Process mining for healthcare decision analytics with micro-costing estimations.

Managing constrained healthcare resources is an important and inescapable role of healthcare decision makers. Allocative decisions are based on downstream consequences of changes to care processes: judging whether the costs involved are offset by the magnitude of the consequences, and therefore whether the change represents value for money. Process mining techniques can inform such decisions by quantitatively discovering, comparing and detailing care processes using recorded data, however the scope of techniques typically excludes anything 'after-the-process' i.e., their accumulated costs and resulting consequences. Cost considerations are increasingly incorporated into process mining techniques, but the majority of healthcare costs for service and overhead components are commonly apportioned and recorded at the patient (trace) level, hiding event level detail. Within decision-analysis, event-driven and individual-level simulation models are sometimes used to forecast the expected downstream consequences of process changes, but are expensive to manually operationalise. In this paper, we address both of these gaps within and between process mining and decision analytics, by better linking them together. In particular, we introduce a new type of process model containing trace data that can be used in individual-level or cohort-level decision-analytical model building. Furthermore, we enhance these models with process-based micro-costing estimations. The approach was evaluated with health economics and decision modelling experts, with discussion centred on how the outputs could be used, and how similar information would otherwise be compiled.

Three novel bird strike likelihood modelling techniques: The case of Brisbane Airport, Australia.

The risk posed by wildlife to air transportation is of great concern worldwide. In Australia alone, 17,336 bird-strike incidents and 401 animal-strike incidents were reported to the Air Transport Safety Board (ATSB) in the period 2010-2019. Moreover, when collisions do occur, the impact can be catastrophic (loss of life, loss of aircraft) and involve significant cost to the affected airline and airport operator (estimated at globally US$1.2 billion per year). On the other side of the coin, civil aviation, and airport operations have significantly affected bird populations. There has been an increasing number of bird strikes, generally fatal to individual birds involved, reported worldwide (annual average of 12,219 reported strikes between 2008-2015 being nearly double the annual average of 6,702 strikes reported 2001-2007) (ICAO, 2018). Airport operations including construction of airport infrastructure, frequent take-offs and landings, airport noise and lights, and wildlife hazard management practices aimed at reducing risk of birdstrike, e.g., spraying to remove weeds and invertebrates, drainage, and even direct killing of individual hazard species, may result in habitat fragmentation, population decline, and rare bird extinction adjacent to airports (Kelly T, 2006; Zhao B, 2019; Steele WK, 2021). Nevertheless, there remains an imperative to continually improve wildlife hazard management methods and strategies so as to reduce the risk to aircraft and to bird populations. Current approved wildlife risk assessment techniques in Australia are limited to ranking of identified hazard species, i.e., are 'static' and, as such, do not provide a day-to-day risk/collision likelihood. The purpose of this study is to move towards a dynamic, evidence-based risk assessment model of wildlife hazards at airports. Ideally, such a model should be sufficiently sensitive and responsive to changing environmental conditions to be able to inform both short and longer term risk mitigation decisions. Challenges include the identification and quantification of contributory risk factors, and the selection and configuration of modelling technique(s) that meet the aforementioned requirements. In this article we focus on likelihood of bird strike and introduce three distinct, but complementary, assessment techniques, i.e., Algebraic, Bayesian, and Clustering (ABC) for measuring the likelihood of bird strike in the face of constantly changing environmental conditions. The ABC techniques are evaluated using environment and wildlife observations routinely collected by the Brisbane Airport Corporation (BAC) wildlife hazard management team. Results indicate that each of the techniques meet the requirements of providing dynamic, realistic collision risks in the face of changing environmental conditions.

xPM: Enhancing exogenous data visibility.

Process mining is a well-established discipline with applications in many industry sectors, including healthcare. To date, few publications have considered the context in which processes execute. Little consideration has been given as to how contextual data (exogenous data) can be practically included for process mining analysis, beyond including case or event attributes in a typical event log. We show that the combination of process data (endogenous) and exogenous data can generate insights not possible with standard process mining techniques. Our contributions are a framework for process mining with exogenous data and new analyses, where exogenous data and process behaviour are linked to process outcomes. Our new analyses visualise exogenous data, highlighting the trends and variations, to show where overlaps or distinctions exist between outcomes. We applied our analyses in a healthcare setting and show that clinicians could extract insights about differences in patients' vital signs (exogenous data) relevant to clinical outcomes. We present two evaluations, using a publicly available data set, MIMIC-III, to demonstrate the applicability of our analysis. These evaluations show that process mining can integrate large amounts of physiologic data and interventions, with resulting discrimination and conversion to clinically interpretable information.

