairs rather than globally. We demonstrate the failures of discount regularization and how we remedy them using our state-action-specific method across simple empirical examples as well as a medical cancer simulator.
Collapse
Affiliation(s)
- Sarah Rathnam
- Harvard University, School of Engineering and Applied Sciences, Cambridge, MA USA
| | | | - Weiwei Pan
- Harvard University, School of Engineering and Applied Sciences, Cambridge, MA USA
| | - Susan A. Murphy
- Harvard University, School of Engineering and Applied Sciences, Cambridge, MA USA
| | - Finale Doshi-Velez
- Harvard University, School of Engineering and Applied Sciences, Cambridge, MA USA
| |
Collapse
|
10
|
Trella AL, Zhang KW, Nahum-Shani I, Shetty V, Doshi-Velez F, Murphy SA. Reward Design For An Online Reinforcement Learning Algorithm Supporting Oral Self-Care. Proc Innov Appl Artif Intell Conf 2023; 37:15724-15730. [PMID: 37637073 PMCID: PMC10457015 DOI: 10.1609/aaai.v37i13.26866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
While dental disease is largely preventable, professional advice on optimal oral hygiene practices is often forgotten or abandoned by patients. Therefore patients may benefit from timely and personalized encouragement to engage in oral self-care behaviors. In this paper, we develop an online reinforcement learning (RL) algorithm for use in optimizing the delivery of mobile-based prompts to encourage oral hygiene behaviors. One of the main challenges in developing such an algorithm is ensuring that the algorithm considers the impact of current actions on the effectiveness of future actions (i.e., delayed effects), especially when the algorithm has been designed to run stably and autonomously in a constrained, real-world setting characterized by highly noisy, sparse data. We address this challenge by designing a quality reward that maximizes the desired health outcome (i.e., high-quality brushing) while minimizing user burden. We also highlight a procedure for optimizing the hyperparameters of the reward by building a simulation environment test bed and evaluating candidates using the test bed. The RL algorithm discussed in this paper will be deployed in Oralytics. To the best of our knowledge, Oralytics is the first mobile health study utilizing an RL algorithm designed to prevent dental disease by optimizing the delivery of motivational messages supporting oral self-care behaviors.
Collapse
Affiliation(s)
| | | | | | - Vivek Shetty
- Schools of Dentistry & Engineering, University of California, Los Angeles
| | | | | |
Collapse
|
11
|
Abstract
We consider the batch (off-line) policy learning problem in the infinite horizon Markov Decision Process. Motivated by mobile health applications, we focus on learning a policy that maximizes the long-term average reward. We propose a doubly robust estimator for the average reward and show that it achieves semiparametric efficiency. Further we develop an optimization algorithm to compute the optimal policy in a parameterized stochastic policy class. The performance of the estimated policy is measured by the difference between the optimal average reward in the policy class and the average reward of the estimated policy and we establish a finite-sample regret guarantee. The performance of the method is illustrated by simulation studies and an analysis of a mobile health study promoting physical activity.
Collapse
Affiliation(s)
- Peng Liao
- Department of Statistics, Harvard University
| | - Zhengling Qi
- Department of Decision Sciences, George Washington University
| | | | | | | |
Collapse
|
12
|
Qian T, Walton AE, Collins LM, Klasnja P, Lanza ST, Nahum-Shani I, Rabbi M, Russell MA, Walton MA, Yoo H, Murphy SA. The microrandomized trial for developing digital interventions: Experimental design and data analysis considerations. Psychol Methods 2022; 27:874-894. [PMID: 35025583 PMCID: PMC9276848 DOI: 10.1037/met0000283] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Just-in-time adaptive interventions (JITAIs) are time-varying adaptive interventions that use frequent opportunities for the intervention to be adapted-weekly, daily, or even many times a day. The microrandomized trial (MRT) has emerged for use in informing the construction of JITAIs. MRTs can be used to address research questions about whether and under what circumstances JITAI components are effective, with the ultimate objective of developing effective and efficient JITAI. The purpose of this article is to clarify why, when, and how to use MRTs; to highlight elements that must be considered when designing and implementing an MRT; and to review primary and secondary analyses methods for MRTs. We briefly review key elements of JITAIs and discuss a variety of considerations that go into planning and designing an MRT. We provide a definition of causal excursion effects suitable for use in primary and secondary analyses of MRT data to inform JITAI development. We review the weighted and centered least-squares (WCLS) estimator which provides consistent causal excursion effect estimators from MRT data. We describe how the WCLS estimator along with associated test statistics can be obtained using standard statistical software such as R (R Core Team, 2019). Throughout we illustrate the MRT design and analyses using the HeartSteps MRT, for developing a JITAI to increase physical activity among sedentary individuals. We supplement the HeartSteps MRT with two other MRTs, SARA and BariFit, each of which highlights different research questions that can be addressed using the MRT and experimental design considerations that might arise. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
Collapse
|
13
|
Abstract
The notion of "engagement," which plays an important role in various domains of psychology, is gaining increased currency as a concept that is critical to the success of digital interventions. However, engagement remains an ill-defined construct, with different fields generating their own domain-specific definitions. Moreover, given that digital interactions in real-world settings are characterized by multiple demands and choice alternatives competing for an individual's effort and attention, they involve fast and often impulsive decision-making. Prior research seeking to uncover the mechanisms underlying engagement has nonetheless focused mainly on psychological factors and social influences and neglected to account for the role of neural mechanisms that shape individual choices. This article aims to integrate theories and empirical evidence across multiple domains to define engagement and discuss opportunities and challenges to promote effective engagement in digital interventions. We also propose the affect-integration-motivation and attention-context-translation (AIM-ACT) framework, which is based on a neurophysiological account of engagement, to shed new light on how in-the-moment engagement unfolds in response to a digital stimulus. Building on this framework, we provide recommendations for designing strategies to promote engagement in digital interventions and highlight directions for future research. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
Collapse
|
14
|
Trella AL, Zhang KW, Nahum-Shani I, Shetty V, Doshi-Velez F, Murphy SA. Designing Reinforcement Learning Algorithms for Digital Interventions: Pre-Implementation Guidelines. Algorithms 2022; 15:255. [PMID: 36713810 PMCID: PMC9881427 DOI: 10.3390/a15080255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Online reinforcement learning (RL) algorithms are increasingly used to personalize digital interventions in the fields of mobile health and online education. Common challenges in designing and testing an RL algorithm in these settings include ensuring the RL algorithm can learn and run stably under real-time constraints, and accounting for the complexity of the environment, e.g., a lack of accurate mechanistic models for the user dynamics. To guide how one can tackle these challenges, we extend the PCS (predictability, computability, stability) framework, a data science framework that incorporates best practices from machine learning and statistics in supervised learning to the design of RL algorithms for the digital interventions setting. Furthermore, we provide guidelines on how to design simulation environments, a crucial tool for evaluating RL candidate algorithms using the PCS framework. We show how we used the PCS framework to design an RL algorithm for Oralytics, a mobile health study aiming to improve users' tooth-brushing behaviors through the personalized delivery of intervention messages. Oralytics will go into the field in late 2022.
Collapse
Affiliation(s)
- Anna L. Trella
- School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02420, USA
- Correspondence:
| | - Kelly W. Zhang
- School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02420, USA
| | - Inbal Nahum-Shani
- Institute for Social Research, University of Michigan, Ann Arbor, MI 48109, USA
| | - Vivek Shetty
- Schools of Dentistry & Engineering, University of California, Los Angeles, CA 90095, USA
| | - Finale Doshi-Velez
- School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02420, USA
| | - Susan A. Murphy
- School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02420, USA
| |
Collapse
|
15
|
Baker EL, Murphy SA. Delegation: A Core Leadership Skill. J Public Health Manag Pract 2022; 28:430-432. [PMID: 35616573 DOI: 10.1097/phh.0000000000001545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Edward L Baker
- UNC Gillings School of Global Public Health, Chapel Hill, North Carolina (Dr Baker); Harvard T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts (Dr Baker); and Business Consultants Group, Inc, Rancho Mirage, California (Dr Murphy)
| | | |
Collapse
|
16
|
Thorpe D, Fouyaxis J, Lipschitz JM, Nielson A, Li W, Murphy SA, Bidargaddi N. Cost and Effort Considerations for the Development of Intervention Studies Using Mobile Health Platforms: Pragmatic Case Study. JMIR Form Res 2022; 6:e29988. [PMID: 35357313 PMCID: PMC9015742 DOI: 10.2196/29988] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 12/02/2021] [Accepted: 01/14/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The research marketplace has seen a flood of open-source or commercial mobile health (mHealth) platforms that can collect and use user data in real time. However, there is a lack of practical literature on how these platforms are developed, integrated into study designs, and adopted, including important information around cost and effort considerations. OBJECTIVE We intend to build critical literacy in the clinician-researcher readership into the cost, effort, and processes involved in developing and operationalizing an mHealth platform, focusing on Intui, an mHealth platform that we developed. METHODS We describe the development of the Intui mHealth platform and general principles of its operationalization across sites. RESULTS We provide a worked example in the form of a case study. Intui was operationalized in the design of a behavioral activation intervention in collaboration with a mental health service provider. We describe the design specifications of the study site, the developed software, and the cost and effort required to build the final product. CONCLUSIONS Study designs, researcher needs, and technical considerations can impact effort and costs associated with the use of mHealth platforms. Greater transparency from platform developers about the impact of these factors on practical considerations relevant to end users such as clinician-researchers is crucial to increasing critical literacy around mHealth, thereby aiding in the widespread use of these potentially beneficial technologies and building clinician confidence in these tools.
