Colleen Kenost

Challenges and remediation for Patient Safety Indicators in the transition to ICD-10-CM

Reporting of hospital adverse events relies on Patient Safety Indicators (PSIs) using International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) codes. The US transition to ICD-10-CM in 2015 could result in erroneous comparisons of PSIs. Using the General Equivalent Mappings (GEMs), we compared the accuracy of ICD-9-CM coded PSIs against recommended ICD-10-CM codes from the Centers for Medicaid/Medicare Services (CMS). We further predict their impact in a cohort of 38 644 patients (1 446 581 visits and 399 hospitals). We compared the predicted results to the published PSI related ICD-10-CM diagnosis codes. We provide the first report of substantial hospital safety reporting errors with five direct comparisons from the 23 types of PSIs (transfusion and anesthesia related PSIs). One PSI was excluded from the comparison between code sets due to reorganization, while 15 additional PSIs were inaccurate to a lesser degree due to the complexity of the coding translation. The ICD-10-CM translations proposed by CMS pose impending risks for (1) comparing safety incidents, (2) inflating the number of PSIs, and (3) increasing the variability of calculations attributable to the abundance of coding system translations. Ethical organizations addressing ‘data-, process-, and system-focused’ improvements could be penalized using the new ICD-10-CM Agency for Healthcare Research and Quality PSIs because of apparent increases in PSIs bearing the same PSI identifier and label, yet calculated differently. Here we investigate which PSIs would reliably transition between ICD-9-CM and ICD-10-CM, and those at risk of under-reporting and over-reporting adverse events while the frequency of these adverse events remain unchanged.

Metrics and tools for consistent cohort discovery and financial analyses post-transition to ICD-10-CM

In the United States, International Classification of Disease Clinical Modification (ICD-9-CM, the ninth revision) diagnosis codes are commonly used to identify patient cohorts and to conduct financial analyses related to disease. In October 2015, the healthcare system of the United States will transition to ICD-10-CM (the tenth revision) diagnosis codes. One challenge posed to clinical researchers and other analysts is conducting diagnosis-related queries across datasets containing both coding schemes. Further, healthcare administrators will manage growth, trends, and strategic planning with these dually-coded datasets. The majority of the ICD-9-CM to ICD-10-CM translations are complex and nonreciprocal, creating convoluted representations and meanings. Similarly, mapping back from ICD-10-CM to ICD-9-CM is equally complex, yet different from mapping forward, as relationships are likewise nonreciprocal. Indeed, 10 of the 21 top clinical categories are complex as 78% of their diagnosis codes are labeled as “convoluted” by our analyses. Analysis and research related to external causes of morbidity, injury, and poisoning will face the greatest challenges due to 41 745 (90%) convolutions and a decrease in the number of codes. We created a web portal tool and translation tables to list all ICD-9-CM diagnosis codes related to the specific input of ICD-10-CM diagnosis codes and their level of complexity: “identity” (reciprocal), “class-to-subclass,” “subclass-to-class,” “convoluted,” or “no mapping.” These tools provide guidance on ambiguous and complex translations to reveal where reports or analyses may be challenging to impossible. Web portal: http://www.lussierlab.org/transition-to-ICD9CM/ Tables annotated with levels of translation complexity: http://www.lussierlab.org/publications/ICD10to9

kMEn: Analyzing noisy and bidirectional transcriptional pathway responses in single subjects

MOTIVATION Understanding dynamic, patient-level transcriptomic response to therapy is an important step forward for precision medicine. However, conventional transcriptome analysis aims to discover cohort-level change, lacking the capacity to unveil patient-specific response to therapy. To address this gap, we previously developed two N-of-1-pathways methods, Wilcoxon and Mahalanobis distance, to detect unidirectionally responsive transcripts within a pathway using a pair of samples from a single subject. Yet, these methods cannot recognize bidirectionally (up and down) responsive pathways. Further, our previous approaches have not been assessed in presence of background noise and are not designed to identify differentially expressed mRNAs between two samples of a patient taken in different contexts (e.g. cancer vs non cancer), which we termed responsive transcripts (RTs). METHODS We propose a new N-of-1-pathways method, k-Means Enrichment (kMEn), that detects bidirectionally responsive pathways, despite background noise, using a pair of transcriptomes from a single patient. kMEn identifies transcripts responsive to the stimulus through k-means clustering and then tests for an over-representation of the responsive genes within each pathway. The pathways identified by kMEn are mechanistically interpretable pathways significantly responding to a stimulus. RESULTS In ∼9000 simulations varying six parameters, superior performance of kMEn over previous single-subject methods is evident by: (i) improved precision-recall at various levels of bidirectional response and (ii) lower rates of false positives (1-specificity) when more than 10% of genes in the genome are differentially expressed (background noise). In a clinical proof-of-concept, personal treatment-specific pathways identified by kMEn correlate with therapeutic response (p-value<0.01). CONCLUSION Through improved single-subject transcriptome dynamics of bidirectionally-regulated signals, kMEn provides a novel approach to identify mechanism-level biomarkers.

