Medical Decision-making Process Research Articles

Alternative medical waste treatment during COVID-19 case study in Hospital X Jakarta City

Medical waste management in health care facilities is very important because medical waste has various health risks. One hospital can incur up to Rp 1 billion/year for medical waste treatment costs. This study aims to analyze the proper processing of medical waste in hospitals in Jakarta during the pandemic. This type of research is a descriptive observational study conducted cross-sectional through observations on solid waste management at Hospital X, Jakarta City. Decision analysis in this study uses the Analytical Hierarchy Process (AHP) method to support the medical waste treatment decision-making process. In this study, two processing methods are given, namely the incinerator and autoclave. An incinerator is a thermal process used to treat medical waste at controlled temperatures. An autoclave is a medical waste treatment that combines moisture, heat, and pressure to sterilize medical waste. The results of the AHP show that hospitals should optimize autoclaves to sterilize highly infectious waste, which can also be used to sterilize sharp medical waste. Meanwhile, medical waste treatment using incinerators can generate other waste in the form of ash from combustion residues. Ash from the combustion process can contain heavy metals such as Cr, Zn, and Pb. Therefore, a strategy is needed to deal with this waste generation so that the final treatment does not end in a landfill but can be a useful product.

Monitoring Length of Stay of Acute Myocardial Infarction Patients: A Times Series Analysis Using Statistical Process Control.

Given that length of stay (LOS) of acute myocardial infarction (AMI) patients has a significant impact on the utilization of hospital resources and the health status of communities, this study focused on how best to monitor LOS of AMI patients admitted to U.S. hospitals by employing statistical process control (SPC). Data were abstracted from the Healthcare Cost and Utilization Project Nationwide Readmissions Database between 2010 and 2016. A total of 1,491 patients were examined in the study. Patients who were admitted to nonfederal government (public) hospitals in metropolitan areas of at least 1 million residents with the primary diagnosis of AMI were abstracted. They were excluded if they developed AMI secondary to an interventional procedure or surgery, died during their index hospitalization, and were admitted and discharged on the same day. Patients were also excluded if they were discharged to short-term hospitals, nursing facilities, intermediate care facilities, home healthcare, or against medical advice. Individual moving range (I-MR) charts were used to monitor LOS of individual AMI patients in each subgroup from 2010 to 2016. The results showed I-MR charts could be used to indicate statistically out-of-control signals on LOS. Specifically, I-MR charts showed that LOS decreased between 2010 and 2016. LOS appeared to be longer at teaching hospitals compared to nonteaching hospitals and varied by gender. Female patients appeared to stay longer than male patients in the hospitals. The application of SPC and control charts can facilitate improved decision-making in healthcare organizations. This study shows the value of integrating control charts in administrative and medical decision-making processes. It may also help healthcare providers and managers achieve higher quality and lower cost of care.

Making Patient Contextual Data Concrete: Abstraction Hierarchyto Understand Patient Self-Management of Type 2 Diabetes

Social determinants of health (SDOH) and other contextual factors influence a patient’s ability to adhere to a plan of care. Providers must understand these factors in order to develop treatment plans which best meet patient needs and preferences. This is particularly important for patients with type 2 diabetes, which is primarily managed by the patient. Abstraction hierarchy is a modeling technique from the cognitive work analysis framework which describes system components at multiple levels of abstraction. This study seeks to examine SDOH as they relate to type 2 diabetes management by the patient and activities carried out by the primary care provider to incorporate these factors into the medical decision-making process. The abstraction hierarchy was developed based on previous literature and interviews with patients and primary care medical personnel. The resulting abstraction hierarchy can be used to inform future screening tools and patient-centered care interventions for addressing SDOH for patients with type 2 diabetes.

MAC-spinal meningioma score: A proposal for a quick-to-use scoring sheet of the MIB-1 index in sporadic spinal meningiomas.