Collapse
Affiliation(s)
- Dan Thorpe
- Flinders Digital Health Research Lab, College of Medicine and Public Health, Flinders University, Clovelly Park, Australia
| | - John Fouyaxis
- Flinders Digital Health Research Lab, College of Medicine and Public Health, Flinders University, Clovelly Park, Australia
| | | | - Amy Nielson
- Flinders Digital Health Research Lab, College of Medicine and Public Health, Flinders University, Clovelly Park, Australia
| | - Wenhao Li
- Flinders Digital Health Research Lab, College of Medicine and Public Health, Flinders University, Clovelly Park, Australia
| | - Susan A Murphy
- Radcliffe Institute, Harvard University, Boston, MA, United States
| | - Niranjan Bidargaddi
- Flinders Digital Health Research Lab, College of Medicine and Public Health, Flinders University, Clovelly Park, Australia
| |
Collapse
|
17
|
Coppersmith DDL, Dempsey W, Kleiman EM, Bentley KH, Murphy SA, Nock MK. Just-in-Time Adaptive Interventions for Suicide Prevention: Promise, Challenges, and Future Directions. Psychiatry 2022; 85:317-333. [PMID: 35848800 PMCID: PMC9643598 DOI: 10.1080/00332747.2022.2092828] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The suicide rate (currently 14 per 100,000) has barely changed in the United States over the past 100 years. There is a need for new ways of preventing suicide. Further, research has revealed that suicidal thoughts and behaviors and the factors that drive them are dynamic, heterogeneous, and interactive. Most existing interventions for suicidal thoughts and behaviors are infrequent, not accessible when most needed, and not systematically tailored to the person using their own data (e.g., from their own smartphone). Advances in technology offer an opportunity to develop new interventions that may better match the dynamic, heterogeneous, and interactive nature of suicidal thoughts and behaviors. Just-In-Time Adaptive Interventions (JITAIs), which use smartphones and wearables, are designed to provide the right type of support at the right time by adapting to changes in internal states and external contexts, offering a promising pathway toward more effective suicide prevention. In this review, we highlight the potential of JITAIs for suicide prevention, challenges ahead (e.g., measurement, ethics), and possible solutions to these challenges.
Collapse
|
18
|
Zhang KW, Janson L, Murphy SA. Statistical Inference with M-Estimators on Adaptively Collected Data. Adv Neural Inf Process Syst 2021; 34:7460-7471. [PMID: 35757490 PMCID: PMC9232184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Bandit algorithms are increasingly used in real-world sequential decision-making problems. Associated with this is an increased desire to be able to use the resulting datasets to answer scientific questions like: Did one type of ad lead to more purchases? In which contexts is a mobile health intervention effective? However, classical statistical approaches fail to provide valid confidence intervals when used with data collected with bandit algorithms. Alternative methods have recently been developed for simple models (e.g., comparison of means). Yet there is a lack of general methods for conducting statistical inference using more complex models on data collected with (contextual) bandit algorithms; for example, current methods cannot be used for valid inference on parameters in a logistic regression model for a binary reward. In this work, we develop theory justifying the use of M-estimators-which includes estimators based on empirical risk minimization as well as maximum likelihood-on data collected with adaptive algorithms, including (contextual) bandit algorithms. Specifically, we show that M-estimators, modified with particular adaptive weights, can be used to construct asymptotically valid confidence regions for a variety of inferential targets.
Collapse
Affiliation(s)
| | | | - Susan A Murphy
- Departments of Statistics and Computer Science, Harvard University
| |
Collapse
|
19
|
Nahum-Shani I, Rabbi M, Yap J, Philyaw-Kotov ML, Klasnja P, Bonar EE, Cunningham RM, Murphy SA, Walton MA. Translating strategies for promoting engagement in mobile health: A proof-of-concept microrandomized trial. Health Psychol 2021; 40:974-987. [PMID: 34735165 DOI: 10.1037/hea0001101] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Mobile technologies allow for accessible and cost-effective health monitoring and intervention delivery. Despite these advantages, mobile health (mHealth) engagement is often insufficient. While monetary incentives may increase engagement, they can backfire, dampening intrinsic motivations and undermining intervention scalability. Theories from psychology and behavioral economics suggest useful nonmonetary strategies for promoting engagement; however, examinations of the applicability of these strategies to mHealth engagement are lacking. This proof-of-concept study evaluates the translation of theoretically-grounded engagement strategies into mHealth, by testing their potential utility in promoting daily self-reporting. METHOD A microrandomized trial (MRT) was conducted with adolescents and emerging adults with past-month substance use. Participants were randomized multiple times daily to receive theoretically-grounded strategies, namely reciprocity (the delivery of inspirational quote prior to self-reporting window) and nonmonetary reinforcers (e.g., the delivery of meme/gif following self-reporting completion) to improve proximal engagement in daily mHealth self-reporting. RESULTS Daily self-reporting rates (62.3%; n = 68) were slightly lower than prior literature, albeit with much lower financial incentives. The utility of specific strategies was found to depend on contextual factors pertaining to the individual's receptivity and risk for disengagement. For example, the effect of reciprocity significantly varied depending on whether this strategy was employed (vs. not employed) during the weekend. The nonmonetary reinforcement strategy resulted in different outcomes when operationalized in various ways. CONCLUSIONS While the results support the translation of the reciprocity strategy into this mHealth setting, the translation of nonmonetary reinforcement requires further consideration prior to inclusion in a full scale MRT. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
Collapse
|
20
|
Nahum-Shani I, Potter LN, Lam CY, Yap J, Moreno A, Stoffel R, Wu Z, Wan N, Dempsey W, Kumar S, Ertin E, Murphy SA, Rehg JM, Wetter DW. The mobile assistance for regulating smoking (MARS) micro-randomized trial design protocol. Contemp Clin Trials 2021; 110:106513. [PMID: 34314855 PMCID: PMC8824313 DOI: 10.1016/j.cct.2021.106513] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/13/2021] [Accepted: 07/16/2021] [Indexed: 11/30/2022]
Abstract
Smoking is the leading preventable cause of death and disability in the U.S. Empirical evidence suggests that engaging in evidence-based self-regulatory strategies (e.g., behavioral substitution, mindful attention) can improve smokers' ability to resist craving and build self-regulatory skills. However, poor engagement represents a major barrier to maximizing the impact of self-regulatory strategies. This paper describes the protocol for Mobile Assistance for Regulating Smoking (MARS) - a research study designed to inform the development of a mobile health (mHealth) intervention for promoting real-time, real-world engagement in evidence-based self-regulatory strategies. The study will employ a 10-day Micro-Randomized Trial (MRT) enrolling 112 smokers attempting to quit. Utilizing a mobile smoking cessation app, the MRT will randomize each individual multiple times per day to either: (a) no intervention prompt; (b) a prompt recommending brief (low effort) cognitive and/or behavioral self-regulatory strategies; or (c) a prompt recommending more effortful cognitive or mindfulness-based strategies. Prompts will be delivered via push notifications from the MARS mobile app. The goal is to investigate whether, what type of, and under what conditions prompting the individual to engage in self-regulatory strategies increases engagement. The results will build the empirical foundation necessary to develop a mHealth intervention that effectively utilizes intensive longitudinal self-report and sensor-based assessments of emotions, context and other factors to engage an individual in the type of self-regulatory activity that would be most beneficial given their real-time, real-world circumstances. This type of mHealth intervention holds enormous potential to expand the reach and impact of smoking cessation treatments.
Collapse
Affiliation(s)
- Inbal Nahum-Shani
- Institute for Social Research, University of Michigan, Ann Arbor, MI, United States of America.
