Geographically-based screening policies for diabetic retinopathy (DR) can be effective in developing teleretinal imaging (TRI) guidelines while identifying patients with limited geographic access to eye care. This study conducts cost-effectiveness analysis of different screening policies for urban and rural diabetic patients in Western Pennsylvania. A Monte Carlo simulation model was used to evaluate the cost-effectiveness of 2 standardized screening policies (annual clinic-based screening (ACS) and annual TRI-based screening (ATRI)) and a personalized TRI-based screening policy (PTRI) for both urban and rural cohorts. PTRI was generated by a previously developed mathematical model that autonomously makes semi-annual screening recommendations based on each patient’s disease progression and compliance (Dorali et al. IOVS 2022; 63(7)). For each policy, hypothetical urban and rural cohorts of 50,000 patients were simulated and lifetime QALYs and costs were collected for each patient. TRI compliance rates were derived from electronic medical records. Compliance with clinic-based screening was selected from literature-based values (12-45% for rural patients and 50-65% for urban patients). For a base case urban cohort with an A1C level of 7% and entering age of 40, costs per QALY gain (CPQ) for ACS, ATRI, and PTRI were $744.93±1.57, $792.38±1.64, and $714.60±1.56, respectively; PTRI produced more cost saving than ACS with the same QALY gain (See Fig 1). For a base case rural cohort, CPQ for ACS, ATRI, and PTRI were $869.15±1.80, $819.24±1.88, and $761.51±1.42, respectively; both ATRI and PTRI dominated ACS in QALY gains and cost saving (Fig 1). PTRI recommended TRI more to rural patients (94.13±0.01%) than to urban patients (87.20±0.02%). For the rural cohort, the minimum average TRI compliance rate such that ATRI is more cost-effective than ACS was 56% (Fig 2). TRI-based screening was found more beneficial for rural patients. PTRI was found dominant in QALY gain and cost saving for both urban and rural cohorts against standardized policies. These findings suggest that TRI is best utilized when location-specific factors such as geographic access to care or TRI compliance are considered.
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Developing behavior-based diabetic retinopathy screening guidelines
Purpose : Personalized screening guidelines can be an effective strategy to prevent diabetic retinopathy (DR)-related vision loss. However, these strategies typically do not capture behavior-based factors such as a patient’s compliance or cost preferences. This study develops a mathematical model to identify screening policies that capture both DR progression and behavioral factors to provide personalized recommendations. Methods : A partially observable Markov decision process model (POMDP) is developed to provide personalized screening recommendations. For each patient, the model estimates the patient’s probability of having a sight-threatening diabetic eye disorder (STDED) yearly via Bayesian inference based on natural history, screening results, and compliance behavior. The model then determines a personalized, threshold-based recommendation for each patient annually--either no action (NA), teleretinal imaging (TRI), or clinical screening (CS)--based on the patient’s current probability of having STDED as well as patient-specific preference between cost saving ($) and QALY gain. The framework is applied to a hypothetical cohort of 40-year-old African American male patients. Results : For the base population with TRI and CS compliance rates of 65% and 55% and equal preference for cost and QALY, NA is identified as an optimal recommendation when the patient’s probability of having STDED is less than 0.72%, TRI when the probability is [0.72%, 2.09%], and CS when the probability is above 2.09%. Simulated against annual clinical screening, the model-based policy finds an average decrease of 7.07% in cost/QALY (95% CI; 6.93-7.23%) and 15.05% in blindness prevalence over a patient’s lifetime (95% CI; 14.88-15.23%). For patients with equal preference for cost and QALY, the model identifies 6 different types of threshold-based policies (See Fig 1). For patients with strong preference for QALY gain, CS-only policies had an increase in prevalence by a factor of 19.2 (see Fig 2). Conclusions : The POMDP model is highly flexible and responsive in incorporating behavioral factors when providing personalized screening recommendations. As a decision support tool, providers can use this modeling framework to provide unique, catered recommendations.
