Open AccessAn informatics consult approach for generating clinical evidence for treatment decisions
Author(s) -
Alvina Lai,
Wai Hoong Chang,
Constantinos Parisinos,
Michail Katsoulis,
Ruth Blackburn,
Anoop D Shah,
Vincent Nguyen,
Spiros Denaxas,
George Davey Smith,
Tom R. Gaunt,
Krishnarajah Nirantharakumar,
Murray P. Cox,
Dónall Forde,
Folkert W. Asselbergs,
Steve Harris,
Sylvia Richardson,
Reecha Sofat,
Richard Dobson,
Aroon D. Hingorani,
Riyaz Patel,
Jonathan A C Sterne,
Amitava Banerjee,
Alastair K.O. Denniston,
Simon Ball,
Neil J. Sebire,
Nigam H. Shah,
Graham Foster,
Bryan Williams,
Harry Hemingway
Publication year - 2021
Publication title -
bmc medical informatics and decision making
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.777
H-Index - 73
ISSN - 1472-6947
DOI - 10.1186/s12911-021-01638-z
Subject(s) - medicine , observational study , warfarin , stroke (engine) , health informatics , population , randomized controlled trial , contraindication , informatics , hazard ratio , intensive care medicine , emergency medicine , atrial fibrillation , confidence interval , alternative medicine , public health , pathology , mechanical engineering , electrical engineering , environmental health , engineering
Background An Informatics Consult has been proposed in which clinicians request novel evidence from large scale health data resources, tailored to the treatment of a specific patient. However, the availability of such consultations is lacking. We seek to provide an Informatics Consult for a situation where a treatment indication and contraindication coexist in the same patient, i.e., anti-coagulation use for stroke prevention in a patient with both atrial fibrillation (AF) and liver cirrhosis. Methods We examined four sources of evidence for the effect of warfarin on stroke risk or all-cause mortality from: (1) randomised controlled trials (RCTs), (2) meta-analysis of prior observational studies, (3) trial emulation (using population electronic health records (N = 3,854,710) and (4) genetic evidence (Mendelian randomisation). We developed prototype forms to request an Informatics Consult and return of results in electronic health record systems. Results We found 0 RCT reports and 0 trials recruiting for patients with AF and cirrhosis. We found broad concordance across the three new sources of evidence we generated. Meta-analysis of prior observational studies showed that warfarin use was associated with lower stroke risk (hazard ratio [HR] = 0.71, CI 0.39–1.29). In a target trial emulation, warfarin was associated with lower all-cause mortality (HR = 0.61, CI 0.49–0.76) and ischaemic stroke (HR = 0.27, CI 0.08–0.91). Mendelian randomisation served as a drug target validation where we found that lower levels of vitamin K1 (warfarin is a vitamin K1 antagonist) are associated with lower stroke risk. A pilot survey with an independent sample of 34 clinicians revealed that 85% of clinicians found information on prognosis useful and that 79% thought that they should have access to the Informatics Consult as a service within their healthcare systems. We identified candidate steps for automation to scale evidence generation and to accelerate the return of results. Conclusion We performed a proof-of-concept Informatics Consult for evidence generation, which may inform treatment decisions in situations where there is dearth of randomised trials. Patients are surprised to know that their clinicians are currently not able to learn in clinic from data on ‘patients like me’. We identify the key challenges in offering such an Informatics Consult as a service. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-021-01638-z.