| | - Lindsey N Potter
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, United States of America
| | - Cho Y Lam
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, United States of America
| | - Jamie Yap
- Institute for Social Research, University of Michigan, Ann Arbor, MI, United States of America
| | - Alexander Moreno
- College of Computing, Georgia Institute of Technology, Atlanta, GA, United States of America
| | - Rebecca Stoffel
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, United States of America
| | - Zhenke Wu
- School of Public Health, University of Michigan, Ann Arbor, MI, United States of America
| | - Neng Wan
- Department of Geography, University of Utah, Salt Lake City, UT, United States of America
| | - Walter Dempsey
- School of Public Health, University of Michigan, Ann Arbor, MI, United States of America
| | - Santosh Kumar
- Department of Computer Science, University of Memphis, Memphis, TN, United States of America
| | - Emre Ertin
- Department of Electrical and Computer Engineering, The Ohio State University, Columbus, OH, United States of America
| | - Susan A Murphy
- Departments of Statistics & Computer Science, Harvard University, Cambridge, MA, United States of America
| | - James M Rehg
- College of Computing, Georgia Institute of Technology, Atlanta, GA, United States of America
| | - David W Wetter
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, United States of America
| |
Collapse
|
21
|
Murphy SA, Furger R, Kurpad SN, Arpinar VE, Nencka A, Koch K, Budde MD. Filtered Diffusion-Weighted MRI of the Human Cervical Spinal Cord: Feasibility and Application to Traumatic Spinal Cord Injury. AJNR Am J Neuroradiol 2021; 42:2101-2106. [PMID: 34620590 DOI: 10.3174/ajnr.a7295] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 07/07/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE In traumatic spinal cord injury, DTI is sensitive to injury but is unable to differentiate multiple pathologies. Axonal damage is a central feature of the underlying cord injury, but prominent edema confounds its detection. The purpose of this study was to examine a filtered DWI technique in patients with acute spinal cord injury. MATERIALS AND METHODS The MR imaging protocol was first evaluated in a cohort of healthy subjects at 3T (n = 3). Subsequently, patients with acute cervical spinal cord injury (n = 8) underwent filtered DWI concurrent with their acute clinical MR imaging examination <24 hours postinjury at 1.5T. DTI was obtained with 25 directions at a b-value of 800 s/mm2. Filtered DWI used spinal cord-optimized diffusion-weighting along 26 directions with a "filter" b-value of 2000 s/mm2 and a "probe" maximum b-value of 1000 s/mm2. Parallel diffusivity metrics obtained from DTI and filtered DWI were compared. RESULTS The high-strength diffusion-weighting perpendicular to the cord suppressed signals from tissues outside of the spinal cord, including muscle and CSF. The parallel ADC acquired from filtered DWI at the level of injury relative to the most cranial region showed a greater decrease (38.71%) compared with the decrease in axial diffusivity acquired by DTI (17.68%). CONCLUSIONS The results demonstrated that filtered DWI is feasible in the acute setting of spinal cord injury and reveals spinal cord diffusion characteristics not evident with conventional DTI.
Collapse
Affiliation(s)
- S A Murphy
- From the Department of Neurosurgery (S.A.M., R.F., S.N.K., M.D.B.)
| | - R Furger
- From the Department of Neurosurgery (S.A.M., R.F., S.N.K., M.D.B.)
- Center for Neurotrauma Research (R.F., S.N.K., M.D.B.)
| | - S N Kurpad
- From the Department of Neurosurgery (S.A.M., R.F., S.N.K., M.D.B.)
- Center for Neurotrauma Research (R.F., S.N.K., M.D.B.)
| | - V E Arpinar
- Center for Imaging Research (V.E.A., A.N., K.K.), Medical College of Wisconsin, Milwaukee, Wisconsin
| | - A Nencka
- Center for Imaging Research (V.E.A., A.N., K.K.), Medical College of Wisconsin, Milwaukee, Wisconsin
| | - K Koch
- Center for Imaging Research (V.E.A., A.N., K.K.), Medical College of Wisconsin, Milwaukee, Wisconsin
| | - M D Budde
- From the Department of Neurosurgery (S.A.M., R.F., S.N.K., M.D.B.)
- Center for Neurotrauma Research (R.F., S.N.K., M.D.B.)
| |
Collapse
|
22
|
Psihogios AM, Rabbi M, Ahmed A, McKelvey ER, Li Y, Laurenceau JP, Hunger SP, Fleisher L, Pai AL, Schwartz LA, Murphy SA, Barakat LP. Understanding Adolescent and Young Adult 6-Mercaptopurine Adherence and mHealth Engagement During Cancer Treatment: Protocol for Ecological Momentary Assessment. JMIR Res Protoc 2021; 10:e32789. [PMID: 34677129 PMCID: PMC8571686 DOI: 10.2196/32789] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 08/16/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Adolescents and young adults (AYAs) with cancer demonstrate suboptimal oral chemotherapy adherence, increasing their risk of cancer relapse. It is unclear how everyday time-varying contextual factors (eg, mood) affect their adherence, stalling the development of personalized mobile health (mHealth) interventions. Poor engagement is also a challenge across mHealth trials; an effective adherence intervention must be engaging to promote uptake. OBJECTIVE This protocol aims to determine the temporal associations between daily contextual factors and 6-mercaptopurine (6-MP) adherence and explore the proximal impact of various engagement strategies on ecological momentary assessment survey completion. METHODS At the Children's Hospital of Philadelphia, AYAs with acute lymphoblastic leukemia or lymphoma who are prescribed prolonged maintenance chemotherapy that includes daily oral 6-MP are eligible, along with their matched caregivers. Participants will use an ecological momentary assessment app called ADAPTS (Adherence Assessments and Personalized Timely Support)-a version of an open-source app that was modified for AYAs with cancer through a user-centered process-and complete surveys in bursts over 6 months. Theory-informed engagement strategies will be microrandomized to estimate the causal effects on proximal survey completion. RESULTS With funding from the National Cancer Institute and institutional review board approval, of the proposed 30 AYA-caregiver dyads, 60% (18/30) have been enrolled; of the 18 enrolled, 15 (83%) have completed the study so far. CONCLUSIONS This protocol represents an important first step toward prescreening tailoring variables and engagement components for a just-in-time adaptive intervention designed to promote both 6-MP adherence and mHealth engagement. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/32789.
Collapse
Affiliation(s)
- Alexandra M Psihogios
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - Mashfiqui Rabbi
- Department of Statistics, Harvard University, Boston, MA, United States
| | - Annisa Ahmed
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Elise R McKelvey
- Children's Hospital of Philadelphia, La Salle University, Philadelphia, PA, United States
| | - Yimei Li
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | | | - Stephen P Hunger
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - Linda Fleisher
- Health Communications and Health Disparities, Fox Chase Cancer Center, Philadelphia, PA, United States
| | - Ahna Lh Pai
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Lisa A Schwartz
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - Susan A Murphy
- Department of Statistics, Harvard University, Boston, MA, United States
| | - Lamia P Barakat
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| |
Collapse
|
23
|
Abstract
Advances in wearables and digital technology now make it possible to deliver behavioral mobile health interventions to individuals in their everyday life. The micro-randomized trial is increasingly used to provide data to inform the construction of these interventions. In a micro-randomized trial, each individual is repeatedly randomized among multiple intervention options, often hundreds or even thousands of times, over the course of the trial. This work is motivated by multiple micro-randomized trials that have been conducted or are currently in the field, in which the primary outcome is a longitudinal binary outcome. The primary aim of such micro-randomized trials is to examine whether a particular time-varying intervention has an effect on the longitudinal binary outcome, often marginally over all but a small subset of the individual's data. We propose the definition of causal excursion effect that can be used in such primary aim analysis for micro-randomized trials with binary outcomes. Under rather restrictive assumptions one can, based on existing literature, derive a semiparametric, locally efficient estimator of the causal effect. Starting from this estimator, we develop an estimator that can be used as the basis of a primary aim analysis under more plausible assumptions. Simulation studies are conducted to compare the estimators. We illustrate the developed methods using data from the micro-randomized trial, BariFit. In BariFit, the goal is to support weight maintenance for individuals who received bariatric surgery.
Collapse
Affiliation(s)
- Tianchen Qian
- Department of Statistics, University of California, Irvine, Donald Bren Hall, Irvine, California 92697, U.S.A
| | - Hyesun Yoo
- Department of Statistics, University of Michigan, 323 West Hall, 1085 South University, Ann Arbor, Michigan 48109, U.S.A
| | - Predrag Klasnja
- School of Information, University of Michigan, 4364 North Quad, 105 South State Street, Ann Arbor, Michigan 48109, U.S.A
| | - Daniel Almirall
- Department of Statistics, University of Michigan, 323 West Hall, 1085 South University, Ann Arbor, Michigan 48109, U.S.A
| | - Susan A Murphy
- Department of Statistics, Harvard University, 1 Oxford Street, Cambridge, Massachusetts 02138, U.S.A
| |
Collapse
|
24
|
Semco RS, Bergmark BA, Bergmark RW, Murphy SA, Ruff CT, Antman EM, Braunwald E, Giugliano RP. Epistaxis in anticoagulated patients with atrial fibrillation in the ENGAGE AF-TIMI 48 trial. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2983] [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: 11/14/2022] Open
Abstract
Abstract
Background
Epistaxis is common with antithrombotic therapy yet under-investigated in cardiovascular clinical trials and observational studies. These bleeding events are often troublesome to patients and may lead to anticoagulant discontinuation.
Purpose
To describe the frequency, severity, and outcomes of epistaxis in patients with atrial fibrillation (AF) randomized to edoxaban vs warfarin.
Methods
ENGAGE AF-TIMI 48 randomized 21,105 patients with AF and CHADS2 ≥2 to a higher-dose edoxaban regimen (HDER; 60mg daily), a lower-dose edoxaban regimen (LDER; 30mg daily), or warfarin, with edoxaban doses reduced by 50% in patients meeting dose-reduction criteria. Location and severity of bleeding were adjudicated by a blinded Clinical Events Committee using ISTH criteria. Patients with intracranial hemorrhage were excluded from this analysis. Patients with more than one bleeding event were categorized according to the most severe event. The safety cohort with interval censoring during study drug interruption was analyzed. Proportions were compared using a Pearson's chi-squared test and treatment arms were compared using a Cox proportional hazards model.