N-of-1- pathways MixEnrich: advancing precision medicine via single-subject analysis in discovering dynamic changes of transcriptomes

BackgroundTranscriptome analytic tools are commonly used across patient cohorts to develop drugs and predict clinical outcomes. However, as precision medicine pursues more accurate and individualized treatment decisions, these methods are not designed to address single-patient transcriptome analyses. We previously developed and validated the N-of-1-pathways framework using two methods, Wilcoxon and Mahalanobis Distance (MD), for personal transcriptome analysis derived from a pair of samples of a single patient. Although, both methods uncover concordantly dysregulated pathways, they are not designed to detect dysregulated pathways with up- and down-regulated genes (bidirectional dysregulation) that are ubiquitous in biological systems.ResultsWe developed N-of-1-pathways MixEnrich, a mixture model followed by a gene set enrichment test, to uncover bidirectional and concordantly dysregulated pathways one patient at a time. We assess its accuracy in a comprehensive simulation study and in a RNA-Seq data analysis of head and neck squamous cell carcinomas (HNSCCs). In presence of bidirectionally dysregulated genes in the pathway or in presence of high background noise, MixEnrich substantially outperforms previous single-subject transcriptome analysis methods, both in the simulation study and the HNSCCs data analysis (ROC Curves; higher true positive rates; lower false positive rates). Bidirectional and concordant dysregulated pathways uncovered by MixEnrich in each patient largely overlapped with the quasi-gold standard compared to other single-subject and cohort-based transcriptome analyses.ConclusionThe greater performance of MixEnrich presents an advantage over previous methods to meet the promise of providing accurate personal transcriptome analysis to support precision medicine at point of care.

Analysis of aggregated cell-cell statistical distances within pathways unveils therapeutic-resistance mechanisms in circulating tumor cells

Motivation: As ‘omics’ biotechnologies accelerate the capability to contrast a myriad of molecular measurements from a single cell, they also exacerbate current analytical limitations for detecting meaningful single-cell dysregulations. Moreover, mRNA expression alone lacks functional interpretation, limiting opportunities for translation of single-cell transcriptomic insights to precision medicine. Lastly, most single-cell RNA-sequencing analytic approaches are not designed to investigate small populations of cells such as circulating tumor cells shed from solid tumors and isolated from patient blood samples. Results: In response to these characteristics and limitations in current single-cell RNA-sequencing methodology, we introduce an analytic framework that models transcriptome dynamics through the analysis of aggregated cell–cell statistical distances within biomolecular pathways. Cell–cell statistical distances are calculated from pathway mRNA fold changes between two cells. Within an elaborate case study of circulating tumor cells derived from prostate cancer patients, we develop analytic methods of aggregated distances to identify five differentially expressed pathways associated to therapeutic resistance. Our aggregation analyses perform comparably with Gene Set Enrichment Analysis and better than differentially expressed genes followed by gene set enrichment. However, these methods were not designed to inform on differential pathway expression for a single cell. As such, our framework culminates with the novel aggregation method, cell-centric statistics (CCS). CCS quantifies the effect size and significance of differentially expressed pathways for a single cell of interest. Improved rose plots of differentially expressed pathways in each cell highlight the utility of CCS for therapeutic decision-making. Availability and implementation: http://www.lussierlab.org/publications/CCS/ Contact: yves@email.arizona.edu or piegorsch@math.arizona.edu Supplementary information: Supplementary data are available at Bioinformatics online.

