Analyzing the "CareGap": assessing gaps in adherence to clinical guidelines in adult soft tissue sarcoma.

Clinical decision support systems (CDSSs) are gaining popularity as tools that assist physicians in optimizing medical care. These systems typically comply with evidence-based medicine and are designed with input from domain experts. Nonetheless, deviations from CDSS recommendations are abundant across a broad spectrum of disorders, raising the question as to why this phenomenon exists. Here, we analyze this gap in adherence to a clinical guidelines-based CDSS by examining the physician treatment decisions for 1329 adult soft tissue sarcoma patients in northern Italy using patient-specific parameters. Dubbing this analysis "CareGap", we find that deviations correlate strongly with certain disease features such as local versus metastatic clinical presentation. We also notice that deviations from the guideline-based CDSS suggestions occur more frequently for patients with shorter survival time. Such observations can direct physicians' attention to distinct patient cohorts that are prone to higher deviation levels from clinical practice guidelines. This illustrates the value of CareGap analysis in assessing quality of care for subsets of patients within a larger pathology.

Bringing research to the point of care: Hypergenes project study.

With advance of health information IT systems and increasing volumes of disparate biomedical information repositories, harvesting them for research purposes is becoming more difficult. This is partly due to the proprietary nature of the current systems, but also due to diverse requirements of different research paradigms. On the flip side, ever larger amounts of clinical and genomic data are currently accumulated in research projects. Tapping into these research silos would not only contribute to further research, but could help convey timely information to clinicians at the point of care. This paper presents RIMon - a portal-based infrastructure for information-intensive research cycle as used in the Hypergenes project, which aims at building a method to dissect complex genetic traits using essential hypertension as a disease model. RIMon allows users to: (a) collect data from points of care, (b) query and retrieve collected data for analysis, (c) query accumulated information and knowledge to construct disease models based on analysis results, and (d) to eventually make the research results readily available to the clinicians at the point of care. This translational cycle is demonstrated in the Hypergenes project along with a potential usage scenario.

Automatic detection of inconsistencies between free text and coded data in Sarcoma discharge letters.

Discordance between data stored in Electronic Health Records (EHR) may have a harmful effect on patient care. Automatic identification of such situations is an important yet challenging task, especially when the discordance involves information stored in free text fields. Here we present a method to automatically detect inconsistencies between data stored in free text and related coded fields. Using EHR data we train an ensemble of classifiers to predict the value of coded fields from the free text fields. Cases in which the classifiers predict with high confidence a code different from the clinicians' choice are marked as potential inconsistencies. Experimental results over discharge letters of sarcoma patients, verified by a domain expert, demonstrate the validity of our method.

Knowledge-analytics synergy in Clinical Decision Support.

Clinical Decision Support (CDS) systems hold tremendous potential for improving patient care. Most existing systems are knowledge-based tools that rely on relatively simple rules. More recent approaches rely on analytics techniques to automatically mine EHR data to reveal meaningful insights. Here, we propose the Knowledge-Analytics Synergy paradigm for CDS, in which we synergistically combine existing relevant knowledge with analytics applied to EHR data. We propose a framework for implementing such a paradigm and demonstrate its principles over real-world clinical and genomic data of hypertensive patients.

Evicase: an evidence-based case structuring approach for personalized healthcare.

The personalized medicine era stresses a growing need to combine evidence-based medicine with case based reasoning in order to improve the care process. To address this need we suggest a framework to generate multi-tiered statistical structures we call Evicases. Evicase integrates established medical evidence together with patient cases from the bedside. It then uses machine learning algorithms to produce statistical results and aggregators, weighted predictions, and appropriate recommendations. Designed as a stand-alone structure, Evicase can be used for a range of decision support applications including guideline adherence monitoring and personalized prognostic predictions.

Prognostic data-driven clinical decision support - formulation and implications.

Existing Clinical Decision Support Systems (CDSSs) typically rely on rule-based algorithms and focus on tasks like guidelines adherence and drug prescribing and monitoring. However, the increasing dominance of Electronic Health Record technologies and personalized medicine suggest great potential for prognostic data-driven CDSS. A major goal for such systems would be to accurately predict the outcome of patients' candidate treatments by statistical analysis of the clinical data stored at a Health Care Organization. We formally define the concepts involved in the development of such a system, highlight an inherent difficulty arising from bias in treatment allocation, and propose a general strategy to address this difficulty. Experiments over hypertension clinical data demonstrate the validity of our approach.

MEDAL: measuring of emergency departments' adaptive load.