Results
5,247 patients with a bleeding event were included in this analysis, including 1,008 (19.2%) with epistaxis and 4,239 (80.8%) with exclusively non-epistaxis bleeding. Baseline characteristics were similar for patients with epistaxis as compared to non-epistaxis bleeding. Epistaxis events were overall less severe than non-epistaxis bleeds (ISTH major: 3.2% vs 20.7%; CRNM: 64.7% vs 60.1%; minor: 32.1% vs 19.2%; p<0.001; Fig. 1, Panel A). Two life-threatening and no fatal epistaxis bleeds occurred. Permanent study drug discontinuation was similar following epistaxis vs non-epistaxis bleeding in patients with major (59.4% vs 53.6%; p=0.52) or CRNM bleeding (32.5% vs 33.3%; p=0.70), but was significantly higher after minor epistaxis versus minor bleeding at other sites (33.3% vs 23.9%; p=0.001; Fig. 1, Panel B). Compared to warfarin, hazard ratios (HR) for epistaxis bleeding were: 1) major: HDER 0.47 (0.19–1.15), LDER 0.65 (0.29–1.45); 2) major/CRNM: HDER 1.00 (0.84–1.19), LDER 0.70 (0.58–0.85); 3) major/CRNM/minor: HDER 1.09 (0.95–1.26), LDER 0.73 (0.62–0.86) (Fig. 1, Panel C).
Conclusion
Epistaxis was frequent in patients with atrial fibrillation on anticoagulation. When compared to warfarin, LDER reduced the risk of epistaxis by 27–30% while HDER neither increased nor decreased these events. There were significantly higher rates of permanent drug discontinuation following minor epistaxis as compared to minor bleeding at other sites. These findings suggest that epistaxis is symptomatically important, may cause disproportionate interruption in antithrombotic therapy, and deserves increased attention in cardiovascular studies.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Pharma Development Figure 1
Collapse
Affiliation(s)
- R S Semco
- Brigham and Women's Hospital, Center for Surgery and Public Health, Boston, United States of America
| | - B A Bergmark
- Brigham and Women's Hospital, Thrombolysis in Myocardial Infarction (TIMI) Study Group, Boston, United States of America
| | - R W Bergmark
- Brigham and Women's Hospital and Harvard Medical School, Center for Surgery and Public Health and Department of Otolaryngology-Head and Neck Surgery, Boston, United States of America
| | - S A Murphy
- Brigham and Women's Hospital, Thrombolysis in Myocardial Infarction (TIMI) Study Group, Boston, United States of America
| | - C T Ruff
- Brigham and Women's Hospital, Thrombolysis in Myocardial Infarction (TIMI) Study Group, Boston, United States of America
| | - E M Antman
- Brigham and Women's Hospital, Thrombolysis in Myocardial Infarction (TIMI) Study Group, Boston, United States of America
| | - E Braunwald
- Brigham and Women's Hospital, Thrombolysis in Myocardial Infarction (TIMI) Study Group, Boston, United States of America
| | - R P Giugliano
- Brigham and Women's Hospital, Thrombolysis in Myocardial Infarction (TIMI) Study Group, Boston, United States of America
| |
Collapse
|
25
|
Saghafian S, Murphy SA. Innovative Health Care Delivery: The Scientific and Regulatory Challenges in Designing mHealth Interventions. NAM Perspect 2021; 2021:202108b. [PMID: 34611601 DOI: 10.31478/202108b] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
26
|
Affiliation(s)
- Edward L Baker
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (Dr Baker); Harvard T. H. Chan School of Public Health, Boston, Massachusetts (Dr Baker and Ms Hengelbrok); Business Consultants Group, Inc, Rancho Mirage, California (Dr Murphy); and Goizueta Business School and School of Medicine, Emory University, Atlanta, Georgia (Dr Gilkey)
| | | | | | | |
Collapse
|
27
|
Affiliation(s)
- Edward L Baker
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (Dr Baker); Harvard T. H. Chan School of Public Health, Boston, Massachusetts (Dr Baker); and Business Consultants Group, Inc, Rancho Mirage, California (Dr Murphy)
| | | |
Collapse
|
28
|
Zhang KW, Janson L, Murphy SA. Inference for Batched Bandits. Adv Neural Inf Process Syst 2020; 33:9818-9829. [PMID: 35002190 PMCID: PMC8734616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
As bandit algorithms are increasingly utilized in scientific studies and industrial applications, there is an associated increasing need for reliable inference methods based on the resulting adaptively-collected data. In this work, we develop methods for inference on data collected in batches using a bandit algorithm. We first prove that the ordinary least squares estimator (OLS), which is asymptotically normal on independently sampled data, is not asymptotically normal on data collected using standard bandit algorithms when there is no unique optimal arm. This asymptotic non-normality result implies that the naive assumption that the OLS estimator is approximately normal can lead to Type-1 error inflation and confidence intervals with below-nominal coverage probabilities. Second, we introduce the Batched OLS estimator (BOLS) that we prove is (1) asymptotically normal on data collected from both multi-arm and contextual bandits and (2) robust to non-stationarity in the baseline reward.
Collapse
Affiliation(s)
| | | | - Susan A Murphy
- Departments of Statistics and Computer Science, Harvard University
| |
Collapse
|
29
|
Affiliation(s)
- Edward L Baker
- University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina (Dr Baker); Harvard T.H. Chan School of Public Health, Boston, Massachusetts (Dr Baker); and Business Consultants Group, Inc, Rancho Mirage, California (Dr Murphy)
| | | |
Collapse
|
30
|
Kroska EB, Hoel S, Victory A, Murphy SA, McInnis MG, Stowe ZN, Cochran A. Optimizing an Acceptance and Commitment Therapy Microintervention Via a Mobile App With Two Cohorts: Protocol for Micro-Randomized Trials. JMIR Res Protoc 2020; 9:e17086. [PMID: 32965227 PMCID: PMC7542401 DOI: 10.2196/17086] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 07/28/2020] [Accepted: 08/03/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Given gaps in the treatment of mental health, brief adaptive interventions have become a public health imperative. Transdiagnostic interventions may be particularly appropriate given high rates of medical comorbidity and the broader reach of transdiagnostic therapies. One such approach utilized herein is acceptance and commitment therapy (ACT), which is focused on increasing engagement with values, awareness, and openness to internal experiences. ACT theory posits that experiential avoidance is at the center of human suffering, regardless of diagnosis, and, as such, seeks to reduce unworkable experiential avoidance. OBJECTIVE Our objective is to provide the rationale and protocol for examining the safety, feasibility, and effectiveness of optimizing an ACT-based intervention via a mobile app among two disparate samples, which differ in sociodemographic characteristics and symptom profiles. METHODS Twice each day, participants are prompted via a mobile app to complete assessments of mood and activity and are then randomly assigned to an ACT-based intervention or not. These interventions are questions regarding engagement with values, awareness, and openness to internal experiences. Participant responses are recorded. Analyses will examine completion of assessments, change in symptoms from baseline assessment, and proximal change in mood and activity. A primary outcome of interest is proximal change in activity (eg, form and function of behavior and energy consumed by avoidance and values-based behavior) following interventions as a function of time, symptoms, and behavior, where we hypothesize that participants will focus more energy on values-based behaviors. Analyses will be conducted using a weighted and centered least squares approach. Two samples will run concurrently to assess the capacity of optimizing mobile ACT in populations that differ widely in their clinical presentation and sociodemographic characteristics: individuals with bipolar disorder (n=30) and distressed first-generation college students (n=50). RESULTS Recruitment began on September 10, 2019, for the bipolar sample and on October 5, 2019, for the college sample. Participation in the study began on October 18, 2019. CONCLUSIONS This study examines an ACT-based intervention among two disparate samples. Should ACT demonstrate feasibility and preliminary effectiveness in each sample, a large randomized controlled trial applying ACT across diagnoses and demographics would be indicated. The public health implications of such an approach may be far-reaching. TRIAL REGISTRATION ClinicalTrials.gov NCT04098497; https://clinicaltrials.gov/ct2/show/NCT04098497; ClinicalTrials.gov NCT04081662; https://clinicaltrials.gov/ct2/show/NCT04081662. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/17086.
Collapse
Affiliation(s)
- Emily B Kroska
- Department of Psychological and Brain Sciences, University of Iowa, Iowa City, IA, United States
| | - Sydney Hoel
- Department of Psychiatry, University of Wisconsin-Madison, Madison, WI, United States
| | - Amanda Victory
- Department of Psychiatry, University of Michigan-Ann Arbor, Ann Arbor, MI, United States
| | - Susan A Murphy
- Department of Statistics, Harvard University, Cambridge, MA, United States
| | - Melvin G McInnis
- Department of Psychiatry, University of Michigan-Ann Arbor, Ann Arbor, MI, United States
| | - Zachary N Stowe
- Department of Psychiatry, University of Wisconsin-Madison, Madison, WI, United States
| | - Amy Cochran
- Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, United States
- Department of Math, University of Wisconsin-Madison, Madison, WI, United States
| |
Collapse
|
31
|
Qian T, Klasnja P, Murphy SA. Linear mixed models with endogenous covariates: modeling sequential treatment effects with application to a mobile health study. Stat Sci 2020; 35:375-390. [PMID: 33132496 PMCID: PMC7596885 DOI: 10.1214/19-sts720] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Mobile health is a rapidly developing field in which behavioral treatments are delivered to individuals via wearables or smartphones to facilitate health-related behavior change. Micro-randomized trials (MRT) are an experimental design for developing mobile health interventions. In an MRT the treatments are randomized numerous times for each individual over course of the trial. Along with assessing treatment effects, behavioral scientists aim to understand between-person heterogeneity in the treatment effect. A natural approach is the familiar linear mixed model. However, directly applying linear mixed models is problematic because potential moderators of the treatment effect are frequently endogenous-that is, may depend on prior treatment. We discuss model interpretation and biases that arise in the absence of additional assumptions when endogenous covariates are included in a linear mixed model. In particular, when there are endogenous covariates, the coefficients no longer have the customary marginal interpretation. However, these coefficients still have a conditional-on-the-random-effect interpretation. We provide an additional assumption that, if true, allows scientists to use standard software to fit linear mixed model with endogenous covariates, and person-specific predictions of effects can be provided. As an illustration, we assess the effect of activity suggestion in the HeartSteps MRT and analyze the between-person treatment effect heterogeneity.
