Research Paper: Process Mining and Synthetic Health Data: Reflections and Lessons Learnt

Analysing the treatment pathways in real-world health data can provide valuable insight for clinicians and decision-makers. However, the procedures for acquiring real-world data for research can be restrictive, time-consuming and risks disclosing identifiable information. Synthetic data might enable representative analysis without direct access to sensitive data. In the first part of our paper, we propose an approach for grading synthetic data for process analysis based on its fidelity to relationships found in real-world data. In the second part, we apply our grading approach by assessing cancer patient pathways in a synthetic healthcare dataset (The Simulacrum provided by the English National Cancer Registration and Analysis Service) using process mining. Visualisations of the patient pathways within the synthetic data appear plausible, showing relationships between events confirmed in the underlying non-synthetic data. Data quality issues are also present within the synthetic data which reflect real-world problems and artefacts from the synthetic dataset’s creation. Process mining of synthetic data in healthcare is an emerging field with novel challenges. We conclude that researchers should be aware of the risks when extrapolating results produced from research on synthetic data to real-world scenarios and assess findings with analysts who are able to view the underlying data

Measuring the impact of COVID-19 on hospital care pathways

Care pathways in hospitals around the world reported significant disruption during the recent COVID-19 pandemic but measuring the actual impact is more problematic. Process mining can be useful for hospital management to measure the conformance of real-life care to what might be considered normal operations. In this study, we aim to demonstrate that process mining can be used to investigate process changes associated with complex disruptive events. We studied perturbations to accident and emergency (A &E) and maternity pathways in a UK public hospital during the COVID-19 pandemic. Co-incidentally the hospital had implemented a Command Centre approach for patient-flow management affording an opportunity to study both the planned improvement and the disruption due to the pandemic. Our study proposes and demonstrates a method for measuring and investigating the impact of such planned and unplanned disruptions affecting hospital care pathways. We found that during the pandemic, both A &E and maternity pathways had measurable reductions in the mean length of stay and a measurable drop in the percentage of pathways conforming to normative models. There were no distinctive patterns of monthly mean values of length of stay nor conformance throughout the phases of the installation of the hospital’s new Command Centre approach. Due to a deficit in the available A &E data, the findings for A &E pathways could not be interpreted

Direct access cancer testing in primary care: a systematic review of use and clinical outcomes.

BACKGROUND: Direct access (DA) testing allows GPs to refer patients for investigation without consulting a specialist. The aim is to reduce waiting time for investigations and unnecessary appointments, enabling treatment to begin without delay. AIM: To establish the proportion of patients diagnosed with cancer and other diseases through DA testing, time to diagnosis, and suitability of DA investigations. DESIGN AND SETTING: Systematic review assessing the effectiveness of GP DA testing in adults. METHOD: MEDLINE, Embase, and the Cochrane Library were searched. Where possible, study data were pooled and analysed quantitatively. Where this was not possible, the data are presented narratively. RESULTS: The authors identified 60 papers that met pre-specified inclusion criteria. Most studies were carried out in the UK and were judged to be of poor quality. The authors found no significant difference in the pooled cancer conversion rate between GP DA referrals and patients who first consulted a specialist for any test, except gastroscopy. There were also no significant differences in the proportions of patients receiving any non-cancer diagnosis. Referrals for testing were deemed appropriate in 66.4% of those coming from GPs, and in 80.9% of those from consultants; this difference was not significant. The time from referral to testing was significantly shorter for patients referred for DA tests. Patient and GP satisfaction with DA testing was consistently high. CONCLUSION: GP DA testing performs as well as, and on some measures better than, consultant triaged testing on measures of disease detection, appropriateness of referrals, interval from referral to testing, and patient and GP satisfaction

Findings during screening colonoscopies in a Middle Eastern cohort

Background/Aims: Colorectal cancer is the most common cancer in males and the third most common cancer in females. We aim to determine the polyp and adenoma prevalence in a cohort of patients who underwent opportunistic screening colonoscopies. Patients and Methods: A retrospective cohort study was conducted using an endoscopic reporting database of individuals seen at three tertiary care hospitals (two public hospitals and one private) in Riyadh, Saudi Arabia. Consecutive patients who were 45 years of age and older and underwent opportunistic screening colonoscopies between November 2016 and October 2017 were included. We excluded those with a history of colon cancer or colonic resection for any reason, inflammatory bowel disease, gastrointestinal bleeding, or anemia. Results: Around 1180 patients were included in the study with a mean age of 58.6 years (SD = 7.3), with males representing 53.6% and an overall cecal intubation rate of 92.4%. Masses were found in 1.6% of the study population (50% in the sigmoid or rectosigmoid, 37.5% in the rectum). The polyp detection rate in colonoscopies was 24.8% and the adenoma detection rate was 16.8%. The histology of removed polyps was tubular adenomas in 56.6%, hyperplastic polyps in 32.7%, tubulovillous adenomas in 8.2%, and villous adenomas in 2.5%. The majority of the polyps were in the sigmoid colon (28.3%) and rectum (22.0%), followed by the ascending colon (11.2%) and cecum (10.3%), then the transverse colon and descending colon (9.4% each), and multiple locations in the remainder. Conclusion: The prevalence of polyps and adenomas in this cohort is less than that reported in the Western populations