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- Award ID(s):
- 1908244
- NSF-PAR ID:
- 10279199
- Date Published:
- Journal Name:
- Investigative ophthalmology visual science
- Volume:
- 62
- Issue:
- 8
- ISSN:
- 1552-5783
- Page Range / eLocation ID:
- 2652-2652
- Format(s):
- Medium: X
- Sponsoring Org:
- National Science Foundation
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Importance Screening with low-dose computed tomography (CT) has been shown to reduce mortality from lung cancer in randomized clinical trials in which the rate of adherence to follow-up recommendations was over 90%; however, adherence to Lung Computed Tomography Screening Reporting & Data System (Lung-RADS) recommendations has been low in practice. Identifying patients who are at risk of being nonadherent to screening recommendations may enable personalized outreach to improve overall screening adherence.
Objective To identify factors associated with patient nonadherence to Lung-RADS recommendations across multiple screening time points.
Design, Setting, and Participants This cohort study was conducted at a single US academic medical center across 10 geographically distributed sites where lung cancer screening is offered. The study enrolled individuals who underwent low-dose CT screening for lung cancer between July 31, 2013, and November 30, 2021.
Exposures Low-dose CT screening for lung cancer.
Main Outcomes and Measures The main outcome was nonadherence to follow-up recommendations for lung cancer screening, defined as failing to complete a recommended or more invasive follow-up examination (ie, diagnostic dose CT, positron emission tomography–CT, or tissue sampling vs low-dose CT) within 15 months (Lung-RADS score, 1 or 2), 9 months (Lung-RADS score, 3), 5 months (Lung-RADS score, 4A), or 3 months (Lung-RADS score, 4B/X). Multivariable logistic regression was used to identify factors associated with patient nonadherence to baseline Lung-RADS recommendations. A generalized estimating equations model was used to assess whether the pattern of longitudinal Lung-RADS scores was associated with patient nonadherence over time.
Results Among 1979 included patients, 1111 (56.1%) were aged 65 years or older at baseline screening (mean [SD] age, 65.3 [6.6] years), and 1176 (59.4%) were male. The odds of being nonadherent were lower among patients with a baseline Lung-RADS score of 1 or 2 vs 3 (adjusted odds ratio [AOR], 0.35; 95% CI, 0.25-0.50), 4A (AOR, 0.21; 95% CI, 0.13-0.33), or 4B/X, (AOR, 0.10; 95% CI, 0.05-0.19); with a postgraduate vs college degree (AOR, 0.70; 95% CI, 0.53-0.92); with a family history of lung cancer vs no family history (AOR, 0.74; 95% CI, 0.59-0.93); with a high age-adjusted Charlson Comorbidity Index score (≥4) vs a low score (0 or 1) (AOR, 0.67; 95% CI, 0.46-0.98); in the high vs low income category (AOR, 0.79; 95% CI, 0.65-0.98); and referred by physicians from pulmonary or thoracic-related departments vs another department (AOR, 0.56; 95% CI, 0.44-0.73). Among 830 eligible patients who had completed at least 2 screening examinations, the adjusted odds of being nonadherent to Lung-RADS recommendations at the following screening were increased in patients with consecutive Lung-RADS scores of 1 to 2 (AOR, 1.38; 95% CI, 1.12-1.69).
Conclusions and Relevance In this retrospective cohort study, patients with consecutive negative lung cancer screening results were more likely to be nonadherent with follow-up recommendations. These individuals are potential candidates for tailored outreach to improve adherence to recommended annual lung cancer screening.
