Evaluating Machine Learning Classifiers for Glaucoma Referral Decision Support in Primary Care Settings

Several artificial intelligence algorithms have been proposed to help diagnose glaucoma by analyzing the functional and/or structural changes in the eye. These algorithms require carefully curated datasets with access to ocular images. In the current study, we have modeled and evaluated classifiers to predict self-reported glaucoma using a single, easily obtained ocular feature (intraocular pressure (IOP)) and non-ocular features (age, gender, race, body mass index, systolic and diastolic blood pressure, and comorbidities). The classifiers were trained on publicly available data of 3,015 subjects without a glaucoma diagnosis at the time of enrollment. 337 subjects subsequently self-reported a glaucoma diagnosis in a span of 1-12 years after enrollment. The classifiers were evaluated on the ability to identify these subjects by only using their features recorded at the time of enrollment. Support vector machine, logistic regression, and adaptive boosting performed similarly on the dataset with F1 scores of 0.31, 0.30, and 0.28, respectively. Logistic regression had the highest sensitivity at 60% with a specificity of 69%. Predictive classifiers using primarily non-ocular features have the potential to be used for identifying suspected glaucoma in non-eye care settings, including primary care. Further research into finding additional features that improve the performance of predictive classifiers is warranted.

The establishment of a multi-source dataset of images on common oral lesions

Purpose To establish an oral lesion image database that could accelerate the development of artificial intelligence systems for lesion recognition and referral decision. Materials and Methods We describe the establishment of a multi-sourced image dataset through the development of a platform for the collection and annotation of images. Further, we developed a used-friendly tool (MeMoSA® ANNOTATE) for systematic annotation to collect a rich dataset associated with the images. We evaluated the sensitivities comparing referral decisions through the annotation process with the clinical diagnosis of the lesions to identify lesions that are challenging to identify through images alone. Results The image repository hosts 2474 images of oral lesions consisting of oral cancer, oral potentially malignant disorders, benign lesions, normal anatomical variants and normal mucosa that were collected through our platform, MeMoSA® UPLOAD. Over 800 images were annotated by seven oral medicine specialists on MeMoSA®ANNOTATE, to mark the lesion and to collect clinical labels. The sensitivity in referral decision for all lesions that required a referral for cancer management/surveillance was moderate to high depending on the type of lesion (64.3–100%). Conclusion This is the first description of a database with well-annotated oral lesions. This database has already been used for the development of AI algorithm for classifying oral lesions. Further expansion of this database could accelerate the improvement in AI algorithms that can facilitate the early detection of oral potentially malignant disorders and oral cancer.

Determinants of physician networks: an ethnographic study examining the processes that inform patterns of collaboration and referral decision-making among physicians

ObjectiveMost scholarly attention to studying collaborative ties in physician networks has been devoted to quantitatively analysing large, complex datasets. While valuable, such studies can reduce the dynamic and contextual complexities of physician collaborations to numerical values. Qualitative research strategies can contribute to our understanding by addressing the gaps left by more quantitative approaches. This study seeks to contribute to the literature that applies network science approaches to the context of healthcare delivery. We use qualitative, observational and interview, methods to pursue an in-depth, micro-level approach to the deeply social and discursive processes that influence patterns of collaboration and referral decision-making in physician networks.DesignQualitative methodologies that paired ethnographic field observations, semistructured interviews and document analysis were used. An inductive thematic analysis approach was used to analyse, identify and describe patterns in those data.SettingThis study took place in a high-volume cardiovascular department at a major academic medical centre (AMC) located in the Midwest region of the USA.ParticipantsPurposive and snowballing sampling were used to recruit study participants for both the observational and face-to-face in-depth interview portions of the study. In total, 25 clinicians and 43 patients participated in this study.ResultsTwo primary thematic categories were identified: (1) circumstances for external engagement; and (2) clinical conditions for engagement. Thematic subcategories included community engagement, scientific engagement, reputational value, experiential information, professional identity, self-awareness of competence, multidisciplinary programmes and situational factors.ConclusionThis study adds new contextual knowledge about the mechanisms that characterise referral decision-making processes and how these impact the meaning of physician relationships, organisation of healthcare delivery and the knowledge and beliefs that physicians have about their colleagues. This study highlights the nuances that influence how new collaborative networks are formed and maintained by detailing how relationships among physicians develop and evolve over time.