Music therapy was noninferior to verbal standard treatment of traumatized refugees in mental health care: Results from a randomized clinical trial.

Background: Many people with refugee backgrounds suffer from trauma-related complex social and psychological problems, and compliance with standard psychological treatment tends to be low. More culturally adaptable treatment options seem to be needed. Objective: We aimed to investigate whether the music therapy method: 'trauma-focused music and imagery' (tr-MI), characterized by a particular focus on arousal and affect regulation, would be equally effective as the standard psychological talk therapies for ameliorating trauma symptoms in Danish refugees. Methods: A pragmatic, noninferiority, parallel, randomized controlled trial with six-month follow-up was carried out at three clinics for refugees in the public mental health services of the Psychiatry (DK). Seventy-four adults diagnosed with posttraumatic stress disorder (PTSD) were allocated to either music therapy sessions (tr-MI, N = 39) or psychological treatment as usual (TAU, N = 35). Western classical music, new age music, and music from the participants' own national culture were used to generate inner imagery, following a phased treatment protocol. Homework entailed listening to music. The primary outcome was the measurement of trauma symptoms by the Harvard Trauma Questionnaire, section IV (HTQ-IV); secondary measures were somatoform and psychoform dissociation (DSS-20), SDQ-20), attachment (RAAS), and well-being (WHO-5). Treatment effects reflected by primary and secondary measures were estimated using linear mixed models. Results: Tr-MI was noninferior to TAU (mean difference at follow-up HTQ-IV: 0.14, CI (-0.10; 0.38), with a - 0.3 noninferiority margin). A high dropout rate of 40% occurred in the TAU group, compared to 5% in the music therapy group. Secondary measures generated small to medium effect sizes in both groups, with significant medium effect sizes for well-being and psychoform dissociation at follow-up in tr-MI. Conclusions: Tr-MI is an innovative form of psychological treatment in refugee mental health services. Trials comparing music therapy to standardized therapy are needed to substantiate the evidence base for tr-MI therapy.

Antecedentes: Muchas personas con antecedente de condición de refugiadas sufren complejos problemas psicológicos y sociales relacionados con el trauma, y el cumplimiento con el tratamiento psicológico estándar tiende a ser bajo. Parecen ser necesarias opciones de tratamiento más culturalmente adaptadas.Objetivo: Apuntamos a investigar si el método de músico-terapia: 'música e imaginería focalizada en el trauma' (tr-MI), caracterizado por un enfoque particular en el nivel de alerta y regulación emocional, podría ser igualmente efectivo como las terapias psicológicas de conversación para aliviar síntomas de trauma en refugiados daneses.Métodos: Se llevó a cabo un ensayo clínico aleatorizado controlado, pragmático, de no inferioridad, paralelo, con seis meses de seguimiento en tres clínicas para refugiados en servicios públicos de salud mental de Psiquiatría en Dinamarca. Setenta y cuatro adultos diagnosticados con Trastorno de estrés postraumático (TEPT) fueron asignados a sesiones de músico-terapia (tr-MI, N = 39) o al tratamiento psicológico de costumbre (TAU, N = 35). Se utilizó música clásica occidental, música new age, y música de la propia cultura nacional de los participantes, para generar imaginería interior, siguiendo un protocolo de tratamiento por fases. La tarea implicaba escuchar música. El resultado principal fue la medición de síntomas de trauma a través del Cuestionario de Trauma de Harvard, sección IV (HTQ-IV); las mediciones secundarias fueron disociación somatomorfa y psicomorfa (DSS-20, SDQ-20), apego (RAAS), y bienestar (WHO-5). Los efectos del tratamiento reflejados por mediciones primarias y secundarias fueron estimados usando modelos lineales mixtos.Resultados: Tr-MI no fue inferior a TAU (diferencia promedio al seguimiento HTQ-IV: 0.14, IC −0.10; 0.38), con un margen de no-inferioridad de −0.3). Una alta tasa de deserción de un 40% ocurrió en el grupo TAU, comparado con un 5% en el grupo de músico-terapia. Las mediciones secundarias generaron tamaños de efecto pequeños a medianos en ambos grupos, con un tamaño del efecto mediano significativo para bienestar y disociación psicomorfa al seguimiento en tr-MI.Conclusiones: Tr-MI es una forma innovadora de tratamiento psicológico en servicios de salud mental para refugiados. Se necesitan ensayos comparando músico-terapia con terapia estandarizada para probar la base de evidencia para la terapia tr-MI.