ObjectiveMIB-1 index is an important predictor of meningioma progression. However, MIB-1 index is not available in the preoperative tailored medical decision-making process. A preoperative scoring sheet independently estimating MIB-1 indices in spinal meningioma (SM) patients has not been investigated so far.MethodsBetween 2000 and 2020, 128 patients with clinical data, tumor imaging data, inflammatory laboratory (plasma fibrinogen, serum C-reactive protein) data, and neuropathological reports (MIB-1, mitotic count, CD68 staining) underwent surgery for spinal WHO grade 1 and 2 meningioma.ResultsAn optimal MIB-1 index cut-off value (≥5/<5) predicting recurrence was calculated by ROC curve analysis (AUC: 0.83; 95%CI: 0.71-0.96). An increased MIB-1 index (≥5%) was observed in 55 patients (43.0%) and multivariable analysis revealed significant associations with baseline Modified McCormick Scale ≥2, age ≥65, and absence of calcification. A four-point scoring sheet (MAC-Spinal Meningioma) based on Modified McCormick, Age, and Calcification facilitates prediction of the MIB-1 index (sensitivity 71.1%, specificity 60.0%). Among those patients with a preoperative MAC-Meningioma Score ≥3, the probability of a MIB-1 index ≥5% was 81.3%.ConclusionThis novel score (MAC-Spinal Meningioma) supports the preoperative estimation of an increased MIB-1 index, which might support preoperative patient-surgeon consultation, surgical decision making and enable a tailored follow-up schedule or an individual watch-and-wait strategy.

Analysis of downward referral willingness and its influencing factors among recovery phase hospitalized patients in tertiary hospitals

Objectives: This study aimed to understand the willingness of hospitalized patients in stable conditions and in the recovery phase in tertiary hospitals toward downward referral (DR) and to explore its influencing factors. Methods: A questionnaire survey was conducted among hospitalized patients from five tertiary general hospitals. Data were analyzed and processed using SPSS17.0 software. Results: The rate of knowledge regarding the hierarchical medical system and DR willingness were low. Per capital household annual income, the form of medical insurance, and the medical treatment decision-making process are the main factors influencing patients’ willingness. Conclusion: To improve patients’ DR willingness, it is necessary to further strengthen public understanding of the hierarchical medical system and to build the service capabilities of primary medical institutions.

Multimodal MRI-Based Whole-Brain Assessment in Patients In Anoxoischemic Coma by Using 3D Convolutional Neural Networks

BackgroundThere is an unfulfilled need to find the best way to automatically capture, analyze, organize, and merge structural and functional brain magnetic resonance imaging (MRI) data to ultimately extract relevant signals that can assist the medical decision process at the bedside of patients in postanoxic coma. We aimed to develop and validate a deep learning model to leverage multimodal 3D MRI whole-brain times series for an early evaluation of brain damages related to anoxoischemic coma.MethodsThis proof-of-concept, prospective, cohort study was undertaken at the intensive care unit affiliated with the University Hospital (Toulouse, France), between March 2018 and May 2020. All patients were scanned in coma state at least 2 days (4 ± 2 days) after cardiac arrest. Over the same period, age-matched healthy volunteers were recruited and included. Brain MRI quantification encompassed both “functional data” from regions of interest (precuneus and posterior cingulate cortex) with whole-brain functional connectivity analysis and “structural data” (gray matter volume, T1-weighted, fractional anisotropy, and mean diffusivity). A specifically designed 3D convolutional neuronal network (CNN) was created to allow conscious state discrimination (coma vs. controls) by using raw MRI indices as the input. A voxel-wise visualization method based on the study of convolutional filters was applied to support CNN outcome. The Ethics Committee of the University Teaching Hospital of Toulouse, France (2018-A31) approved the study and informed consent was obtained from all participants.ResultsThe final cohort consisted of 29 patients in postanoxic coma and 34 healthy volunteers. Coma patients were successfully discerned from controls by using 3D CNN in combination with different MR indices. The best accuracy was achieved by functional MRI data, in particular with resting-state functional MRI of the posterior cingulate cortex, with an accuracy of 0.96 (range 0.94–0.98) on the test set from 10-time repeated tenfold cross-validation. Even more satisfactory performances were achieved through the majority voting strategy, which was able to compensate for mistakes from single MR indices. Visualization maps allowed us to identify the most relevant regions for each MRI index, notably regions previously described as possibly being involved in consciousness emergence. Interestingly, a posteriori analysis of misclassified patients indicated that they may present some common functional MRI traits with controls, which suggests further favorable outcomes.ConclusionsA fully automated identification of clinically relevant signals from complex multimodal neuroimaging data is a major research topic that may bring a radical paradigm shift in the neuroprognostication of patients with severe brain injury. We report for the first time a successful discrimination between patients in postanoxic coma patients from people serving as controls by using 3D CNN whole-brain structural and functional MRI data.Clinical Trial Numberhttp://ClinicalTrials.gov (No. NCT03482115).