Policy of screening for colorectal cancer in Saudi Arabia: A prospective analysis

Colorectal cancer (CRC) is one of the most common cancers worldwide. Several policies of CRC screening are available in different countries. The idea of screening is to identify patients at risk by detection of precancerous and small cancers early enough before they become advanced. In Saudi Arabia (SA), there is no countrywide policy for CRC screening despite the increasing incidence of the disease. Screening for CRC is a multidisciplinary approach that requires education programs, substantial financial support, several logistic measures, and predetermined resources before implementing such a program. We performed a prospective and systematic analysis of the of the screening policy of CRC in SA in view of high demand, anticipated development, and implementation of such a policy in the near future. We also attempted to investigate the justification for developing such a policy, as well as the difficulties, barriers, and opportunities that may be faced in its implementation. Further, we highlighted the current view of similar international screening policies. In this analysis, we adopted the framework for health policy analysis that examines four areas which may affect policy development, namely; content, context, process and actors

Appropriateness and diagnostic yield of upper gastrointestinal endoscopy in an open-access endoscopy system

Background/Aim: Open access endoscopy (OAE) decreases the waiting time for patients and clinical burden to gastroenterologist; however, the appropriateness of referrals for endoscopy and thus the diagnostic yield of these endoscopies has become an important issue. The aim of this study was to determine the appropriateness of upper gastrointestinal (GI) endoscopy requests in an OAE system. Patients and Methods: A retrospective chart review of all consecutive patients who underwent an upper gastroscopy in the year 2008 was performed and was defined as appropriate or inappropriate according to the American Society for Gastrointestinal Endoscopy (ASGE) guidelines. Endoscopic findings were recorded and classified as positive or negative. Referrals were categorized as being from a gastroenterologist, internist, surgeon, primary care physicians or others, and on an inpatient or out-patient basis. Results: A total of 505 consecutive patients were included. The mean age was 45.3 (standard deviation 18.1), 259 (51%) of them were males. 31% of the referrals were thought to be inappropriate. Referrals from primary care physicians were inappropriate in 47% of patients while only 19.5% of gastroenterologists referrals were considered inappropriate. Nearly, 37.8% of the out-patient referrals were inappropriate compared to only 7.8% for inpatients. Abnormal findings were found in 78.5% and 78% of patients referred by gastroenterologists and surgeons respectively while in those referred by primary care physicians it was (49.7%). Inpatients referred for endoscopy had abnormal findings in (81.7%) while in out-patients it was (66.6%). The most common appropriate indications in order of frequency were "upper abdominal distress that persisted despite an appropriate trial of therapy "(78.9%),′′persistent vomiting of unknown cause "(19.2%), upper GI bleeding or unexplained iron deficiency anemia (7.6%). The sensitivity and specificity of the ASGE guidelines in our study population was 70.3% and 35% respectively. Conclusion: A large proportion of patients referred for endoscopy through our open-access endoscopy unit are considered inappropriate, with significant differences among specialties. These results suggest that if proper education of practitioners was implemented, a better utilization would be expected

Predictors of failure of endoscopic retrograde cholangiography in clearing bile duct stone on the initial procedure

Background/Aims: The aim of this study is to predict cases where the clearance of the biliary system from stones at the initial endoscopic retrograde cholangiopancreatography (ERCP) might be of value for better risk-stratifying patients. We attempted to identify factors that are associated with a higher failure rate of clearing the biliary system on the index ERCP. Patients and Methods: This is a retrospective study from January 2008 to January 2015. All patients with bile duct stones confirmed on ERCP were included in this study. Patients who had prior attempts of bile duct stone extraction were excluded. Results: A total of 554 ERCPs were performed to extract biliary duct stones from 426 patients. The mean age was 46.3 years and 41.7% were males. The group where the index ERCP did not clear the biliary system tended to be older (50.4 vs. 45.2 years, P = 0.03). On multivariate analysis, the presence of fever (OR 4.64; 95% CI, 1.66–12.79), a larger number of filling defects (OR 1.34; 95% CI, 1.13–1.93), presence of a stricture distal to a stone (OR 4.63; 95% CI, 1.36–15.78), the use of an extraction basket (OR 3.23; 95% CI, 1.56–6.74), and/or mechanical lithotripsy (OR 3.05; 95% CI, 1.10–8.49) were all associated with a lower odds of clearing the biliary system. The use of an extraction balloon was associated with the success of clearing the biliary system (99.7% vs. 77.4%, P < 0.01) and a lower odds of failing (OR 0.01; 95% CI, 0.00–0.08) on multivariate analysis. Conclusion: A few of the characteristics that are found on cholangiography at the index ERCP could be used to identify patients that might require more than one ERCP to clear the biliary system from stones