Trauma by-pass guideline: A data-driven conformance analysis for road trauma cases in Queensland.

OBJECTIVE: Study objectives were to (i) develop and test a whole-of-system method for identifying patients who meet a major trauma by-pass guideline definition; (ii) apply this method to assess conformance to the current 2006 guideline for a road trauma cohort; and (iii) leverage relevant findings to propose improvements to the guideline. METHODS: Retrospective analysis of existing, routinely collected data relating to Queensland road trauma patients July 2015 to June 2017. Data from ambulance, aero-medical retrievals, ED, hospital and death registers were linked and used for analysis. Processes of care measured included: frequency of pre-hospital triage criteria, distribution of destination (trauma service level), compliance with guideline (recommended vs actual destination), trauma service level by threat to life (injury severity) (all modes of transport and aero-medical in particular), proportion of patients requiring only ED, transport pathway (direct vs inter-hospital transfer). RESULTS: 3847 cases were identified from data as meeting criteria for major trauma by-pass. The top five most frequently used criteria for qualifying patients as meeting the major trauma by-pass guideline were pulse rate, vehicle rollover, possible spinal cord injury, respiration rate and entrapment. The study demonstrates a 65% conformance to the clinical guideline. Overtriaged patients (transported to higher trauma service than recommended) generally reveal International Classification of Disease Injury Severity Score representing a high threat to life. CONCLUSION: Overall, the present study found good conformance, with overtriage rate as expected by clinicians. It is recommended to include data values to capture paramedics assessment of trauma level to enable more accurate assessment of conformance to guideline and future revision of the thresholds.

Feasibility of Short-Term PrEP Uptake for Men Who Have Sex With Men With Episodic Periods of Increased HIV Risk.

BACKGROUND: Pre-exposure prophylaxis (PrEP) with emtricitabine/tenofovir disoproxil fumarate is efficacious in reducing HIV acquisition. For some gay, bisexual, and other men who have sex with men (MSM), daily ongoing PrEP may be unsuitable for use as a long-term prevention strategy because of episodic risk, cost issues, or concerns about the biological consequences of medication. SETTING: This study evaluated the feasibility of short-term, fixed-interval episodic PrEP (Epi-PrEP) for use among vacationing MSM. We describe the feasibility of implementing a clinic-based Epi-PrEP pilot program for 48 MSM who reported occasional condomless sex and anticipated a defined high-risk time. METHODS: This was a nonrandomized naturalistic study of an observational clinical intervention. The primary outcome assessed was adherence, as measured by self-report and plasma tenofovir levels. RESULTS: Of 54 MSM who enrolled in the study, 48 completed the 3-month visit. The majority (93.7%) had tenofovir concentrations consistent with daily use on returning from vacation. Almost 3/4 reported condomless sex during vacation, and about 1/3 reported recreational drug use. During the 3-month follow-up, 1 participant had become HIV-infected because of a lapse in continued access to the PrEP after study. Although adverse events were common, none were serious. More than 70% of participants indicated an interest in daily ongoing PrEP use. CONCLUSIONS: Epi-PrEP was well tolerated by at risk MSM in this study, with high levels of medication adherence. Many participants felt the experience of initiating PrEP while on vacation could be a means for transition to long-term PrEP use.

A Comparative Process Mining Analysis of Road Trauma Patient Pathways.