Presentation of ethical criteria during medical decision-making for critically ill patients: a mixed methods study.

Every medical decision is based on balancing medical knowledge, ethical considerations, and patient preferences. Previous surveys have mainly covered the ethical knowledge of medical staff. The aim of this study is to evaluate the feasibility of an innovative concept regarding how ethical criteria are applied to clinical decision-making during critical illness. An online survey including a short case vignette was carried out at a university hospital among physicians specialising in intensive care medicine in Germany. After free text responses regarding further required case information, the participants were asked to rank decision criteria during the course of the case vignette. A qualitative evaluation was performed by two independent investigators, based on a transcription into categories. This was followed by a quantitative analysis of ranked criteria. Our analysis has shown that doctors are initially inclined to consider medical information when making treatment decisions. When complications occur, ethical values are more often included in the decision-making. The qualitative evaluation reveiled that the patient's will was consistently regarded as the leading criterion for decision-making. In the quantitative evaluation, patient's well-being, quality of life, and patient autonomy were rated as the most important decision criteria. Economic factors were ranked least important. A mixed methods approach is able to reflect the complexity of ethical reasoning within the medical decision-making process, suggesting the feasibility of this concept. The study was registered under DRKS-ID: DKRS00011905 (April 2017).

Development of a Decision-Aid Form (DAF) for the stratification of care in a French comprehensive cancer center, a tool to support identification of care goals.

For cancer patients, life-threatening complications may be difficult to anticipate, which can lead to complex medical decision-making processes. Since 2015, the Gustave Roussy Cancer Center has used a Decision-Aid Form (DAF), which contains an estimated gradation of care in cases where patients' conditions worsen. In this study, we assessed the acceptability of the DAF and the predictive value of the proposed stratification of care with regard to care delivered and patient's outcomes. During a 5-month period, all patients who had been transferred from Site 1 to Site 2 of the hospital were prospectively included. A DAF was completed for 89.3% of the 206 patients included. Planned stratification of care was indicated in nearly all cases. The involvement of the palliative care team was indicated in only 29% of the DAF. The value of the WHO/ECOG Performance Status (PS) was limited. Finally, the field "information for patients and relatives" was infrequently completed. Although the possibility of transfer to the Intensive Care Unit was proposed for two-thirds of the patients, 76% of the 35 patients experiencing an acute event received only medical or palliative care. Overall, the level of therapeutic commitment suggested by the DAF was most often revised towards less aggressive care. The results of our study suggest that implementing an advanced stratification record is possible in a French cultural setting. To achieve complete cultural acceptance, our large integrated institutional program continues to play a key role in anticipating intent, tracing and sharing information with patients and their relatives.

