TY - JOUR
T1 - An informatics consult approach for generating clinical evidence for treatment decisions
AU - Lai, Alvina G
AU - Chang, Wai Hoong
AU - Parisinos, Constantinos A
AU - Katsoulis, Michail
AU - Blackburn, Ruth M
AU - Shah, Anoop D
AU - Nguyen, Vincent
AU - Denaxas, Spiros
AU - Davey Smith, George
AU - Gaunt, Tom R
AU - Nirantharakumar, Krishnarajah
AU - Cox, Murray P
AU - Forde, Donall
AU - Asselbergs, Folkert W
AU - Harris, Steve
AU - Richardson, Sylvia
AU - Sofat, Reecha
AU - Dobson, Richard J B
AU - Hingorani, Aroon
AU - Patel, Riyaz
AU - Sterne, Jonathan
AU - Banerjee, Amitava
AU - Denniston, Alastair K
AU - Ball, Simon
AU - Sebire, Neil J
AU - Shah, Nigam H
AU - Foster, Graham R
AU - Williams, Bryan
AU - Hemingway, Harry
N1 - Funding Information:
AGL is supported by funding from the Wellcome Trust (204841/Z/16/Z), National Institute for Health Research (NIHR) University College London Hospitals Biomedical Research Centre (BRC714/HI/RW/101440), NIHR Great Ormond Street Hospital Biomedical Research Centre (19RX02) and the Health Data Research UK Better Care Catalyst Award (CFC0125). MK is funded by the British Heart Foundation (FS/18/5/33319). RMB is supported by a UKRI Innovation Fellowship funded by the Medical Research Council (Grant No: MR/S003797/1). ADS is supported by a postdoctoral fellowship from THIS Institute. RJBD is supported by the NIHR Biomedical Research Centres at South London and Maudsley NHS Foundation Trust (SLAM; IS-BRC1215-20018); Health Data Research UK; UK Research and Innovation (UKRI) London Medical Imaging & Artificial Intelligence Centre for Value Based Healthcare; the BigData@Heart Consortium (Grant No. 116074 of the European Union Horizon 2020 programme); the NIHR BRC and Research Informatics Unit at University College London Hospitals; and the NIHR Applied Research Collaboration South London at KCHFT. GDS and TG are funded by the Medical Research Council Integrative Epidemiology Unit at the University of Bristol MC_UU_00011/1&4. HH is an NIHR Senior Investigator and is funded by the NIHR University College London Hospitals Biomedical Research Centre, supported by Health Data Research UK (LOND1). The funding bodies do not play any roles in the design of the study and collection, analysis, and interpretation of data in writing the manuscript.
Publisher Copyright:
© 2021, The Author(s).
PY - 2021/12
Y1 - 2021/12
N2 - BACKGROUND: An Informatics Consult has been proposed in which clinicians request novel evidence from large scale health data resources, tailored to the treatment of a specific patient. However, the availability of such consultations is lacking. We seek to provide an Informatics Consult for a situation where a treatment indication and contraindication coexist in the same patient, i.e., anti-coagulation use for stroke prevention in a patient with both atrial fibrillation (AF) and liver cirrhosis.METHODS: We examined four sources of evidence for the effect of warfarin on stroke risk or all-cause mortality from: (1) randomised controlled trials (RCTs), (2) meta-analysis of prior observational studies, (3) trial emulation (using population electronic health records (N = 3,854,710) and (4) genetic evidence (Mendelian randomisation). We developed prototype forms to request an Informatics Consult and return of results in electronic health record systems.RESULTS: We found 0 RCT reports and 0 trials recruiting for patients with AF and cirrhosis. We found broad concordance across the three new sources of evidence we generated. Meta-analysis of prior observational studies showed that warfarin use was associated with lower stroke risk (hazard ratio [HR] = 0.71, CI 0.39-1.29). In a target trial emulation, warfarin was associated with lower all-cause mortality (HR = 0.61, CI 0.49-0.76) and ischaemic stroke (HR = 0.27, CI 0.08-0.91). Mendelian randomisation served as a drug target validation where we found that lower levels of vitamin K1 (warfarin is a vitamin K1 antagonist) are associated with lower stroke risk. A pilot survey with an independent sample of 34 clinicians revealed that 85% of clinicians found information on prognosis useful and that 79% thought that they should have access to the Informatics Consult as a service within their healthcare systems. We identified candidate steps for automation to scale evidence generation and to accelerate the return of results.CONCLUSION: We performed a proof-of-concept Informatics Consult for evidence generation, which may inform treatment decisions in situations where there is dearth of randomised trials. Patients are surprised to know that their clinicians are currently not able to learn in clinic from data on 'patients like me'. We identify the key challenges in offering such an Informatics Consult as a service.
AB - BACKGROUND: An Informatics Consult has been proposed in which clinicians request novel evidence from large scale health data resources, tailored to the treatment of a specific patient. However, the availability of such consultations is lacking. We seek to provide an Informatics Consult for a situation where a treatment indication and contraindication coexist in the same patient, i.e., anti-coagulation use for stroke prevention in a patient with both atrial fibrillation (AF) and liver cirrhosis.METHODS: We examined four sources of evidence for the effect of warfarin on stroke risk or all-cause mortality from: (1) randomised controlled trials (RCTs), (2) meta-analysis of prior observational studies, (3) trial emulation (using population electronic health records (N = 3,854,710) and (4) genetic evidence (Mendelian randomisation). We developed prototype forms to request an Informatics Consult and return of results in electronic health record systems.RESULTS: We found 0 RCT reports and 0 trials recruiting for patients with AF and cirrhosis. We found broad concordance across the three new sources of evidence we generated. Meta-analysis of prior observational studies showed that warfarin use was associated with lower stroke risk (hazard ratio [HR] = 0.71, CI 0.39-1.29). In a target trial emulation, warfarin was associated with lower all-cause mortality (HR = 0.61, CI 0.49-0.76) and ischaemic stroke (HR = 0.27, CI 0.08-0.91). Mendelian randomisation served as a drug target validation where we found that lower levels of vitamin K1 (warfarin is a vitamin K1 antagonist) are associated with lower stroke risk. A pilot survey with an independent sample of 34 clinicians revealed that 85% of clinicians found information on prognosis useful and that 79% thought that they should have access to the Informatics Consult as a service within their healthcare systems. We identified candidate steps for automation to scale evidence generation and to accelerate the return of results.CONCLUSION: We performed a proof-of-concept Informatics Consult for evidence generation, which may inform treatment decisions in situations where there is dearth of randomised trials. Patients are surprised to know that their clinicians are currently not able to learn in clinic from data on 'patients like me'. We identify the key challenges in offering such an Informatics Consult as a service.
KW - Anticoagulants/therapeutic use
KW - Atrial Fibrillation/drug therapy
KW - Humans
KW - Informatics
KW - Referral and Consultation
KW - Stroke/drug therapy
KW - Treatment Outcome
KW - Warfarin/therapeutic use
UR - http://www.scopus.com/inward/record.url?scp=85117320262&partnerID=8YFLogxK
U2 - 10.1186/s12911-021-01638-z
DO - 10.1186/s12911-021-01638-z
M3 - Review article
C2 - 34641870
SN - 1472-6947
VL - 21
SP - 1
EP - 14
JO - BMC Medical Informatics and Decision Making
JF - BMC Medical Informatics and Decision Making
IS - 1
M1 - 281
ER -