Collapse
Affiliation(s)
- Tianchen Qian
- Department of Statistics, Harvard University, Cambridge, MA 02138
- School of Information, University of Michigan, Ann Arbor, MI 48109
| | - Predrag Klasnja
- Department of Statistics, Harvard University, Cambridge, MA 02138
- School of Information, University of Michigan, Ann Arbor, MI 48109
| | - Susan A Murphy
- Department of Statistics, Harvard University, Cambridge, MA 02138
- School of Information, University of Michigan, Ann Arbor, MI 48109
| |
Collapse
|
32
|
Carpenter SM, Menictas M, Nahum-Shani I, Wetter DW, Murphy SA. Developments in Mobile Health Just-in-Time Adaptive Interventions for Addiction Science. Curr Addict Rep 2020; 7:280-290. [PMID: 33747711 PMCID: PMC7968352 DOI: 10.1007/s40429-020-00322-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW Addiction is a serious and prevalent problem across the globe. An important challenge facing intervention science is how to support addiction treatment and recovery while mitigating the associated cost and stigma. A promising solution is the use of mobile health (mHealth) just-in-time adaptive interventions (JITAIs), in which intervention options are delivered in situ via a mobile device when individuals are most in need. RECENT FINDINGS The present review describes the use of mHealth JITAIs to support addiction treatment and recovery, and provides guidance on when and how the micro-randomized trial (MRT) can be used to optimize a JITAI. We describe the design of five mHealth JITAIs in addiction and three MRT studies, and discuss challenges and future directions. SUMMARY This review aims to provide guidance for constructing effective JITAIs to support addiction treatment and recovery.
Collapse
Affiliation(s)
| | | | - Inbal Nahum-Shani
- Institute for Social Research, University of Michigan, Ann Arbor, MI
| | - David W. Wetter
- Huntsman Cancer Institute and the University of Utah, Salt Lake City, UT
| | | |
Collapse
|
33
|
Qian T, Klasnja P, Murphy SA. Rejoinder: Linear Mixed Models with Endogenous Covariates: Modeling Sequential Treatment Effects with Application to a Mobile Health Study. Stat Sci 2020. [DOI: 10.1214/20-sts794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
34
|
Klasnja P, Smith S, Seewald NJ, Lee A, Hall K, Luers B, Hekler EB, Murphy SA. Efficacy of Contextually Tailored Suggestions for Physical Activity: A Micro-randomized Optimization Trial of HeartSteps. Ann Behav Med 2020; 53:573-582. [PMID: 30192907 DOI: 10.1093/abm/kay067] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND HeartSteps is an mHealth intervention that encourages regular walking via activity suggestions tailored to the individuals' current context. PURPOSE We conducted a micro-randomized trial (MRT) to evaluate the efficacy of HeartSteps' activity suggestions to optimize the intervention. METHODS We conducted a 6-week MRT with 44 adults. Contextually tailored suggestions could be delivered up to five times per day at user-selected times. At each of these five times, for each participant on each day of the study, HeartSteps randomized whether to provide an activity suggestion, and, if so, whether to provide a walking or an antisedentary suggestion. We used a centered and weighted least squares method to analyze the effect of suggestions on the 30-min step count following suggestion randomization. RESULTS Averaging over study days and types of activity suggestions, delivering a suggestion versus no suggestion increased the 30-min step count by 14% (p = .06), 35 additional steps over the 253-step average. The effect was not evenly distributed in time. Providing any type of suggestion versus no suggestion initially increased the step count by 66% (167 steps; p < .01), but this effect diminished over time. Averaging over study days, delivering a walking suggestion versus no suggestion increased the average step count by 24% (59 steps; p = .02). This increase was greater at the start of study (107% or 271 additional steps; p < .01), but decreased over time. Antisedentary suggestions had no detectable effect on the 30-min step count. CONCLUSION Contextually tailored walking suggestions are a promising way of initiating bouts of walking throughout the day. CLINICAL TRIAL INFORMATION This study was registered on ClinicalTrials.gov number NCT03225521.
Collapse
Affiliation(s)
- Predrag Klasnja
- Kaiser Permanente Washington Health Research Institute, Minor Ave, Suite, Seattle, WA, USA.,School of Information, University of Michigan, Ann Arbor, MI, USA
| | - Shawna Smith
- Insitute for Social Research, University of Michigan, Ann Arbor, MI, USA.,School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Andy Lee
- School of Information, University of Michigan, Ann Arbor, MI, USA
| | - Kelly Hall
- Department of Statistics, University of Michigan, Ann Arbor, MI, USA
| | - Brook Luers
- Department of Statistics, University of Michigan, Ann Arbor, MI, USA
| | - Eric B Hekler
- School of Medicine, University of California San Diego, San Diego, CA, USA
| | - Susan A Murphy
- Department of Statistics, Harvard University, Cambridge, MA, USA
| |
Collapse
|
35
|
Dempsey W, Liao P, Kumar S, Murphy SA. THE STRATIFIED MICRO-RANDOMIZED TRIAL DESIGN: SAMPLE SIZE CONSIDERATIONS FOR TESTING NESTED CAUSAL EFFECTS OF TIME-VARYING TREATMENTS. Ann Appl Stat 2020; 14:661-684. [PMID: 33868539 DOI: 10.1214/19-aoas1293] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Technological advancements in the field of mobile devices and wearable sensors have helped overcome obstacles in the delivery of care, making it possible to deliver behavioral treatments anytime and anywhere. Here, we discuss our work on the design of a mobile health smoking cessation intervention study with the goal of assessing whether reminders, delivered at times of stress, result in a reduction/prevention of stress in the near-term, and whether this effect changes with time in study. Multiple statistical challenges arose in this effort, leading to the development of the stratified micro-randomized trial design. In these designs, each individual is randomized to treatment repeatedly at times determined by predictions of risk. These risk times may be impacted by prior treatment. We describe the statistical challenges and detail how they can be met.
Collapse
|
36
|
Wongvibulsin S, Martin SS, Saria S, Zeger SL, Murphy SA. An Individualized, Data-Driven Digital Approach for Precision Behavior Change. Am J Lifestyle Med 2020; 14:289-293. [PMID: 32477031 PMCID: PMC7232899 DOI: 10.1177/1559827619843489] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/25/2019] [Accepted: 03/22/2019] [Indexed: 12/18/2022] Open
Abstract
Chronic disease now affects approximately half of the US population, causes 7 in 10 deaths, and accounts for roughly 80% of US health care expenditure. Because the root causes of chronic diseases are largely behavioral, effective therapies require frequent, individualized interventions that extend beyond the hospital and clinic to reach patients in their day-to-day lives. However, a mismatch currently exists between what the health care system is equipped to provide and the interventions necessary to effectively address the chronic disease burden. To remedy this health crisis, we present an individualized, data-driven digital approach for chronic disease management and prevention through precision behavior change. The rapid growth of information, biological, and communication technologies makes this an opportune time to develop digital tools that deliver precision interventions for health behavior change to address the chronic disease crisis. Building on this rapid growth, we propose a framework that includes the precise targeting of risk-producing behaviors using real-time sensing technology, machine learning data analysis to identify the most effective intervention, and delivery of that intervention with health-reinforcing feedback to provide real-time, individualized support to empower sustainable health behavior change.