“Like Not Having an Arm”: Perspectives of Patients, Caregivers, and Practitioners on the Impact of Visitor Restrictions on Cancer Care During the COVID-19 Pandemic (RP405)

Outcomes1. Understand how caregiver absence affected the patient and caregiver dyadic relationship2. Understand how caregiver absence affected cancer and palliative care practitionersImportanceVisitor restriction policies to prevent the spread of COVID-19 between patients and practitioners have been widespread during the pandemic, resulting in the exclusion of caregivers at key points of cancer care and treatment decision making.Objective(s)Explore how visitor restrictions impacted cancer treatment decision making and care from patient, caregiver, and practitioner perspectives.Method(s)71 interviews, including 48 cancer patients, 4 family caregivers, and 19 cancer and palliative care practitioners from four academic cancer centers in the US between August 2020 and July 2021.ResultsVisitor restrictions that prevented caregivers from participating in clinic appointments and perioperative hospital stays were universally disliked by patients, caregivers, and practitioners. Patients felt deprived of an advocate to help ask questions and to process and retain medical information when patients felt overwhelmed or impaired with “chemo brain.” Caregivers discussed that visitor restrictions made them feel “out of the loop” and increased their anxiety about the patient's care. Cancer practitioners described how visitor restrictions impaired care because caregivers were not present to share valuable health information that the patient may have forgotten or neglected to mention, and clinicians had to spend extra time to call caregivers to relay information. Some surgical oncologists expressed moral distress because they perceived that the absence of caregivers negatively affected their patients’ health outcomes because caregivers were not there to provide emotional support during hospital stays.Conclusion(s)Our data indicate that the structure of the medical decision-making relationship is more tripartite than bilateral, with caregivers being a significant third actor within the medical decision-making process. Caregivers provided support in the decision-making and care process to both patients and practitioners, and their absence created additional burden on both.ImpactAs the pandemic continues into its second year with new surges and a return to visitor restrictions, health systems should reconsider visitor policies to ease the emotional and physical burden on patients, caregivers, and practitioners.

A cumulative prospect theory-based method for group medical emergency decision-making with interval uncertainty.

BackgroundAn emergency response to a medical situation is generally considered to be a risk decision-making problem. When an emergency event occurs, it makes sense to take into account more than one decision maker’s opinions and psychological behaviors. The existing research tends to ignore these multidimensional aspects. To fill this literature gap, we propose a multi-attribute model. MethodsThe model is based on cumulative prospect theory (CPT), considering multiple experts’ psychological factors. By not assuming full rationality, we extend existing models to allow multiple experts’ risk preferences to be incorporated into the decision-making process in the case of an emergency. Then, traditional CPT is extended by allowing for multiple attributes. In addition, rather than using crisp data, interval values are adopted to tackle the usual uncertainties in reality.ResultsThe multi-attribute CPT based model proposed can deal with the selection of potential emergency alternatives. The model incorporates interval values to allow more uncertainty and the comparative studies show that the optimal solution changes under different scenarios.ConclusionsOur illustrative example and comparative study show that considering multiple experts and multiple attributes is more reasonable, especially in complicated situations under an emergency. In addition, decision-makers’ risk preferences highly affect the selection outcomes, highlighting their importance in the medical decision-making process. Our proposed model can be applied to similar fields with appropriate modifications.

Wise Choices in Health Care Especially Benefit Older People.

In the real world of medical interactions, it is necessary to simultaneously manage several comorbidities. Moreover, in each case there are usually several different treatment options and only some of these will include medication. If medication is to be used, then it often needs to be deployed in the context of organ dysfunction, such as chronic renal impairment. For older people, how choice is made can be even more complicated because when there is cognitive impairment it may be necessary for consumer decisions to be made by a proxy such as a legal authority or a doctor. How then can the complexities of the medical decision-making process be negotiated logically, safely, and equitably?