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Precision medicine that enables personalized treatment decision support has become an increasingly important research topic in chronic disease care. The main challenges in designing a treatment algorithm include modeling individual disease progression dynamics and designing adaptive treatment selection strategy. This study aims to develop an adaptive treatment selection framework tailored to an individual patient’s disease progression pattern and treatment response. We propose a Partially Observable Collaborative Model (POCM) to capture the individual variations in a heterogeneous population and optimize treatment outcomes in three stages. The POCM first infers the disease progression models by subgroup patterns using population data in stage one and then fine-tunes the models for individual patients with a small number of treatment trials in stage two. In stage three, we show how the treatment policies based on the Partially Observable Markov Decision Process (POMDP) can be tailored to individual patients by utilizing the disease models learned from the POCM. Using a simulated population of chronic depression patients, we show that the POCM can more accurately estimate the personal disease progression than the traditional method of solving a hidden Markov model. We also compare the POMDP treatment policies with other heuristic policies and demonstrate that the POCM-based policies give the highest net monetary benefits in majority of parameter settings. To conclude, the POCM method is a promising approach to model the chronic disease progression process and recommend a personalized treatment plan for individual patients in a heterogeneous population.more » « less
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Abstract Prostate cancer (PCa) is common in American men with long latent periods, during which the disease is asymptomatic. Active surveillance is a monitoring strategy commonly used for patients diagnosed with low‐risk PCa who may harbor latent high‐risk PCa. The optimal monitoring strategy attempts to minimize the disutility of testing while ensuring that the patient is detected at the earliest time when the disease progresses. Unfortunately, guidelines for the active surveillance of PCa are often one‐size‐fits‐all strategies that ignore the heterogeneity among multiple patient types. In contrast, personalized strategies based on partially observable Markov decision process (POMDP) models are challenging to implement in practice given the large number of possible strategies that can be used. This article presents a two‐stage stochastic programming approach that selects a set of strategies for predefined cardinality based on patients' disease risks. The first‐stage decision variables include binary variables for the selection of periods at which to test patients in each strategy and the assignment of multiple patient types to strategies. The objective is to maximize a weighted reward function that considers the need for cancer detection, missed detection, and cost of monitoring patients. We discuss the structure and complexity of the model and reformulate a logic‐based Bender's decomposition formulation that can solve realistic instances to optimality. We present a case study for the active surveillance of PCa and show that our model results in strategies that vary in intensity according to patient disease risk. Finally, we show that our model can generate a small number of strategies that can significantly improve the existing “one‐size‐fits‐all” guideline strategies used in practice.
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OBJECTIVE Current clinical guidelines for managing type 2 diabetes do not differentiate based on patient-specific factors. We present a data-driven algorithm for personalized diabetes management that improves health outcomes relative to the standard of care.
RESEARCH DESIGN AND METHODS We modeled outcomes under 13 pharmacological therapies based on electronic medical records from 1999 to 2014 for 10,806 patients with type 2 diabetes from Boston Medical Center. For each patient visit, we analyzed the range of outcomes under alternative care using a k-nearest neighbor approach. The neighbors were chosen to maximize similarity on individual patient characteristics and medical history that were most predictive of health outcomes. The recommendation algorithm prescribes the regimen with best predicted outcome if the expected improvement from switching regimens exceeds a threshold. We evaluated the effect of recommendations on matched patient outcomes from unseen data.
RESULTS Among the 48,140 patient visits in the test set, the algorithm’s recommendation mirrored the observed standard of care in 68.2% of visits. For patient visits in which the algorithmic recommendation differed from the standard of care, the mean posttreatment glycated hemoglobin A1c (HbA1c) under the algorithm was lower than standard of care by 0.44 ± 0.03% (4.8 ± 0.3 mmol/mol) (P < 0.001), from 8.37% under the standard of care to 7.93% under our algorithm (68.0 to 63.2 mmol/mol).
CONCLUSIONS A personalized approach to diabetes management yielded substantial improvements in HbA1c outcomes relative to the standard of care. Our prototyped dashboard visualizing the recommendation algorithm can be used by providers to inform diabetes care and improve outcomes.
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Accepted Manuscript1.0
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- The DOI is not currently available.