Collapse
Affiliation(s)
- Shannon Wongvibulsin
- Shannon Wongvibulsin, PhD, Johns Hopkins University School of Medicine, Johns Hopkins University, 1830 E. Monument Street, Suite 2-300, Baltimore, MD 21205; e-mail:
| | - Seth S. Martin
- Johns Hopkins University School of Medicine, Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland (SW)
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland (SSM)
- Department of Computer Science and Applied Math and Statistics and Armstrong Institute for Patient Safety and Quality, Department of Health Policy and Management, and Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland (SS)
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (SLZ)
- Department of Statistics and Department of Computer Science, Harvard University, Cambridge, Massachusetts (SAM)
| | - Suchi Saria
- Johns Hopkins University School of Medicine, Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland (SW)
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland (SSM)
- Department of Computer Science and Applied Math and Statistics and Armstrong Institute for Patient Safety and Quality, Department of Health Policy and Management, and Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland (SS)
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (SLZ)
- Department of Statistics and Department of Computer Science, Harvard University, Cambridge, Massachusetts (SAM)
| | - Scott L. Zeger
- Johns Hopkins University School of Medicine, Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland (SW)
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland (SSM)
- Department of Computer Science and Applied Math and Statistics and Armstrong Institute for Patient Safety and Quality, Department of Health Policy and Management, and Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland (SS)
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (SLZ)
- Department of Statistics and Department of Computer Science, Harvard University, Cambridge, Massachusetts (SAM)
| | - Susan A. Murphy
- Johns Hopkins University School of Medicine, Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland (SW)
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland (SSM)
- Department of Computer Science and Applied Math and Statistics and Armstrong Institute for Patient Safety and Quality, Department of Health Policy and Management, and Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland (SS)
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (SLZ)
- Department of Statistics and Department of Computer Science, Harvard University, Cambridge, Massachusetts (SAM)
| |
Collapse
|
37
|
Nahum-Shani I, Smith SN, Spring BJ, Collins LM, Witkiewitz K, Tewari A, Murphy SA. Just-in-Time Adaptive Interventions (JITAIs) in Mobile Health: Key Components and Design Principles for Ongoing Health Behavior Support. Ann Behav Med 2019; 52:446-462. [PMID: 27663578 PMCID: PMC5364076 DOI: 10.1007/s12160-016-9830-8] [Citation(s) in RCA: 803] [Impact Index Per Article: 160.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
Background The just-in-time adaptive intervention (JITAI) is an intervention design aiming to provide the right type/amount of support, at the right time, by adapting to an individual's changing internal and contextual state. The availability of increasingly powerful mobile and sensing technologies underpins the use of JITAIs to support health behavior, as in such a setting an individual's state can change rapidly, unexpectedly, and in his/her natural environment. Purpose Despite the increasing use and appeal of JITAIs, a major gap exists between the growing technological capabilities for delivering JITAIs and research on the development and evaluation of these interventions. Many JITAIs have been developed with minimal use of empirical evidence, theory, or accepted treatment guidelines. Here, we take an essential first step towards bridging this gap. Methods Building on health behavior theories and the extant literature on JITAIs, we clarify the scientific motivation for JITAIs, define their fundamental components, and highlight design principles related to these components. Examples of JITAIs from various domains of health behavior research are used for illustration. Conclusions As we enter a new era of technological capacity for delivering JITAIs, it is critical that researchers develop sophisticated and nuanced health behavior theories capable of guiding the construction of such interventions. Particular attention has to be given to better understanding the implications of providing timely and ecologically sound support for intervention adherence and retention.
Collapse
Affiliation(s)
- Inbal Nahum-Shani
- Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | - Shawna N Smith
- Division of General Medicine, Department of Internal Medicine and Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | - Bonnie J Spring
- Feinberg School of Medicine, Northwestern University, Evanston, IL, USA
| | - Linda M Collins
- TheMethodology Center andDepartment ofHuman Development & Family Studies, Penn State, State College, PA, USA
| | - Katie Witkiewitz
- Department of Psychology, University of New Mexico, Albuquerque, NM, USA
| | - Ambuj Tewari
- Department of Statistics and Department of EECS, University of Michigan, Ann Arbor, MI, USA
| | - Susan A Murphy
- Department of Statistics, and Institute for Social Research,University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
38
|
Seewald NJ, Smith SN, Lee AJ, Klasnja P, Murphy SA. Practical Considerations for Data Collection and Management in Mobile Health Micro-randomized Trials. Stat Biosci 2019; 11:355-370. [PMID: 31462937 PMCID: PMC6713230 DOI: 10.1007/s12561-018-09228-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 10/10/2018] [Accepted: 12/14/2018] [Indexed: 11/24/2022]
Abstract
There is a growing interest in leveraging the prevalence of mobile technology to improve health by delivering momentary, contextualized interventions to individuals' smartphones. A just-in-time adaptive intervention (JITAI) adjusts to an individual's changing state and/or context to provide the right treatment, at the right time, in the right place. Micro-randomized trials (MRTs) allow for the collection of data which aid in the construction of an optimized JITAI by sequentially randomizing participants to different treatment options at each of many decision points throughout the study. Often, this data is collected passively using a mobile phone. To assess the causal effect of treatment on a near-term outcome, care must be taken when designing the data collection system to ensure it is of appropriately high quality. Here, we make several recommendations for collecting and managing data from an MRT. We provide advice on selecting which features to collect and when, choosing between "agents" to implement randomization, identifying sources of missing data, and overcoming other novel challenges. The recommendations are informed by our experience with HeartSteps, an MRT designed to test the effects of an intervention aimed at increasing physical activity in sedentary adults. We also provide a checklist which can be used in designing a data collection system so that scientists can focus more on their questions of interest, and less on cleaning data.
Collapse
Affiliation(s)
- Nicholas J Seewald
- University of Michigan, Department of Statistics, 311 West Hall, 1085 South University Ave, Ann Arbor, MI, 48109,
| | - Shawna N Smith
- University of Michigan, Departments of Psychiatry and General Medicine
| | | | | | - Susan A Murphy
- Harvard University, Departments of Statistics and Computer Science
| |
Collapse
|
39
|
Fröhlich H, Balling R, Beerenwinkel N, Kohlbacher O, Kumar S, Lengauer T, Maathuis MH, Moreau Y, Murphy SA, Przytycka TM, Rebhan M, Röst H, Schuppert A, Schwab M, Spang R, Stekhoven D, Sun J, Weber A, Ziemek D, Zupan B. From hype to reality: data science enabling personalized medicine. BMC Med 2018; 16:150. [PMID: 30145981 PMCID: PMC6109989 DOI: 10.1186/s12916-018-1122-7] [Citation(s) in RCA: 167] [Impact Index Per Article: 27.8] [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] [Received: 03/28/2018] [Accepted: 07/09/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Personalized, precision, P4, or stratified medicine is understood as a medical approach in which patients are stratified based on their disease subtype, risk, prognosis, or treatment response using specialized diagnostic tests. The key idea is to base medical decisions on individual patient characteristics, including molecular and behavioral biomarkers, rather than on population averages. Personalized medicine is deeply connected to and dependent on data science, specifically machine learning (often named Artificial Intelligence in the mainstream media). While during recent years there has been a lot of enthusiasm about the potential of 'big data' and machine learning-based solutions, there exist only few examples that impact current clinical practice. The lack of impact on clinical practice can largely be attributed to insufficient performance of predictive models, difficulties to interpret complex model predictions, and lack of validation via prospective clinical trials that demonstrate a clear benefit compared to the standard of care. In this paper, we review the potential of state-of-the-art data science approaches for personalized medicine, discuss open challenges, and highlight directions that may help to overcome them in the future. CONCLUSIONS There is a need for an interdisciplinary effort, including data scientists, physicians, patient advocates, regulatory agencies, and health insurance organizations. Partially unrealistic expectations and concerns about data science-based solutions need to be better managed. In parallel, computational methods must advance more to provide direct benefit to clinical practice.
Collapse
Affiliation(s)
- Holger Fröhlich
- UCB Biosciences GmbH, Alfred-Nobel-Str. Str. 10, 40789 Monheim, Germany
- University of Bonn, Bonn-Aachen International Center for IT, Endenicher Allee 19c, 53115 Bonn, Germany
| | - Rudi Balling
- University of Luxembourg, 6 avenue du Swing, 4367 Belvaux, Luxembourg
| | - Niko Beerenwinkel
- Department of Biosciences and Engineering, ETH Zurich, Mattenstr. 26, 4058 Basel, Switzerland
| | - Oliver Kohlbacher
- University of Tübingen, WSI/ZBIT, Sand 14, 72076 Tübingen, Germany
- Max Planck Institute for Developmental Biology, Max-Planck-Ring 5, 72076 Tübingen, Germany
- Quantitative Biology Center, University of Tübingen, Auf der Morgenstelle 8, 72076 Tübingen, Germany
- Institute for Translational Bioinformatics, University Medical Center Tübingen, Sand 14, 72076 Tübingen, Germany
| | - Santosh Kumar
- Department of Computer Science, University of Memphis, 2222 Dunn Hall, Memphis, TN 38152 USA
| | - Thomas Lengauer
- Max-Planck-Institute for Informatics, 66123 Saarbrücken, Germany
| | - Marloes H. Maathuis
- ETH Zurich, Seminar für Statistik, Rämistrasse 101, 8092 Zurich, Switzerland
| | - Yves Moreau
- University of Leuven, ESAT, Kasteelpark Arenberg 10, 3001 Leuven, Belgium
| | - Susan A. Murphy
- Harvard University, Science Center 400 Suite, Oxford Street, Cambridge, MA 02138-2901 USA
| | - Teresa M. Przytycka
- National Center of Biotechnology Information, National Institute of Health, 8600 Rockville Pike, Bethesda, MD 20894-6075 USA
| | - Michael Rebhan
- Novartis Institutes for Biomedical Research, 4056 Basel, Switzerland
| | - Hannes Röst
- Donnelly Centre for Cellular and Biomolecular Research, University of Toronto, 160 College Street, Toronto, ON M5S 3E1 Canada
| | - Andreas Schuppert
- RWTH Aachen, Joint Research Center for Computational Biomedicine, Pauwelsstrasse 19, 52074 Aachen, Germany
| | - Matthias Schwab
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Aucherbachstrasse 112, 70376 Stuttgart, Germany
- University of Tübingen, Departments of Clinical Pharmacology and of Pharmacy and Biochemistry, Tübingen, Germany
| | - Rainer Spang
- University of Regensburg, Institute of Functional Genomics, Am BioPark 9, 93053 Regensburg, Germany
| | - Daniel Stekhoven
- ETH Zurich, NEXUS Personalized Health Technol., Otto-Stern-Weg 7, 8093 Zurich, Switzerland
| | - Jimeng Sun
- Georgia Tech University, 801 Atlantic Drive, Atlanta, GA 30332-0280 USA
| | - Andreas Weber
- Institute for Computer Science, University of Bonn, Endenicher Allee 19a, 53115 Bonn, Germany
| | - Daniel Ziemek
- Pfizer, Worldwide Research and Development, Linkstraße 10, 10785 Berlin, Germany
| | - Blaz Zupan
- Faculty of Computer and Information Science, University of Ljubljana, Večna pot 113, SI-1000 Ljubljana, Slovenia
| |
Collapse
|
40
|
Shortreed SM, Laber E, Scott Stroup T, Pineau J, Murphy SA. A multiple imputation strategy for sequential multiple assignment randomized trials. Stat Med 2017; 36:3760. [DOI: 10.1002/sim.7285] [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: 11/10/2022]
|
41
|
Abstract
In mobile health interventions aimed at behavior change and maintenance, treatments are provided in real time to manage current or impending high risk situations or promote healthy behaviors in near real time. Currently there is great scientific interest in developing data analysis approaches to guide the development of mobile interventions. In particular data from mobile health studies might be used to examine effect moderators-individual characteristics, time-varying context or past treatment response that moderate the effect of current treatment on a subsequent response. This paper introduces a formal definition for moderated effects in terms of potential outcomes, a definition that is particularly suited to mobile interventions, where treatment occasions are numerous, individuals are not always available for treatment, and potential moderators might be influenced by past treatment. Methods for estimating moderated effects are developed and compared. The proposed approach is illustrated using BASICS-Mobile, a smartphone-based intervention designed to curb heavy drinking and smoking among college students.