Clinical decision making for prediction of otitis using machine learning approach

This study investigates the relationship between autoimmune disease otitis and gut microbial community abundance by using machine learning as an aid in the medical decision-making process. Stool samples of healthy and otitis diseased infants were obtained from the curatedMetagenomicData package. Class imbalance present in the dataset was handled by oversampling a minority class. Afterwards, we built several machine learning models (support vector machine, k-nn, artificial neural networks, random forest and gradient boosting) to predict otitis from gut microbial samples. The best overall accuracy was obtained by the random forest classifier, 0.99, followed by support vector machine and gradient boosting algorithms, both achieving 0.96 accuracy. We also obtained the most informative predictors as potential microbial biomarkers for otitis disease. The obtained results showed better accuracy in prediction of otitis from microbial metagenome than previously proposed methods found in literature.

Comparative analysis of the role of medical staff in Korea following the coronavirus pandemic

The aim of this study is to analyse the roles played by medical personnel such as doctors and nurses in Korea in the context of Covid, and to suggest directions for responding to possible pandemics in the future from the perspective of the roles of medical personnel. For this analysis, Korean YouTube video contents were analysed; the analysis methods employed were text-mining and ego network analysis. The analysis target period was 2020, the year in which the Corona pandemic was declared, and 2021, one year after the declaration of the pandemic. As a result of the analysis six themes, derived from the perspective of the role of medical professionals, were selected in respect of each year. In the future, the Korean medical policy decision-making process should aim to reflect these topics.

The reimbursement coverage decisions and pricing rules for medical devices in Taiwan.

Medical technology is undergoing rapid transformations, and the classifications of medical devices have also expanded greatly; therefore, it is necessary to develop appropriate reimbursement policies and pricing mechanisms in a timely manner. This paper aims to introduce the reimbursement coverage and pricing rules for medical devices in Taiwan. In addition, this paper identifies and evaluates available health technology assessments (HTA) and literature on published websites concerning medical device decision-making processes and pricing systems in South Korea and Japan, which are near Taiwan and have similar reimbursement coverage processes. Reimbursement policy and pricing mechanisms are constantly being revised in Taiwan, Japan, and South Korea. Recently, all three countries attempted to establish new reimbursement coverage decision-making and pricing rules, adopting a differentiated approach based on the level of evidence required for the appropriated reimbursement in terms of a feasible evaluation mechanism for providing patients with more effective medical devices. This article is expected to contribute to providing references to new reimbursement coverage decision-making and pricing rules.

Complexity in shared decision making: a qualitative analysis of clinical encounters and patient/physician interviews

Background: Shared decision making is a complex clinical activity, for which the most effective educational interventions are unclear. Cultural Historical Activity Theory (CHAT) can be utilized as a framework to help medical educators understand and teach shared decision making. The objective of this qualitative study was to utilize CHAT to explore, through analysis of clinical encounters and interviews, patient and provider perspectives of a medical decision-making process that included use of a decision aid mobile application (app). Methods: Female patients from age 17 to 45, who sought care at a contraceptive clinic between April and June 2019, and physicians providing care in the clinic, were recruited for this study. Patients utilized the decision aid app prior to the visit. The clinical encounter and semi-structured interviews with each patient and physician were recorded. Template analysis was used to analyze the transcripts with themes including elements of activity systems within CHAT, tensions within and between activity systems, and agency. Results: In total, 21 patients and eight providers participated in the study. Evidence of CHAT elements were identified for each patient-physician dyad. In analyzing occurrences of codes across transcripts, recurring contradictions and themes emerged, such as how the app is utilized as a mediating tool and the importance of patient and physician communities. Conclusions: Through analysis of clinical encounters and focused interviews, patient and provider perspectives provided a unique understanding of the complex process of decision-making. These findings can assist educators in developing more effective teaching strategies that may lead to enhanced patient agency, effective relational agency, and successful shared decision making.

Medical Decision-Making Practices for Unrepresented Residents in Nursing Homes.