A genome-by-environment interaction classifier for precision medicine: Personal transcriptome response to rhinovirus identifies children prone to asthma exacerbations

Abstract Objective To introduce a disease prognosis framework enabled by a robust classification scheme derived from patient-specific transcriptomic response to stimulation. Materials and Methods Within an illustrative case study to predict asthma exacerbation, we designed a stimulation assay that reveals individualized transcriptomic response to human rhinovirus. Gene expression from peripheral blood mononuclear cells was quantified from 23 pediatric asthmatic patients and stimulated in vitro with human rhinovirus. Responses were obtained via the single-subject gene set testing methodology “N-of-1-pathways.” The classifier was trained on a related independent training dataset (n = 19). Novel visualizations of personal transcriptomic responses are provided. Results Of the 23 pediatric asthmatic patients, 12 experienced recurrent exacerbations. Our classifier, using individualized responses and trained on an independent dataset, obtained 74% accuracy (area under the receiver operating curve of 71%; 2-sided P = .039). Conventional classifiers using messenger RNA (mRNA) expression within the viral-exposed samples were unsuccessful (all patients predicted to have recurrent exacerbations; accuracy of 52%). Discussion Prognosis based on single time point, static mRNA expression alone neglects the importance of dynamic genome-by-environment interplay in phenotypic presentation. Individualized transcriptomic response quantified at the pathway (gene sets) level reveals interpretable signals related to clinical outcomes. Conclusion The proposed framework provides an innovative approach to precision medicine. We show that quantifying personal pathway–level transcriptomic response to a disease-relevant environmental challenge predicts disease progression. This genome-by-environment interaction assay offers a noninvasive opportunity to translate omics data to clinical practice by improving the ability to predict disease exacerbation and increasing the potential to produce more effective treatment decisions.

Evaluating single-subject study methods for personal transcriptomic interpretations to advance precision medicine

Background Gene expression profiling has benefited medicine by providing clinically relevant insights at the molecular candidate and systems levels. However, to adopt a more ‘precision’ approach that integrates individual variability including ‘omics data into risk assessments, diagnoses, and therapeutic decision making, whole transcriptome expression analysis requires methodological advancements. One need is for users to confidently be able to make individual-level inferences from whole transcriptome data. We propose that biological replicates in isogenic conditions can provide a framework for testing differentially expressed genes (DEGs) in a single subject (ss) in absence of an appropriate external reference standard or replicates. Methods Eight ss methods for identifying genes with differential expression (NOISeq, DEGseq, edgeR, mixture model, DESeq, DESeq2, iDEG, and ensemble) were compared in Yeast (parental line versus snf2 deletion mutant; n=42/condition) and MCF7 breast-cancer cell (baseline and stimulated with estradiol; n=7/condition) RNA-Seq datasets where replicate analysis was used to build reference standards from NOISeq, DEGseq, edgeR, DESeq, DESeq2. Each dataset was randomly partitioned so that approximately two-thirds of the paired samples were used to construct reference standards and the remainder were treated separately as single-subject sample pairs and DEGs were assayed using ss methods. Receiver-operator characteristic (ROC) and precision-recall plots were determined for all ss methods against each RSs in both datasets (525 combinations). Results Consistent with prior analyses of these data, ~50% and ~15% DEGs were respectively obtained in Yeast and MCF7 reference standard datasets regardless of the analytical method. NOISeq, edgeR and DESeq were the most concordant and robust methods for creating a reference standard. Single-subject versions of NOISeq, DEGseq, and an ensemble learner achieved the best median ROC-area-under-the-curve to compare two transcriptomes without replicates regardless of the type of reference standard (>90% in Yeast, >0.75 in MCF7). Conclusion Better and more consistent accuracies are obtained by an ensemble method applied to singlesubject studies across different conditions. In addition, distinct specific sing-subject methods perform better according to different proportions of DEGs. Single-subject methods for identifying DEGs from paired samples need improvement, as no method performs with both precision>90% and recall>90%. http://www.lussiergroup.org/publications/EnsembleBiomarker

iDEG: A single-subject method for assessing gene differential expression from two transcriptomes of an individual