Collapse
Affiliation(s)
| | | | | | - Susan A Murphy
- Department of Statistics, University of Michigan.,Institute for Social Research, University of Michigan
| |
Collapse
|
42
|
Dempsey WH, Moreno A, Scott CK, Dennis ML, Gustafson DH, Murphy SA, Rehg JM. iSurvive: An Interpretable, Event-time Prediction Model for mHealth. Proc Mach Learn Res 2017; 70:970-979. [PMID: 30906932 PMCID: PMC6430609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
An important mobile health (mHealth) task is the use of multimodal data, such as sensor streams and self-report, to construct interpretable time-to-event predictions of, for example, lapse to alcohol or illicit drug use. Interpretability of the prediction model is important for acceptance and adoption by domain scientists, enabling model outputs and parameters to inform theory and guide intervention design. Temporal latent state models are therefore attractive, and so we adopt the continuous time hidden Markov model (CT-HMM) due to its ability to describe irregular arrival times of event data. Standard CT-HMMs, however, are not specialized for predicting the time to a future event, the key variable for mHealth interventions. Also, standard emission models lack a sufficiently rich structure to describe multimodal data and incorporate domain knowledge. We present iSurvive, an extension of classical survival analysis to a CT-HMM. We present a parameter learning method for GLM emissions and survival model fitting, and present promising results on both synthetic data and an mHealth drug use dataset.
Collapse
|
43
|
Klasnja P, Hekler EB, Shiffman S, Boruvka A, Almirall D, Tewari A, Murphy SA. Microrandomized trials: An experimental design for developing just-in-time adaptive interventions. Health Psychol 2016; 34S:1220-8. [PMID: 26651463 DOI: 10.1037/hea0000305] [Citation(s) in RCA: 270] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE This article presents an experimental design, the microrandomized trial, developed to support optimization of just-in-time adaptive interventions (JITAIs). JITAIs are mHealth technologies that aim to deliver the right intervention components at the right times and locations to optimally support individuals' health behaviors. Microrandomized trials offer a way to optimize such interventions by enabling modeling of causal effects and time-varying effect moderation for individual intervention components within a JITAI. METHOD The article describes the microrandomized trial design, enumerates research questions that this experimental design can help answer, and provides an overview of the data analyses that can be used to assess the causal effects of studied intervention components and investigate time-varying moderation of those effects. RESULTS Microrandomized trials enable causal modeling of proximal effects of the randomized intervention components and assessment of time-varying moderation of those effects. CONCLUSION Microrandomized trials can help researchers understand whether their interventions are having intended effects, when and for whom they are effective, and what factors moderate the interventions' effects, enabling creation of more effective JITAIs.
Collapse
Affiliation(s)
| | - Eric B Hekler
- School of Nutrition and Health Promotion, Arizona State University
| | | | | | | | - Ambuj Tewari
- Department of Statistics, University of Michigan
| | | |
Collapse
|
44
|
Abstract
This study describes the current state of Canadian university health sciences librarians' knowledge about, training needs for, and barriers to participating in systematic reviews (SRs). A convenience sample of Canadian librarians was surveyed. Over half of the librarians who had participated in SRs acknowledged participating in a traditional librarian role (e.g., search strategy developer); less than half indicated participating in any one nontraditional librarian role (e.g., data extractor). Lack of time and insufficient training were the most frequently reported barriers to participating in SRs. The findings provide a benchmark for tracking changes in Canadian university health sciences librarians' participation in SRs.
Collapse
|
45
|
Pelham WE, Fabiano GA, Waxmonsky JG, Greiner AR, Gnagy EM, Pelham WE, Coxe S, Verley J, Bhatia I, Hart K, Karch K, Konijnendijk E, Tresco K, Nahum-Shani I, Murphy SA. Treatment Sequencing for Childhood ADHD: A Multiple-Randomization Study of Adaptive Medication and Behavioral Interventions. J Clin Child Adolesc Psychol 2016; 45:396-415. [PMID: 26882332 DOI: 10.1080/15374416.2015.1105138] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Behavioral and pharmacological treatments for children with attention deficit/hyperactivity disorder (ADHD) were evaluated to address whether endpoint outcomes are better depending on which treatment is initiated first and, in case of insufficient response to initial treatment, whether increasing dose of initial treatment or adding the other treatment modality is superior. Children with ADHD (ages 5-12, N = 146, 76% male) were treated for 1 school year. Children were randomized to initiate treatment with low doses of either (a) behavioral parent training (8 group sessions) and brief teacher consultation to establish a Daily Report Card or (b) extended-release methylphenidate (equivalent to .15 mg/kg/dose bid). After 8 weeks or at later monthly intervals as necessary, insufficient responders were rerandomized to secondary interventions that either increased the dose/intensity of the initial treatment or added the other treatment modality, with adaptive adjustments monthly as needed to these secondary treatments. The group beginning with behavioral treatment displayed significantly lower rates of observed classroom rule violations (the primary outcome) at study endpoint and tended to have fewer out-of-class disciplinary events. Further, adding medication secondary to initial behavior modification resulted in better outcomes on the primary outcomes and parent/teacher ratings of oppositional behavior than adding behavior modification to initial medication. Normalization rates on teacher and parent ratings were generally high. Parents who began treatment with behavioral parent training had substantially better attendance than those assigned to receive training following medication. Beginning treatment with behavioral intervention produced better outcomes overall than beginning treatment with medication.
Collapse
Affiliation(s)
- William E Pelham
- a Center for Children and Families, Department of Psychology , Florida International University
| | - Gregory A Fabiano
- b Department of Counseling, School, and Educational Psychology , State University of New York at Buffalo
| | - James G Waxmonsky
- c Department of Psychiatry, Pennsylvania State Hershey Medical Center , Pennsylvania State University
| | - Andrew R Greiner
- f Center for Children and Families , Florida International University
| | - Elizabeth M Gnagy
- f Center for Children and Families , Florida International University
| | - William E Pelham
- d REACH Institute, Department of Psychology , Arizona State University
| | - Stefany Coxe
- a Center for Children and Families, Department of Psychology , Florida International University
| | | | - Ira Bhatia
- g State University of New York at Buffalo
| | - Katie Hart
- a Center for Children and Families, Department of Psychology , Florida International University
| | | | | | - Katy Tresco
- h Department of Psychology , Philadelphia College of Osteopathic Medicine
| | | | - Susan A Murphy
- i Institute for Social Research, Departments of Statistics and Psychiatry , University of Michigan
| |
Collapse
|
46
|
Abstract
OBJECTIVE Adaptive intensive interventions are introduced, and new methods from the field of control engineering for use in their design are illustrated. METHOD A detailed step-by-step explanation of how control engineering methods can be used with intensive longitudinal data to design an adaptive intensive intervention is provided. The methods are evaluated via simulation. RESULTS Simulation results illustrate how the designed adaptive intensive intervention can result in improved outcomes with less treatment by providing treatment only when it is needed. Furthermore, the methods are robust to model misspecification as well as the influence of unobserved causes. CONCLUSIONS These new methods can be used to design adaptive interventions that are effective yet reduce participant burden.