Unrepresented adults are individuals who lack decision-making capacity and have neither an available surrogate decision maker nor an applicable advance directive. Currently, the prevalence of unrepresented nursing home (NH) residents and how medical decisions are made is unknown. We examined (1) the prevalence of unrepresented NH residents, (2) NH policies and procedures to address medical decision making for those residents, and (3) NH staff's perceptions of medical decision making for unrepresented residents. We reviewed resident medical records and NH policy and procedure documents. We also conducted a survey of NH staff using an investigator-developed questionnaire. Sixty-six staff members recruited from 3 NHs (433 residents total) in 1 metropolitan area of Georgia, USA. Medical records and policy and procedure documents were reviewed using preset criteria. The survey included 31 structured and open-ended questions regarding medical decision-making practices for unrepresented residents (eg, awareness of medical decision-making processes, experiences in medical decision making, and suggestions to improve practice). We used descriptive statistics and conventional content analysis. Four residents (1%) met the criteria of being unrepresented. We found no written statements that specifically addressed medical decision making for unrepresented residents in the participating NHs. Of 66 survey participants, 11 had been involved in medical decision making for unrepresented residents. The most common decisions involved do-not-resuscitate orders, major medical and surgical treatments, and life-sustaining treatments. These decisions were made primarily by relying on the resident's physician or through discussions within the facility's interdisciplinary team. Suggestions included adopting explicit mechanisms or protocols related to decision making for unrepresented residents, education/training, and resources for group-based decision making. Although prevalence in the 3 NHs was low, NH care providers, ethical and legal professionals, and other key stakeholders should discuss practical approaches and policies to systematically identify unrepresented residents and to improve NHs' medical decision-making practices for them.

Quality of Life After Vestibular Schwannoma Surgery: A Question of Perspective.

ObjectiveHealth-related quality of life (HRQoL) and self-reported outcome measures have a relevant impact on the medical decision-making process. They capture either the current status and allow for multiple prospective evaluations in the course of a treatment or rely on the retrospective comparison of health of patients before and after an intervention to assess its benefit. Importantly, these patient-assessed measures may be influenced by psychological factors. We compared HRQoL and perceived benefit in the course of surgical vestibular schwannoma (VS) treatment, as assessed by the patients from a prospective and retrospective point-of-view, and evaluated the influence of co-morbid depression.MethodsWithin a prospective observational single-center study, forty-three patients with VS were investigated before and after retrosigmoid tumor resection. SF-36, Beck Depression Inventory and patient-assessed clinical symptoms were acquired before surgery and at follow-up. At follow-up, the Glasgow Benefit Inventory (GBI) was acquired as well.ResultsSF-36 scores were significantly lower than the age and sex matched normative data in six and three out of eight categories before and after surgery, respectively. Three categories improved significantly after vs. before surgery; one of them (global health) reached a minimal clinical important difference. In contrast, patients reported predominantly a deterioration, when asked for a retrospective evaluation of the benefit (i.e., GBI). Depression correlated with both SF-36 and GBI, determined dissatisfaction, improved significantly after surgery and was the measure that had the largest impact on HRQoL.ConclusionProspective and retrospective HRQoL measures may lead to different findings and can be confounded by psychological factors.

A Divergence-Based Medical Decision-Making Process of COVID-19 Diagnosis

This study is concerned with introducing a class of parametric and symmetric divergence measures under hesitant fuzzy environment. The proposed divergence measures have several interesting properties which make their use attractive. In order for exploring the features of proposed divergence measures for hesitant fuzzy sets (HFSs), we compare them with other existing ones in terms of divergence-initiated weighs and counter-intuitive cases. In the process of comparison, we first modify the conventional framework of hesitant fuzzy additive ratio assessment (HFARAS) using the proposed divergence measures, and then, the superiority of proposed measures is further demonstrated in a COVID-19 case study. There, we notify that the other existing divergence measures may not provide satisfactory results.

