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Abstract: Treatment assignment in observational studies is complex and can be influenced by many factors that include patient characteristics, physician practices, and health care systems. These influences can present heterogeneity or clustering effects in the treatment assignment. If those heterogeneity or clustering effects are not appropriately adjusted, the estimated treatment effect may be severely biased. Through a series of models that mimic various level of heterogeneity in treatment assignment in observational studies, we evaluate, through simulation study, the performance of several estimators under the impact of different types of heterogeneity. These estimators include propensity score stratification, propensity score inverse probability weighting, propensity score regression and the partial least squares method. Our results suggest that the partial least squares method is most robust while the dummy variable adjustment method in propensity regression also performs fairly consistently. We use the proposed method to analyze a data set from the German Breast Cancer Study Group study. Keywords: Heterogeneity, partial least squares, propensity score.Download Full Article |
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Abstract: Purpose:To show how a private eye care center in Turkey initiated Six Sigma principles to reduce the number of complications encounteredduring and after femtosecondlaser-assisted LASIK (IntraLase) surgeries. Method: Data were collected for five years. To analyse the complications among 448 surgeries, main tools of Six Sigma’s Define-Measure-Analyze-Improve-Control (DMAIC) improvement cycle such as SIPOC table, Fishbone Diagram and, Failure, Mode and Effect Analysis were implemented. Sources and root causes of seventeen types of complications were identified and reported. Results: For a successful IntraLase surgery, experience of the refractive surgeon, patient’s anatomy and calibration of laser power were determined to be the “critical few” factors whereas, patient’s psychology, sterilization and hygiene, and suction-ring’s pressure were found to be the “trivial many” factors. The most frequently occurring complication was found to be subconjunctival haemorrhage. Conclusion:The process sigma level of the process was measured to be 3.3547. The surgical team concluded that sixteen complications (out of seventeen) should be significantly reduced by taking the necessary preventive measures. Keywords: Six Sigma, Ophthalmology, IntraLase Surgery, Complications. |
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Abstract: Diabetic nephropathy (DN) is a generic term referring to deleterious effect on renal structure and/or function caused by diabetes mellitus. World Health Organization estimates that diabetes affects more than 170 million people worldwide and this number may rise to 370 million by 2030. The rate of rise in Serum Creatinine (SrCr) is a well-accepted marker for the progression of Diabetic Nephropathy (DN). In this paper, survival functions of type 2 diabetic patients with renal complication are estimated. Firstly, most appropriate distribution for duration of diabetes is selected through minimum Akaike Information Criterion value, Gamma distribution is found to be an appropriate model. Secondly, the parameters estimates of the selected distribution are obtained by fitting a Generalized Linear Model (GLM), with duration of diabetes as the response variable and predictors as SrCr and number of successes (number of times SrCr values exceed its normal range (1.4 mg/dl)). These covariates are linked with the response variable using two different link functions namely log and reciprocal links. Using the estimates of parameters obtained from generalized linear regression analysis, survival functions for different durations under both the links are estimated. Further we compared the estimated survival functions under both the links with Kaplan Meier (KM) estimates graphically. Findings suggested that the Kaplan Meier estimate and Gamma distribution under both links provided a close estimate of survival functions. Median survival time is 16.3 years and 16.8 years obtained from KM method and Gamma GLM respectively. Keywords: Akaike Information Criterion, Gamma distribution, generalized linear models, Kaplan Meier method, log link, reciprocal link, serum creatinine, survival distributions.Download Full Article |
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Abstract: The purpose of this study was to develop an age scale for assessing activities of daily living (ADL) among community-dwelling adults aged 75 years or older. Participants were 1006 older Japanese: 312 men (79.6 ± 4.3 years) and 694 women, (79.9 ± 5.5 years). Participants completed a battery of 8 performance tests related to ADL and the Barthel index (BI) questionnaire. Spearman rank-order correlation analysis was applied to obtain the correlation of the 8 ADL performance tests with the total BI score. Three variables were high rank-order correlated with BI, secondly those items were subjected to the principal component analysis. The weighted combination of the principal component scores was summed. Resulting in an ADL score (ADLS), women = 0.075 X1 – 0.082 X2 – 0.063 X3 + 0.124, men = 0.051 X1 – 0.105 X2 – 0.099 X3 + 0.249, where X1 = hand-grip strength, X2 = timed up and go, X3 = five-chair sit to stand. Individual ADLS was transformed to an ADL age scale (ADLA). The estimation was – 5.493 ADLS + 79.90 for women, and – 4.272 ADLS + 79.57 for men. Due to the distortion at the regression edges, the equation was corrected as suggested by Dubina et al. ADLA women after correction was = 0.447 (chronological age: CA) – 5.49ADLS + 44.17, men = 0.519CA – 4.27ADLS + 38.26. ADLA can be used to identify or monitor the characteristics of the ADL levels of physical abilities in older Japanese aged 75 years or older. Keywords: Age assessment, principal component analysis, physical function, 75 years and older, older Japanese.Download Full Article |
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Abstract: Longitudinal research on older persons in the medical intensive care unit (MICU) is often complicated by the time-dependent confounding of concurrently administered interventions such as medications and intubation. Such temporal confounding can bias the respective longitudinal associations between concurrently administered treatments and a longitudinal outcome such as delirium. Although marginal structural models address time-dependent confounding, their application is non-trivial and preferably justified by empirical evidence. Using data from a longitudinal study of older persons in the MICU, we constructed a plausibility score from 0 – 10 where higher values indicate higher plausibility of time-dependent confounding of the association between a time-varying explanatory variable and an outcome. Based on longitudinal plots, measures of correlation, and longitudinal regression, the plausibility scores were compared to the differences in estimates obtained with non-weighted and marginal structural models of next day delirium. The plausibility scores of the three possible pairings of daily doses of fentanyl, haloperidol, and intubation indicated the following: low plausibility for haloperidol and intubation, moderate plausibility for fentanyl and haloperidol, and high plausibility for fentanyl and intubation. Comparing multivariable models of next day delirium with and without adjustment for time-dependent confounding, only intubation’s association changed substantively. In our observational study of older persons in the MICU, the plausibility scores were generally reflective of the observed differences between coefficients estimated from non-weighted and marginal structural models. Keywords: Time dependent confounding, cross-correlation, longitudinal, marginal structural model, ICU.Download Full Article |