In this paper we report on key findings and lessons from a process mining case study conducted to analyse transport pathways discovered across the time-critical phase of pre-hospital care for persons involved in road traffic crashes in Queensland (Australia). In this study, a case is defined as being an individual patient's journey from roadside to definitive care. We describe challenges in constructing an event log from source data provided by emergency services and hospitals, including record linkage (no standard patient identifier), and constructing a unified view of response, retrieval, transport and pre-hospital care from interleaving processes of the individual service providers. We analyse three separate cohorts of patients according to their degree of interaction with Queensland Health's hospital system (C1:no transport required, C2:transported but no Queensland Health hospital, C3:transported and hospitalisation). Variant analysis and subsequent process modelling show high levels of variance in each cohort resulting from a combination of data collection, data linkage and actual differences in process execution. For Cohort 3, automated process modelling generated 'spaghetti' models. Expert-guided editing resulted in readable models with acceptable fitness, which were used for process analysis. We also conduct a comparative performance analysis of transport segment based on hospital `remoteness'. With regard to the field of process mining, we reach various conclusions including (i) in a complex domain, the current crop of automated process algorithms do not generate readable models, however, (ii) such models provide a starting point for expert-guided editing of models (where the tool allows) which can yield models that have acceptable quality and are readable by domain experts, (iii) process improvement opportunities were largely suggested by domain experts (after reviewing analysis results) rather than being directly derived by process mining tools, meaning that the field needs to become more prescriptive (automated derivation of improvement opportunities).

Privacy-Preserving Process Mining in Healthcare.

Process mining has been successfully applied in the healthcare domain and has helped touncover various insights for improving healthcare processes. While the benefits of process miningare widely acknowledged, many people rightfully have concerns about irresponsible uses of personaldata. Healthcare information systems contain highly sensitive information and healthcare regulationsoften require protection of data privacy. The need to comply with strict privacy requirements mayresult in a decreased data utility for analysis. Until recently, data privacy issues did not get muchattention in the process mining community; however, several privacy-preserving data transformationtechniques have been proposed in the data mining community. Many similarities between datamining and process mining exist, but there are key differences that make privacy-preserving datamining techniques unsuitable to anonymise process data (without adaptations). In this article, weanalyse data privacy and utility requirements for healthcare process data and assess the suitabilityof privacy-preserving data transformation methods to anonymise healthcare data. We demonstratehow some of these anonymisation methods affect various process mining results using three publiclyavailable healthcare event logs. We describe a framework for privacy-preserving process mining thatcan support healthcare process mining analyses. We also advocate the recording of privacy metadatato capture information about privacy-preserving transformations performed on an event log.

Non-vitamin K antagonist oral anticoagulants (NOACs) for thromboembolic prevention, are they safe in congenital heart disease? Results of a worldwide study.

BACKGROUND: Current guidelines consider vitamin K antagonists (VKA) the oral anticoagulant agents of choice in adults with atrial arrhythmias (AA) and moderate or complex forms of congenital heart disease, significant valvular lesions, or bioprosthetic valves, pending safety data on non-VKA oral anticoagulants (NOACs). Therefore, the international NOTE registry was initiated to assess safety, change in adherence and quality of life (QoL) associated with NOACs in adults with congenital heart disease (ACHD). METHODS: An international multicenter prospective study of NOACs in ACHD was established. Follow-up occurred at 6 months and yearly thereafter. Primary endpoints were thromboembolism and major bleeding. Secondary endpoints included minor bleeding, change in therapy adherence (≥80% medication refill rate, ≥6 out of 8 on Morisky-8 questionnaire) and QoL (SF-36 questionnaire). RESULTS: In total, 530 ACHD patients (mean age 47 SD 15 years; 55% male) with predominantly moderate or complex defects (85%), significant valvular lesions (46%) and/or bioprosthetic valves (11%) using NOACs (rivaroxaban 43%; apixaban 39%; dabigatran 12%; edoxaban 7%) were enrolled. The most common indication was AA (91%). Over a median follow-up of 1.0 [IQR 0.0-2.0] year, thromboembolic event rate was 1.0% [95%CI 0.4-2.0] (n = 6) per year, with 1.1% [95%CI 0.5-2.2] (n = 7) annualized rate of major bleeding and 6.3% [95%CI 4.5-8.5] (n = 37) annualized rate of minor bleeding. Adherence was sufficient during 2 years follow-up in 80-93% of patients. At 1-year follow-up, among the subset of previous VKA-users who completed the survey (n = 33), QoL improved in 6 out of 8 domains (p ≪ 0.05). CONCLUSIONS: Initial results from our worldwide prospective study suggest that NOACs are safe and may be effective for thromboembolic prevention in adults with heterogeneous forms of congenital heart disease.