Self-referral of Chinese patients with advanced chronic kidney disease and treatment decision-making: A qualitative study

Rationale, aims, and objectives: Chinese patients with advanced chronic kidney disease (CKD), especially rural patients possibly occur self-referral behavior and then treatment decisions followed. It is unclear the relationship between self-referral and treatment decision-making. Thus, the aim of this study was to explore the perceptions and views of self-referral and treatment decision making among patients with advanced chronic kidney disease. Methods: We conducted semi-structured interviews with 26 patients with advanced kidney disease and 12 nephrologists. Interviews were conducted and analyzed thematically until reaching thematic saturation. Results: We identified three themes reflected: 1) self-referral decision making (self-referral motive, barrier to self-referral, seeking for self-referral information); 2) the views and experience of self-referral care (facilitating shared decision making, imposing psychological pressure, feeling about self-referral communication, challenge to staff-patient relationship); 3) treatment decision making (decisional awareness and roles, cost-benefit trade-off and redicision). Conclusions: Our study identified that organizational and demographic factors, self-referral motives worked together at the self-referral decision-making and treatment decision-making when advanced CKD patients facing with healthcare facilities and treatment options. Those findings suggest stakeholders should accelerate the popularization of peritoneal dialysis technology and establish the CKD screening and management systems. For self-referral patients with advanced CKD, our results suggest specialized dialysis transition care to improve quality of communication and soothe patients’ negative emotion.

The moderating role of perceived social risk in bank credit card referral programs

PurposeThe purpose of this paper is to investigate how the effects of referral rewards in referral reward programs (RRPs) are moderated through perceived social risk of a recommender.Design/methodology/approachA total of 717 consumers are accessed through Amazon's Mechanical Turk worker panel. The authors use t-test and analysis of variance to test the proposed hypotheses.FindingsThe findings show that consumers with high perceived social risk balance financial rewards with social risks, while low social risk consumers largely ignore these social risk elements surrounding a referral decision.Originality/valueThe inclusion of perceived social risk provides the opportunity to fully understand how a consumer goes about balancing social risk and referral rewards in making referral decisions. The concept of social risk has not been previously applied to this context.

Survival of altruistic gatekeepers: Kickbacks in medical markets

Patients often rely on the advice of their general practitioner (GP) to decide which treatment best fits their needs. Hospitals, in turn, might influence GPs’ referral decision through kickbacks. We present a model with a monopolistic hospital and competitive GPs who vary in the degree of altruism towards their heterogeneous patients and show that an equilibrium without crowding out exists that separates GPs into referrers and care providers. Naïve patients visit purely selfish (referring) GPs, while rational patients sort themselves between the two groups of GPs. Finally, we investigate the scope for regulation, including an optimal coinsurance rate.

Self-referral of Chinese patients with advanced chronic kidney disease and treatment decision-making: A qualitative study

Background: Chinese patients with advanced chronic kidney disease, especially rural patients possibly occur self-referral behavior and then treatment decisions followed. It is unclear the relationship between self-referral and treatment decision-making. Thus, the aim of this study was to explore HCPs and patient with advanced CKD perceptions of self-referral and treatment decision making. Methods: We conducted semi-structured interviews with 22 patients with advanced kidney disease and 8 health care professionals. Interviews were conducted and analyzed thematically until reaching thematic saturation. Results: We identified three themes reflected: 1) self-referral decision making (self-referral motive, barrier to self-referral, seeking for self-referral information); 2) the views and experience of self-referral care (facilitating shared decision making, imposing psychological pressure, feeling about self-referral communication, challenge to staff-patient relationship); 3) treatment decision making (decisional awareness and roles, cost-benefit trade-off and redicision). Conclusions: Our study identified that organizational and demographic factors, self-referral motives worked together at the self-referral decision-making and treatment decision-making when advanced CKD patients facing with healthcare facilities and treatment options. Those findings suggest stakeholders should accelerate the popularization of peritoneal dialysis technology and establish the CKD screening and management systems. For self-referral patients with advanced CKD, our results suggest specialized dialysis transition care to improve quality of communication and soothe patients’ negative emotion.

Emergency obstetric care among referrals in more than 24 weeks gestation at a tertiary care teaching institution in Kerala, India

Background: One of the biggest barriers confronting efforts to reduce maternal mortality through increased skilled delivery is access to emergency obstetric care. This study aimed to look into the profile of emergency obstetric referrals. Referral-decision interval, reasons and morbidities of referral were analysed and their neonatal outcomes assessed.Methods: This observational study reviewed 90 emergency obstetric referrals over 3 years from June 2013 to February 2016.Results: In-labour referrals constituted the majority of emergency obstetric referrals. Preterm obstetric referrals needed emergency interventions in view of medical/obstetric indications and it was statistically significant. Referral- decision and referral-arrival interval was significant in emergency group (p-value-0.001). Babies born to mothers who were obstetric emergency referrals had extended NICU stay (p-value-0.001). There was a maternal death and four near-misses in this research.Conclusions: Timely decisions taken during interhospital emergency referrals resulted in better perinatal outcomes by prompt maternal interventions.