Collapse
Affiliation(s)
| | - Korkut Bekiroglu
- Department of Electrical Engineering, The Pennsylvania State University
| | | | | |
Collapse
|
47
|
Liao P, Klasnja P, Tewari A, Murphy SA. Sample size calculations for micro-randomized trials in mHealth. Stat Med 2015; 35:1944-71. [PMID: 26707831 DOI: 10.1002/sim.6847] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [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: 03/27/2015] [Revised: 09/20/2015] [Accepted: 11/24/2015] [Indexed: 11/06/2022]
Abstract
The use and development of mobile interventions are experiencing rapid growth. In "just-in-time" mobile interventions, treatments are provided via a mobile device, and they are intended to help an individual make healthy decisions 'in the moment,' and thus have a proximal, near future impact. Currently, the development of mobile interventions is proceeding at a much faster pace than that of associated data science methods. A first step toward developing data-based methods is to provide an experimental design for testing the proximal effects of these just-in-time treatments. In this paper, we propose a 'micro-randomized' trial design for this purpose. In a micro-randomized trial, treatments are sequentially randomized throughout the conduct of the study, with the result that each participant may be randomized at the 100s or 1000s of occasions at which a treatment might be provided. Further, we develop a test statistic for assessing the proximal effect of a treatment as well as an associated sample size calculator. We conduct simulation evaluations of the sample size calculator in various settings. Rules of thumb that might be used in designing a micro-randomized trial are discussed. This work is motivated by our collaboration on the HeartSteps mobile application designed to increase physical activity. Copyright © 2015 John Wiley & Sons, Ltd.
Collapse
Affiliation(s)
- Peng Liao
- Department of Statistics, University of Michigan, MI, 48109, Ann Arbor, U.S.A
| | - Predrag Klasnja
- School of Information, University of Michigan, MI, 48109, Ann Arbor, U.S.A
| | - Ambuj Tewari
- Department of Statistics, University of Michigan, MI, 48109, Ann Arbor, U.S.A
| | - Susan A Murphy
- Department of Statistics, University of Michigan, MI, 48109, Ann Arbor, U.S.A
| |
Collapse
|
48
|
Abstract
Data from activity trackers and mobile phones can be used to craft personalised health interventions. But measuring the efficacy of these "treatments" requires a rethink of the traditional randomised trial.
Collapse
Affiliation(s)
- Walter Dempsey
- Postdoctoral research fellow at the University of Michigan, Department of Statistics
| | - Peng Liao
- Graduate student at the University of Michigan, Department of Statistics
| | - Pedja Klasnja
- Assistant professor of information, School of Information, and assistant professor of health behavior and health education, School of Public Health at the University of Michigan
| | - Inbal Nahum-Shani
- Research assistant professor at the Survey Research Center, Institute for Social Research, University of Michigan
| | - Susan A Murphy
- H.E. Robbins Distinguished University Professor of Statistics, professor of psychiatry, and research professor, Institute for Social Research at the University of Michigan
| |
Collapse
|
49
|
Kumar S, Abowd GD, Abraham WT, al'Absi M, Beck JG, Chau DH, Condie T, Conroy DE, Ertin E, Estrin D, Ganesan D, Lam C, Marlin B, Marsh CB, Murphy SA, Nahum-Shani I, Patrick K, Rehg JM, Sharmin M, Shetty V, Sim I, Spring B, Srivastava M, Wetter DW. Center of excellence for mobile sensor data-to-knowledge (MD2K). J Am Med Inform Assoc 2015; 22:1137-42. [PMID: 26555017 DOI: 10.1093/jamia/ocv056] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [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: 02/20/2015] [Accepted: 04/27/2015] [Indexed: 11/13/2022] Open
Abstract
Mobile sensor data-to-knowledge (MD2K) was chosen as one of 11 Big Data Centers of Excellence by the National Institutes of Health, as part of its Big Data-to-Knowledge initiative. MD2K is developing innovative tools to streamline the collection, integration, management, visualization, analysis, and interpretation of health data generated by mobile and wearable sensors. The goal of the big data solutions being developed by MD2K is to reliably quantify physical, biological, behavioral, social, and environmental factors that contribute to health and disease risk. The research conducted by MD2K is targeted at improving health through early detection of adverse health events and by facilitating prevention. MD2K will make its tools, software, and training materials widely available and will also organize workshops and seminars to encourage their use by researchers and clinicians.
Collapse
Affiliation(s)
- Santosh Kumar
- Computer Science, University of Memphis, Memphis, TN
| | - Gregory D Abowd
- School of Interactive Computing, Georgia Institute of Technology, Atlanta, GA
| | | | - Mustafa al'Absi
- Duluth Medical Research Institute (DMRI), University of Minnesota Medical School, Duluth, MN
| | | | - Duen Horng Chau
- School of Computational Science & Engineering, Georgia Institute of Technology, Atlanta, GA
| | - Tyson Condie
- Computer Science, University of California, Los Angeles, CA
| | - David E Conroy
- Preventive Medicine, Northwestern University, Chicago, IL
| | - Emre Ertin
- Electrical & Computer Engineering, The Ohio State University, Columbus, OH
| | | | - Deepak Ganesan
- Computer Science, University of Massachusetts, Amherst, MA
| | - Cho Lam
- Psychology, Rice University, Houston, TX
| | | | - Clay B Marsh
- Health Sciences, West Virginia University, Morgantown, WV
| | | | - Inbal Nahum-Shani
- Institute for Social Research, University of Michigan, Ann Arbor, MI
| | - Kevin Patrick
- The Qualcomm Institute, University of California, San Diego, La Jolla, CA
| | - James M Rehg
- School of Interactive Computing, Georgia Institute of Technology, Atlanta, GA
| | | | - Vivek Shetty
- School of Dentistry, University of California, Los Angeles, CA
| | - Ida Sim
- Medicine, University of California, San Francisco, CA
| | - Bonnie Spring
- Preventive Medicine, Northwestern University, Chicago, IL
| | - Mani Srivastava
- Electrical Engineering, University of California, Los Angeles, CA
| | | |
Collapse
|
50
|
Steffel J, Giugliano RP, Braunwald E, Murphy SA, Atar D, Heidbuchel H, Camm AJ, Antman EM, Ruff CT. Edoxaban vs. warfarin in patients with atrial fibrillation on amiodarone: a subgroup analysis of the ENGAGE AF-TIMI 48 trial. Eur Heart J 2015; 36:2239-45. [PMID: 25971288 DOI: 10.1093/eurheartj/ehv201] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 05/01/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In the ENGAGE AF-TIMI 48 trial, the higher-dose edoxaban (HDE) regimen had a similar incidence of ischaemic stroke compared with warfarin, whereas a higher incidence was observed with the lower-dose regimen (LDE). Amiodarone increases edoxaban plasma levels via P-glycoprotein inhibition. The current pre-specified exploratory analysis was performed to determine the effect of amiodarone on the relative efficacy and safety profile of edoxaban. METHODS AND RESULTS At randomization, 2492 patients (11.8%) were receiving amiodarone. The primary efficacy endpoint of stroke or systemic embolic event was significantly lower with LDE compared with warfarin in amiodarone treated patients vs. patients not on amiodarone (hazard ratio [HR] 0.60, 95% confidence intervals [CIs] 0.36-0.99 and HR 1.20, 95% CI 1.03-1.40, respectively; P interaction <0.01). In patients randomized to HDE, no such interaction for efficacy was observed (HR 0.73, 95% CI 0.46-1.17 vs. HR 0.89, 95% CI 0.75-1.05, P interaction = 0.446). Major bleeding was similar in patients on LDE (HR 0.35, 95% CI 0.21-0.59 vs. HR 0.53, 95% CI 0.46-0.61, P interaction = 0.131) and HDE (HR 0.94, 95% CI 0.65-1.38 vs. HR 0.79, 95% CI 0.69-0.90, P interaction = 0.392) when compared with warfarin, independent of amiodarone use. CONCLUSIONS Patients randomized to the LDE treated with amiodarone at the time of randomization demonstrated a significant reduction in ischaemic events vs. warfarin when compared with those not on amiodarone, while preserving a favourable bleeding profile. In contrast, amiodarone had no effect on the relative efficacy and safety of HDE.
Collapse
Affiliation(s)
- J Steffel
- Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland
| | - R P Giugliano
- Cardiovascular Division, Brigham and Women's Hospital, TIMI Study Group, 350 Longwood Avenue, 1st Floor Offices, Boston 02115, MA, USA
| | - E Braunwald
- Cardiovascular Division, Brigham and Women's Hospital, TIMI Study Group, 350 Longwood Avenue, 1st Floor Offices, Boston 02115, MA, USA
| | - S A Murphy
- Cardiovascular Division, Brigham and Women's Hospital, TIMI Study Group, 350 Longwood Avenue, 1st Floor Offices, Boston 02115, MA, USA
| | - D Atar
- Department of Cardiology B, Oslo University Hospital Ulleval, University of Oslo, Oslo, Norway
| | - H Heidbuchel
- Hasselt University and Heart Center, Jessa Hospital, Hasselt, Belgium
| | - A J Camm
- Division of Clinical Sciences, St. George's University of London, Cranmer Terrace, London SW17 0RE, UK
| | - E M Antman
- Cardiovascular Division, Brigham and Women's Hospital, TIMI Study Group, 350 Longwood Avenue, 1st Floor Offices, Boston 02115, MA, USA
| | - C T Ruff
- Cardiovascular Division, Brigham and Women's Hospital, TIMI Study Group, 350 Longwood Avenue, 1st Floor Offices, Boston 02115, MA, USA
| |
Collapse
|