Leveraging Data Quality to Better Prepare for Process Mining: An Approach Illustrated Through Analysing Road Trauma Pre-Hospital Retrieval and Transport Processes in Queensland.

While noting the importance of data quality, existing process mining methodologies (i) do not provide details on how to assess the quality of event data (ii) do not consider how the identification of data quality issues can be exploited in the planning, data extraction and log building phases of any process mining analysis, (iii) do not highlight potential impacts of poor quality data on different types of process analyses. As our key contribution, we develop a process-centric, data quality-driven approach to preparing for a process mining analysis which can be applied to any existing process mining methodology. Our approach, adapted from elements of the well known CRISP-DM data mining methodology, includes conceptual data modeling, quality assessment at both attribute and event level, and trial discovery and conformance to develop understanding of system processes and data properties to inform data extraction. We illustrate our approach in a case study involving the Queensland Ambulance Service (QAS) and Retrieval Services Queensland (RSQ). We describe the detailed preparation for a process mining analysis of retrieval and transport processes (ground and aero-medical) for road-trauma patients in Queensland. Sample datasets obtained from QAS and RSQ are utilised to show how quality metrics, data models and exploratory process mining analyses can be used to (i) identify data quality issues, (ii) anticipate and explain certain observable features in process mining analyses, (iii) distinguish between systemic and occasional quality issues, and (iv) reason about the mechanisms by which identified quality issues may have arisen in the event log. We contend that this knowledge can be used to guide the data extraction and pre-processing stages of a process mining case study to properly align the data with the case study research questions.

Brief intervention, physical exercise and cognitive behavioural group therapy for patients with chronic low back pain (The CINS trial).

BACKGROUND AND OBJECTIVE: Cognitive-behavioural treatments (CBT) and physical group exercise (PE) have both shown promising effects in reducing disability and increasing work participation among chronic low back pain (CLBP) patients. A brief cognitive intervention (BI) has previously been demonstrated to reduce work disability in CLBP. The aim of this study was to test if the effect of BI could be further increased by adding either group CBT or group PE. METHODS: A total of 214 patients, all sick listed 2-10 months due to CLBP, were randomized to BI (n = 99), BI + group CBT (n = 55) or BI + group PE (n = 60). Primary outcome was increased work participation at 12 months, whereas secondary outcomes included pain-related disability, subjective health complaints, anxiety, depression, coping and fear avoidance. RESULTS: There were no significant differences between the groups in work participation at 12 months follow-up (χ2  = 1.15, p = 0.56). No significant differences were found on the secondary outcomes either, except for a statistically significant reduction (time by group) in pseudoneurology one domain of subjective health complaints (sleep problems, tiredness, dizziness, anxiety, depression, palpitation, heat flushes) (F2,136  = 3.109, p = 0.048) and anxiety (F2,143  = 4.899, p = 0.009) for the groups BI + group CBT and BI + group PE, compared to BI alone. However, these differences were not significant in post hoc analyses (Scheffé adjusted). CONCLUSION: There was no support for an effect of the added group CBT or group PE treatments to a brief cognitive intervention in this study of patients on sick leave due to low back pain. SIGNIFICANCE: Our study demonstrates that treatments that previously were found to be effective and are included in most treatment guidelines, such as group cognitive-behavior therapy and exercise, were not effective in this given context compared to a brief, cognitive intervention. This implies that an optimized brief intervention is difficult to outperform in patients on sick leave due to low back pain.

Change of immunoglobulins and complement factors in patients with self-injurious behaviour.

OBJECTIVE: As stress activates the inflammatory response system, and attempted suicide is connected with severe stress, we hypothesized that patients hospitalized for self-injurious behaviour have changed immunocompetence. METHOD: The concentration of immunoglobulins IgG, IgA, IgM, and the complement components C3 and C4 in 73 patients hospitalized for self-injurious behaviour was compared with those of 122 healthy controls. The immunoglobulins and complement were quantified by nephelometric technique. RESULTS: The levels of IgG and IgM were significantly lower, and the complement C3 and C4 were significantly higher in self-injurious patients compared with controls. This was valid in both genders and the effects did not interact with gender. CONCLUSIONS: This controlled study showed that the concentrations of immunoglobulins were reduced and complement components were increased in patients who are admitted to hospital for self-injurious behaviour.

