The bird's-eye view: A data-driven approach to understanding patient journeys from claims data.

OBJECTIVE: In preference-sensitive conditions such as back pain, there can be high levels of variability in the trajectory of patient care. We sought to develop a methodology that extracts a realistic and comprehensive understanding of the patient journey using medical and pharmaceutical insurance claims data. MATERIALS AND METHODS: We processed a sample of 10 000 patient episodes (comprised of 113 215 back pain-related claims) into strings of characters, where each letter corresponds to a distinct encounter with the healthcare system. We customized the Levenshtein edit distance algorithm to evaluate the level of similarity between each pair of episodes based on both their content (types of events) and ordering (sequence of events). We then used clustering to extract the main variations of the patient journey. RESULTS: The algorithm resulted in 12 comprehensive and clinically distinct patterns (clusters) of patient journeys that represent the main ways patients are diagnosed and treated for back pain. We further characterized demographic and utilization metrics for each cluster and observed clear differentiation between the clusters in terms of both clinical content and patient characteristics. DISCUSSION: Despite being a complex and often noisy data source, administrative claims provide a unique longitudinal overview of patient care across multiple service providers and locations. This methodology leverages claims to capture a data-driven understanding of how patients traverse the healthcare system. CONCLUSIONS: When tailored to various conditions and patient settings, this methodology can provide accurate overviews of patient journeys and facilitate a shift toward high-quality practice patterns.

Outcome reporting bias in Cochrane systematic reviews: a cross-sectional analysis.

BACKGROUND: Discrepancies in outcome reporting (DOR) between protocol and published studies include inclusions of new outcomes, omission of prespecified outcomes, upgrade and downgrade of secondary and primary outcomes, and changes in definitions of prespecified outcomes. DOR can result in outcome reporting bias (ORB) when changes in outcomes occur after knowledge of results. This has potential to overestimate treatment effects and underestimate harms. This can also occur at the level of systematic reviews when changes in outcomes occur after knowledge of results of included studies. The prevalence of DOR and ORB in systematic reviews is unknown in systematic reviews published post-2007. OBJECTIVE: To estimate the prevalence of DOR and risk of ORB in all Cochrane reviews between the years 2007 and 2014. METHODS: A stratified random sampling approach was applied to collect a representative sample of Cochrane systematic reviews from each Cochrane review group. DOR was assessed by matching outcomes in each systematic review with their respective protocol. When DOR occurred, reviews were further assessed if there was a risk of ORB (unclear, low or high risk). We classified DOR as a high risk for ORB if the discrepancy occurred after knowledge of results in the systematic review. RESULTS: 150 of 350 (43%) review and protocol pairings contained DOR. When reviews were further scrutinised, 23% (35 of 150) of reviews with DOR contained a high risk of ORB, with changes being made after knowledge of results from individual trials. CONCLUSIONS: In our study, we identified just under a half of Cochrane reviews with at least one DOR. Of these, a fifth were at high risk of ORB. The presence of DOR and ORB in Cochrane reviews is of great concern; however, a solution is relatively simple. Authors are encouraged to be transparent where outcomes change and to describe the legitimacy of changing outcomes in order to prevent suspicion of bias.

Managing the incidence of selective reporting bias: a survey of Cochrane review groups.

BACKGROUND: Selective reporting bias (SRB), the incomplete publication of outcomes measured or of analyses performed in a study, may lead to the over- or underestimation of treatment effects or harms. Cochrane systematic reviews of interventions are required to assess the risk of SRB, achieved in part by applying the Cochrane risk of bias tool to each included randomised trial. The Cochrane Handbook outlines strategies for a comprehensive risk of bias assessment, but the extent to which these are followed by Cochrane review groups (CRGs) has not been assessed to date. The objective of this study was to determine the methods which CRGs require of their authors to address SRB within systematic reviews, and how SRB risk assessments are verified. METHODS: A cross-sectional survey was developed and distributed electronically to the 52 CRGs involved in intervention reviews. RESULTS: Responses from 42 CRGs show that the majority refer their authors to the Cochrane Handbook for specific instruction regarding assessments of SRB. The handbook strategies remain variably enforced, with 57 % (24/42) of CRGs not requiring review authors to search for included trial protocols and 31 % (13/42) not requiring that contact with individual study authors be attempted. Only half (48 %, 20/42) of the groups consistently verify review authors' assessments of the risk of SRB to ensure completeness. CONCLUSIONS: A range of practices are used by CRGs for addressing SRB, with many steps outlined in the Cochrane Handbook being encouraged but not required. The majority of CRGs do not consider their review authors to be sufficiently competent to assess for SRB, yet risk of bias assessments are not always verified by editors before publication. The implications of SRB may not be fully appreciated by all CRGs, and resolving the identified issues may require an approach targeting several steps in the systematic review process.

Paraganglioma of the Organ of Zuckerkandl.

Paragangliomas are tumors of the sympathetic and parasympathetic paraganglia. While most paraganglioma are of parasympathetic origin and present as benign palpable masses of the neck, sympathetic paraganglioma are often secretory, presenting with symptoms related to excess catecholamines. Such symptoms include hypertension, headache, palpitations, and diaphoresis. Most sympathetic paraganglioma form within the adrenal medulla, the largest sympathetic paraganglia, and are commonly known as pheochromocytomas. However, sympathetic paragangliomas may present extra-adrenally, carrying a significantly higher risk of malignancy. In this manuscript, we examine a case of a young man with an extra-adrenal sympathetic paraganglioma of the Organ of Zuckerkandl. Furthermore, we discuss appropriate diagnostic workup and treatment of pheochromocytomas and sympathetic paragangliomas.