Where to look for the most frequent biases?

Jager, Kitty J.; Tripepi, Giovanni; Chesnaye, Nicholas C.; Dekker, Friedo W.; Zoccali, Carmine; Stel, Vianda S.

doi:10.1111/nep.13706

Cited by 77 publications

(59 citation statements)

References 24 publications

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“…Given retrospective studies may introduce sampling bias 53 , we included the entire population, not a sample. The results of the NLP algorithm were limited for the first year of entry into VHA healthcare for years 2012–2017, which might underestimate firearm documentation.…”

Section: Limitationsmentioning

confidence: 99%

Documentation of Screening for Firearm Access by Healthcare Providers in the Veterans Healthcare System: A Retrospective Study

Brandt¹,

Workman²,

Farmer³

et al. 2021

WJEM

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Introduction Presence of a firearm is associated with increased risk of violence and suicide. United States military veterans are at disproportionate risk of suicide. Routine healthcare provider screening of firearm access may prompt counseling on safe storage and handling of firearms. The objective of this study was to determine the frequency with which Veterans Health Administration (VHA) healthcare providers document firearm access in electronic health record (EHR) clinical notes, and whether this varied by patient characteristics. Methods The study sample is a post-9–11 cohort of veterans in their first year of VHA care, with at least one outpatient care visit between 2012–2017 (N = 762,953). Demographic data, veteran military service characteristics, and clinical comorbidities were obtained from VHA EHR. We extracted clinical notes for outpatient visits to primary, urgent, or emergency clinics (total 105,316,004). Natural language processing and machine learning (ML) approaches were used to identify documentation of firearm access. A taxonomy of firearm terms was identified and manually annotated with text anchored by these terms, and then trained the ML algorithm. The random-forest algorithm achieved 81.9% accuracy in identifying documentation of firearm access. Results The proportion of patients with EHR-documented access to one or more firearms during their first year of care in the VHA was relatively low and varied by patient characteristics. Men had significantly higher documentation of firearms than women (9.8% vs 7.1%; P < .001) and veterans >50 years old had the lowest (6.5%). Among veterans with any firearm term present, only 24.4% were classified as positive for access to a firearm (24.7% of men and 20.9% of women). Conclusion Natural language processing can identify documentation of access to firearms in clinical notes with acceptable accuracy, but there is a need for investigation into facilitators and barriers for providers and veterans to improve a systemwide process of firearm access screening. Screening, regardless of race/ethnicity, gender, and age, provides additional opportunities to protect veterans from self-harm and violence.

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Section: Limitationsmentioning

confidence: 99%

Documentation of Screening for Firearm Access by Healthcare Providers in the Veterans Healthcare System: A Retrospective Study

Brandt¹,

Workman²,

Farmer³

et al. 2021

WJEM

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“…aims to prevent confounding by indication, also known as selection by prognosis. 7 Confounding by indication usually occurs when clinicians decide who will receive the intervention, as their opinion about the patient's prognosis guides their decision on treatment allocation. 8 For example, patients with more severe symptoms usually receive treatment that is more intensive.…”

Section: Summary At a Glancementioning

confidence: 99%

“…This occurs when the study sample or the groups resulting from randomization are not representative of the source population they were drawn from. 7,11 This can be due to strict inclusion criteria. RCTs outside the field of nephrology often routinely exclude CKD patients and therefore the generalizability of their results to patients with CKD may be questionable.…”

Section: Limitations Of Rctmentioning

confidence: 99%

Evidence‐based medicine—When observational studies are better than randomized controlled trials

et al. 2020

Self Cite

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In evidence‐based medicine, clinical research questions may be addressed by different study designs. This article describes when randomized controlled trials (RCT) are needed and when observational studies are more suitable. According to the Centre for Evidence‐Based Medicine, study designs can be divided into analytic and non‐analytic (descriptive) study designs. Analytic studies aim to quantify the association of an intervention (eg, treatment) or a naturally occurring exposure with an outcome. They can be subdivided into experimental (ie, RCT) and observational studies. The RCT is the best study design to evaluate the intended effect of an intervention, because the randomization procedure breaks the link between the allocation of the intervention and patient prognosis. If the randomization of the intervention or exposure is not possible, one needs to depend on observational analytic studies, but these studies usually suffer from bias and confounding. If the study focuses on unintended effects of interventions (ie, effects of an intervention that are not intended or foreseen), observational analytic studies are the most suitable study designs, provided that there is no link between the allocation of the intervention and the unintended effect. Furthermore, non‐analytic studies (ie, descriptive studies) also rely on observational study designs. In summary, RCTs and observational study designs are inherently different, and depending on the study aim, they each have their own strengths and weaknesses.

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“…Two of the previous publications were compilations of published case reports (8,11), and the other two were based on questionnaires sent out to hematologists (10,12). Publication and recall biases are likely to have influenced patient selection (18). The present study was based on documentation of our patients' findings in the International PNH Registry.…”

Section: Discussionmentioning

confidence: 99%

Pregnancy in Classical Paroxysmal Nocturnal Hemoglobinuria and Aplastic Anemia–Paroxysmal Nocturnal Hemoglobinuria: A High-Risk Constellation

et al. 2020

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Pregnancies in paroxysmal nocturnal hemoglobinuria (PNH) are associated with increased morbidity and mortality. Retrospective studies suggest that outcome has improved with the advent of the complement inhibitor eculizumab. To substantiate this assumption we analyzed the data from patients treated in our department since 2009. All patients were included in the International PNH registry and followed prospectively. We identified 16 pregnancies in 9 patients with classical PNH, and two pregnancies in two patients with aplastic anemia (AA)-PNH. In classical PNH, 13 pregnancies were supported by eculizumab. Breakthrough hemolysis occurred in six pregnancies, necessitating an increase in the biweekly eculizumab dose from 900 mg to 1,200-1,800 mg. Red blood cell transfusions were given in six and platelet transfusions in two pregnancies. A Budd-Chiari syndrome and cholecystitis complicated the course of two pregnancies. Four of 13 pregnancies supported by eculizumab ended in spontaneous abortion or stillbirth, and one was prematurely terminated because of fetal trisomy 21. None of the three pregnancies not supported by eculizumab had a successful outcome. Half the deliveries were preterm. None of the patients died, and, in all but one patient, the post-partum period was uneventful. Both pregnancies in patients with AA-PNH took a favorable course. Our results confirm low maternal mortality and frequent breakthrough hemolysis in pregnant PNH patients receiving eculizumab. Fetal mortality and the rate of preterm delivery were higher than reported previously, possibly related to the use of registry data that are likely to reduce the risk of publication and recall biases.

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Where to look for the most frequent biases?

Cited by 77 publications

References 24 publications

Documentation of Screening for Firearm Access by Healthcare Providers in the Veterans Healthcare System: A Retrospective Study

Documentation of Screening for Firearm Access by Healthcare Providers in the Veterans Healthcare System: A Retrospective Study

Evidence‐based medicine—When observational studies are better than randomized controlled trials

Pregnancy in Classical Paroxysmal Nocturnal Hemoglobinuria and Aplastic Anemia–Paroxysmal Nocturnal Hemoglobinuria: A High-Risk Constellation

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