Differential expression of glyceraldehyde-3-phosphate dehydrogenase (GAPDH), beta actin and hypoxanthine phosphoribosyltransferase (HPRT) in postnatal rabbit sclera.

PURPOSE: GAPDH, beta-actin, HPRT and 18S rRNA are constitutively expressed in all mammalian cells. In accordance with the nature of invariant control, these genes have been used to standardize genes of interest in expression studies. Recent studies have suggested that GAPDH, beta-actin and HPRT in special situations may come under temporary regulatory control, but that 18S rRNA may be more likely to remain constitutive. However, little is known about the quantitative expression of these genes in fibroblasts and in particular during early postnatal development, a time of rapid changes in cell metabolism. In this study we have examined the differential expression of these genes in association with scleral development from an early postnatal age up to young adult status. METHODS: GAPDH, beta-actin, HPRT, and 18S rRNA gene expression were analyzed in the rabbit sclera from 1 day to 8 weeks postnatally by real-time, comparative PCR. RESULTS: Real-time PCR analysis showed that the expression levels of GAPDH, beta-actin, and HPRT were higher in the first postnatal week and then declined. However, from 2 to 8 weeks, the mRNA levels of these three genes underwent significant variations (P < 0.01) in their levels of expression. In contrast, the expression level of 18S rRNA showed no significant variation (P >or= 0.5) over this time period. Conclusions. The present study shows that GAPDH, beta actin and HPRT gene were differentially expressed in early postnatal scleral development. It also suggests that these gene products could be implicated in the developmental process and have a crucial role in the early postnatal period. This study demonstrates that 18S rRNA may be preferable to normalize genes of interest in studies of early development.

[Occurrence of anxiety and depression in cancer patients. An investigation at the Norwegian Radium Hospital]. / Forekomst av angst og depresjon hos kreftpasienter. En punktprevalensundersøkelse ved det Norske Radiumhospital.

The prevalence of anxiety and depression was evaluated in 716 unselected hospitalised patients and out-patients seen at the Norwegian Radium Hospital using the Hospital Anxiety and Depression Scale (HADS), the EORTC QLQ-C33 and an ad hoc designed questionnaire, the latter assessing socio-demographic data and disease-related parameters. The prevalence of anxiety and depression was 13% and 9%, respectively, as assessed with the HADS. In the logistic regression analysis, none of the disease-related factors remained independent parameters predictive for psychiatric distress, whereas a history of previous psychiatric problems and impaired social life were correlated both with anxiety and depression. Female gender, impaired physical activity and impaired social role function were additional predictive parameters for anxiety, whereas fatigue predicted depression. Careful attention should be paid to cancer patients displaying these significant problems in order to diagnose and treat depression and anxiety disorders of clinical importance.

Prevalence of anxiety and depression in cancer patients seen at the Norwegian Radium Hospital.

The aim of this study was to investigate the prevalence of anxiety and depression in cancer patients seen at the Norwegian Radium Hospital, using the Hospital Anxiety and Depression Scale (HADS), the EORTC QLQ-C33 and an ad hoc designed questionnaire. In addition, information about the patients' malignant disease and treatment was obtained. The prevalence of anxiety and depression among 716 evaluable patients was 13% and 9% respectively, as assessed with HADS. In hospitalised patients, the risk of psychiatric distress was approximately twice that of patients in the outpatient clinic. Female patients reported significantly more anxiety than men. Patients < 30 or > 70 years old expressed less anxiety than all other patients. Age or gender had no influence on the occurrence of depression. Impaired ability to continue professional work and/or daily life activities, impaired social life and previous psychiatric problems were significantly correlated with anxiety and depression as were impaired physical function, fatigue and pain. The prevalence of depression, but not anxiety, increased in the presence of distant metastases, with less than a month since diagnosis, and with relapse or progression. In the logistic regression analysis, a history of previous psychiatric problems and impaired social life were correlated with both anxiety and depression. Female gender, impaired physical activity and impaired social role function were additional predictive parameters for anxiety, whereas fatigue predicted depression. Careful attention should be paid to cancer patients displaying these problems in order to diagnose and treat depression and anxiety disorders.