We propose an innovative approach for measuring real-time operational load within emergency departments. Medical informatics, operations researchers, and other decision makers in the health care field have yet to come to an agreement regarding standardized matrices for measuring operational load within emergency departments. As a result, it is difficult to develop methods and approaches for reducing operational load. We propose a flexible framework based on neural networks. These networks can calculate user-tuned load value, based on a set of well-defined operational and clinical indicators. The operational load value is calculated by learning the weights of the raw operational indicators within a particular emergency department.

Driver gene classification reveals a substantial overrepresentation of tumor suppressors among very large chromatin-regulating proteins.

Compiling a comprehensive list of cancer driver genes is imperative for oncology diagnostics and drug development. While driver genes are typically discovered by analysis of tumor genomes, infrequently mutated driver genes often evade detection due to limited sample sizes. Here, we address sample size limitations by integrating tumor genomics data with a wide spectrum of gene-specific properties to search for rare drivers, functionally classify them, and detect features characteristic of driver genes. We show that our approach, CAnceR geNe similarity-based Annotator and Finder (CARNAF), enables detection of potentially novel drivers that eluded over a dozen pan-cancer/multi-tumor type studies. In particular, feature analysis reveals a highly concentrated pool of known and putative tumor suppressors among the <1% of genes that encode very large, chromatin-regulating proteins. Thus, our study highlights the need for deeper characterization of very large, epigenetic regulators in the context of cancer causality.

A Novel Computational Tool for Mining Real-Life Data: Application in the Metastatic Colorectal Cancer Care Setting.

BACKGROUND: Randomized clinical trials constitute the gold-standard for evaluating new anti-cancer therapies; however, real-life data are key in complementing clinically useful information. We developed a computational tool for real-life data analysis and applied it to the metastatic colorectal cancer (mCRC) setting. This tool addressed the impact of oncology/non-oncology parameters on treatment patterns and clinical outcomes. METHODS: The developed tool enables extraction of any computerized information including comorbidities and use of drugs (oncological/non-oncological) per individual HMO member. The study in which we evaluated this tool was a retrospective cohort study that included Maccabi Healthcare Services members with mCRC receiving bevacizumab with fluoropyrimidines (FP), FP plus oxaliplatin (FP-O), or FP plus irinotecan (FP-I) in the first-line between 9/2006 and 12/2013. RESULTS: The analysis included 753 patients of whom 15.4% underwent subsequent metastasectomy (the Surgery group). For the entire cohort, median overall survival (OS) was 20.5 months; in the Surgery group, median duration of bevacizumab-containing therapy (DOT) pre-surgery was 6.1 months; median OS was not reached. In the Non-surgery group, median OS and DOT were 18.7 and 11.4 months, respectively; no significant OS differences were noted between FP-O and FP-I, whereas FP use was associated with shorter OS (12.3 month; p <0.002; notably, these patients were older). Patients who received both FP-O- and FP-I-based regimens achieved numerically longer OS vs. those who received only one of these regimens (22.1 [19.9-24.0] vs. 18.9 [15.5-21.9] months). Among patients assessed for wild-type KRAS and treated with subsequent anti-EGFR agent, OS was 25.4 months and 18.7 months for 124 treated vs. 37 non-treated patients (non-significant). Cox analysis (controlling for age and gender) identified several non-oncology parameters associated with poorer clinical outcomes including concurrent use of diuretics and proton-pump inhibitors. CONCLUSIONS: Our tool provided insights that confirmed/complemented information gained from randomized-clinical trials. Prospective tool implementation is warranted.

Understanding Deviations from Clinical Practice Guidelines in Adult Soft Tissue Sarcoma.

In recent years we have witnessed the increasing adoption of clinical practice guidelines (CPGs) as decision support tools that guide medical treatment. As CPGs gain popularity, it has become evident that physicians frequently deviate from CPG recommendations, both erroneously and due to sound medical rationale. In this study we developed a methodology to computationally identify these deviation cases and understand their movitation. This was achieved using an integrated approach consisting of natural language processing, data modeling, and comparison methods to characterize deviations from CPG recommendations for 1431 adult soft tissue sarcoma patients. The results show that 48.9% of patient treatment programs deviate from CPG recommendations, with the largest deviation type being overtreatment, followed by differences in drug treatments. Interestingly, we identified over a dozen potential reasons for these deviations, with those directly related to the patients' cancer status being most abundant. These findings can be used to modify CPGs, increase adherence to CPG recommendations, reduce treatment cost, and potentially impact sarcoma care. Our approach can be applied to additional diseases that are subject to high deviation levels from CPGs.