MEDICAL DECISION-MAKING AND EDUCATION RELATED TO OSTOMY SURGERY IN PEDIATRIC PATIENTS WITH IBD: QUALITATIVE THEMES FROM MULTIDISCIPLINARY PROVIDER FOCUS GROUPS

Abstract INTRODUCTION Pediatric patients with Inflammatory Bowel Disease (IBD) may undergo ostomy surgery, which surgically diverts stool to be collected in a bag worn on the abdomen. In addition to medical decision-making about ostomy surgery being innately complex and necessary to take a developmental approach, the medical decision also intersects with multiple disciplines and arguably requires nuanced coordination and collaboration for optimal medical decision-making and educational support. METHODS Multidisciplinary providers at a large, urban pediatric institution were recruited to participate in semi-scripted focus groups on medical decision-making and education related to ostomy surgery in pediatric patients with IBD. Focus groups occurred virtually and were recorded and transcribed for qualitative analysis of focus group content, with iterative analysis to generate qualitative themes. RESULTS Three focus groups were held, with a total of n=12 providers across all focus groups. Participants included pediatric GI providers (n=6), surgeons (n=2), GI nurse practitioner (n=1), GI social worker (n=1), and ostomy nurses (n=2). Participants reported providing care to patients at the institution for an average of 10 years (SD=9.7), and all worked with pediatric IBD patients. Focus group themes included 1) Ostomy surgery as a later treatment option for IBD patients, 2) Perception of “Defeat”/“failure,” 3) Differences between IBD patients (e.g., Crohn’s Disease versus ulcerative colitis), 4) Patients feeling unwell medically pre-operatively plays a role, 5) Psychosocial needs/support of patients, 6) Professional role issues/Provider Role considerations, 7) Provider perceptions of ostomies, 8) Provider Concerns/Needs, 10) Timing Considerations/Concerns, 11) Family Considerations/Challenges, and 12) Coordination/collaboration challenges. CONCLUSIONS The decision to consider ostomy surgery in pediatric IBD is often a complex decision that requires nuanced medical decision-making conversations and education for the patient and the parent/family. Further, this medical decision-making process often involves coordination and collaboration with multidisciplinary providers and often occurs over a period of time. This work assessed multidisciplinary providers’ perception of coordination and collaboration across specialties in supporting young people with IBD considering ostomy surgery. Qualitative themes identified psychosocial needs of patients and families throughout the process, various roles of multidisciplinary providers in the ostomy surgery decision, and logistical timing and coordination concerns during this medical decision. This work highlights the developmental and psychosocial considerations in supporting patients and parents through a complex medical decision.

The Stockholm CREAtinine Measurements (SCREAM) project: Fostering improvements in chronic kidney disease care.

SCREAM (Stockholm CREAtinine Measurements project) was initiated in 2010 in collaboration with the healthcare provider of Stockholm County healthcare to quantify potential medication errors, estimate the burden of chronic kidney disease (CKD) and to illustrate the value of incorporating measures of kidney function into the medical decision process. Because most patients are unaware of their CKD and diagnoses are seldom issued, SCREAM took advantage of the commonness of serum/plasma creatinine testing, which can be used to estimate the glomerular filtration rate (eGFR) and classify the stage of CKD severity. SCREAM is periodically updated, and at present contains healthcare information of all residents in Stockholm region during 2006-2019 (about 3 million people), enriched with a broad range of laboratory measurements for those in whom creatinine or albuminuria has been measured (about 1.8 million people). This health information was linked with national administrative and quality registries via the unique personal identification number of each Swedish citizen, conforming the richest characterization in Sweden of the population's journey through health and disease. This review discusses the context of its creation, strengths and weakness, key findings and plans for the future. We summarize our findings related to the burden of CKD in Sweden, its adverse health risks (such as risk of infections, cancer or dementia) and how underlying kidney function alters the risk-benefit ratio of common medications. Results have had clinical impact and demonstrate the importance of population-based research in the spectrum of clinical research to improve health.