Abstract Background Accurate profiling of gene expression in a single subject has the potential to be a powerful precision medicine tool, useful for unveiling individual disease mechanisms and responses. However, expression analysis tools for RNA-sequencing (RNA-Seq) data require replicate samples to estimate gene-wise data variability and make inferences, which is costly and not easily obtainable in clinical practice. Strategies to implement DEGSeq, DESeq, and edgeR for comparing two conditions without replicates (TCWR) have been proposed without evaluation, while NOISeq-sim was validated in a restricted way using qPCR on 400 transcripts. These methods impose restrictive assumptions in TCWR limiting inferential opportunities. Methods We propose a new method that borrows information across different genes from the same individual using a partitioned window to strategically bypass the requirement of replicates per condition. We termed this method “iDEG”, which identifies individualized Differentially Expressed Genes in a single subject sampled under two conditions without replicates, i.e., a baseline sample (unaffected tissue) vs. a case sample (tumor). iDEG transforms RNA-Seq data such that, under the null hypothesis, differences of transformed expression counts follow a distribution and variance calculated across a local partition of related transcripts at baseline expression. This transformation enables modeling genes with a two-group mixture model from which the probability of differential expression for each gene is then estimated by an empirical Bayes approach with a local false discovery rate control. To compare the performance of iDEG to other methods applied to TCWR, we conducted simulations assuming a Negative Binomial distribution with varying dispersion parameters and percentages of differentially expressed genes (DEGs). Results Our extensive simulation studies demonstrate that iDEG’s F1 accuracy scores better than the other methods at 5% 90% and recall>75% and low false positive rate ( Conclusion The partitioned window strategy provides a novel and accurate way to borrow information across genes locally and would probably increase the accuracy of all relevant methods.Accurate profiling of gene expression in a single subject has the potential to be a powerful precision medicine tool, useful for unveiling individual disease mechanisms and responses. However, most expression analysis tools for RNA-sequencing (RNA-Seq) data require replicate samples to estimate gene-wise data variability and make inferences, which is costly and not easily obtainable in clinical practice. We propose the iDEG method to identify individualized Differentially Expressed Genes in a single subject sampled under two conditions without replicates, i.e. a baseline sample (unaffected tissue) vs. a case sample (tumor). iDEG borrows information across different genes from the same individual using a partitioned window to strategically bypass the requirement of replicates per condition. It then transforms RNA-Seq data such that, under the null hypothesis, differences of transformed expression counts follow a distribution and variance calculated across a local partition of related transcripts at baseline expression. This transformation enables modeling genes with a two-group mixture model from which the probability of differential expression for each gene is then estimated by an empirical Bayes approach with a local false discovery rate control. Our extensive simulation studies demonstrate iDEGs substantially was the only technique keeping high precision (>90%), recall (>75%) and low false positive rate (<1%) accuracy under thousands of scenarios when compared to DESeq, edgeR, and DEGseq. Software available at: http://www.lussiergroup.org/publications/iDEGCalculating Differentially Expressed Genes (DEGs) from RNA-sequencing requires replicates to estimate gene-wise variability, infeasible in clinics. By imposing restrictive transcriptome-wide assumptions limiting inferential opportunities of conventional methods (edgeR, NOISeq-sim, DESeq, DEGseq), comparing two conditions without replicates (TCWR) has been proposed, but not evaluated. Under TCWR conditions (e.g., unaffected tissue vs. tumor), differences of transformed expression of the proposed individualized DEG (iDEG) method follow a distribution calculated across a local partition of related transcripts at baseline expression; thereafter the probability of each DEG is estimated by empirical Bayes with local false discovery rate control using a two-group mixture model. In extensive simulation studies of TCWR methods, iDEG and NOISeq are more accurate at 5%<DEGs<20% (precision>90%, recall>75%, false_positive_rate<1%) and 30%<DEGs<40% (precision=recall∼90%), respectively. The proposed iDEG method borrows localized distribution information from the same individual, a strategy that improves accuracy to compare transcriptomes in absence of replicates at low DEGs conditions. http://www.lussiergroup.org/publications/iDEG

Developing a ‘personalome’ for precision medicine: emerging methods that compute interpretable effect sizes from single-subject transcriptomes

Abstract The development of computational methods capable of analyzing -omics data at the individual level is critical for the success of precision medicine. Although unprecedented opportunities now exist to gather data on an individual’s -omics profile (‘personalome’), interpreting and extracting meaningful information from single-subject -omics remain underdeveloped, particularly for quantitative non-sequence measurements, including complete transcriptome or proteome expression and metabolite abundance. Conventional bioinformatics approaches have largely been designed for making population-level inferences about ‘average’ disease processes; thus, they may not adequately capture and describe individual variability. Novel approaches intended to exploit a variety of -omics data are required for identifying individualized signals for meaningful interpretation. In this review—intended for biomedical researchers, computational biologists and bioinformaticians—we survey emerging computational and translational informatics methods capable of constructing a single subjects ‘personalome’ for predicting clinical outcomes or therapeutic responses, with an emphasis on methods that provide interpretable readouts. Key points: (i) the single-subject analytics of the transcriptome shows the greatest development to date and, (ii) the methods were all validated in simulations, cross-validations or independent retrospective data sets. This survey uncovers a growing field that offers numerous opportunities for the development of novel validation methods and opens the door for future studies focusing on the interpretation of comprehensive ‘personalomes’ through the integration of multiple -omics, providing valuable insights into individual patient outcomes and treatments.