Assessment of Claims of Improved Prediction Beyond the Framingham Risk Score

被引:210
作者
Tzoulaki, Ioanna [2 ]
Liberopoulos, George [1 ]
Ioannidis, John P. A. [1 ,3 ,4 ,5 ]
机构
[1] Univ Ioannina, Sch Med, Dept Hyg & Epidemiol, Clin & Mol Epidemiol Unit, GR-45110 Ioannina, Greece
[2] Univ London Imperial Coll Sci Technol & Med, Dept Epidemiol & Publ Hlth, London, England
[3] Fdn Res & Technol Hellas, Biomed Res Inst, Ioannina, Greece
[4] Tufts Univ, Sch Med, Inst Clin Res & Hlth Policy Studies, Tufts Med Ctr, Boston, MA 02111 USA
[5] Tufts Univ, Sch Med, Dept Med, Boston, MA 02111 USA
来源
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION | 2009年 / 302卷 / 21期
关键词
CORONARY-HEART-DISEASE; C-REACTIVE PROTEIN; INTIMA-MEDIA THICKNESS; APPARENTLY HEALTHY-MEN; ANKLE BRACHIAL INDEX; MIDDLE-AGED MEN; CARDIOVASCULAR-DISEASE; PROGNOSTIC VALUE; MYOCARDIAL-INFARCTION; METABOLIC SYNDROME;
D O I
10.1001/jama.2009.1757
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
Context With heightened interest in predictive medicine, many studies try to document information that can improve prediction of major clinical outcomes. Objective To evaluate the reported design and analysis of studies that examined whether additional predictors improve predictive performance when added to the Framingham risk score (FRS), one of the most widely validated and cited clinical prediction scores. Study Selection Two independent investigators searched 1908 articles citing the article that described the FRS in 1998 until September 2009 through the ISI Web of Knowledge database. Articles were eligible if they included any analyses comparing the predictive performance of the FRS vs the FRS plus some additional predictor for a prospectively assessed outcome. Data Analyses We recorded information on FRS calculation, modeling of additional predictors, outcomes assessed, population evaluated, subgroup analysis documentation, and flaws in the methods that may have affected the reported improvements in predictive ability. We also evaluated the correlation of reported design and analysis features with the predictive model discrimination and improvements with the additional predictors. Results We evaluated 79 eligible articles. Forty-nine studies (62%) did not calculate the FRS as it has been proposed, 15 (19%) modeled the additional predictor in more than 1 way and presented only the best-fit or area-under-the-curve (AUC) results for only 1 model, 41 (52%) did not examine the original outcome that the FRS was developed for, 33 (42%) studied a population different from what the FRS was intended for, and 25 (32%) claimed improved prediction in 1 subgroup but only 7 (9%) formally tested subgroup differences. Evaluation of independence in multivariable regressions, discrimination in AUC, calibration, and reclassification were reported in 77, 36, 7, and 7 studies, respectively, but these methods were adequately documented in only 60, 13, 4, and 2 studies, respectively. Overall, 63 studies (80%) claimed some improved prediction. Increase in AUC was larger when the predictive performance of the FRS was lower (rho = -0.57, P < .001). Increase in AUC was significantly larger when evaluation of independence in multivariable regression or discrimination in AUC analysis was not adequately documented and when the additional predictor had been modeled in more than 1 way and only 1 model was reported for AUC. Conclusion The majority of examined studies claimed that they found factors that could offer additional predictive value beyond what the FRS could achieve; however, most had flaws in their design, analyses, and reporting that cast some doubt on the reliability of the claims for improved prediction. JAMA. 2009;302(21):2345-2352
引用
收藏
页码:2345 / 2352
页数:8
相关论文
共 96 条
[1]   Elevated fibrinogen and homocysteine levels enhance the risk of mortality in patients from a high-risk preventive cardiology clinic [J].
Acevedo, M ;
Pearce, GL ;
Kottke-Marchant, K ;
Sprecher, DL .
ARTERIOSCLEROSIS THROMBOSIS AND VASCULAR BIOLOGY, 2002, 22 (06) :1042-1045
[2]   Is personalized medicine finally arriving? [J].
Allison, Malorye .
NATURE BIOTECHNOLOGY, 2008, 26 (05) :509-517
[3]   Methodological challenges in the evaluation of prognostic factors in breast cancer [J].
Altman, DG ;
Lyman, GH .
BREAST CANCER RESEARCH AND TREATMENT, 1998, 52 (1-3) :289-303
[4]   Low-grade albuminuria and incidence of cardiovascular disease events in nonhypertensive and nondiabetic individuals -: The Framingham heart study [J].
Ärnlöv, J ;
Evans, JC ;
Meigs, JB ;
Wang, TJ ;
Fox, CS ;
Levy, D ;
Benjamin, EJ ;
D'Agostino, RB ;
Vasan, RS .
CIRCULATION, 2005, 112 (07) :969-975
[5]   Cholesterol levels in small LDL particles predict the risk of coronary heart disease in the EPIC-Norfolk prospective population study [J].
Arsenault, Benoit J. ;
Lemieux, Isabelle ;
Despres, Jean-Pierre ;
Wareham, Nicholas J. ;
Luben, Robert ;
Kastelein, John J. P. ;
Khaw, Kay-Tee ;
Boekholdt, S. Matthijs .
EUROPEAN HEART JOURNAL, 2007, 28 (22) :2770-2777
[6]   Usefulness of exercise testing in the prediction of coronary disease risk among asymptomatic persons as a function of the Framingham risk score [J].
Balady, GJ ;
Larson, MG ;
Vasan, RS ;
Leip, EP ;
O'Donnell, CJ ;
Levy, D .
CIRCULATION, 2004, 110 (14) :1920-1925
[7]   Measurement of carotid artery intima-media thickness in dyslipidemic patients increases the power of traditional risk factors to predict cardiovascular events [J].
Baldassarre, Damiano ;
Amato, Mauro ;
Pustina, Linda ;
Castelnuovo, Samuela ;
Sanvito, Silvia ;
Gerosa, Lorenzo ;
Veglia, Fabrizio ;
Keidar, Shlomo ;
Tremoli, Elena ;
Sirtori, Cesare R. .
ATHEROSCLEROSIS, 2007, 191 (02) :403-408
[8]   Factors associated with findings of published trials of drug-drug comparisons: Why some statins appear more efficacious than others [J].
Bero, Lisa ;
Oostvogel, Fieke ;
Bacchetti, Peter ;
Lee, Kirby .
PLOS MEDICINE, 2007, 4 (06) :1001-1010
[9]   C-reactive protein levels and coronary artery disease incidence and mortality in apparently healthy men and women: The EPIC-Norfolk prospective population study 1993-2003 [J].
Boekholdt, S. Matthijs ;
Hack, C. Erik ;
Sandhu, Manjinder S. ;
Luben, Robert ;
Bingham, Sheila A. ;
Wareham, Nicholas J. ;
Peters, Ron J. G. ;
Jukema, J. Wouter ;
Day, Nicholas E. ;
Kastelein, John J. P. ;
Khaw, Kay-Tee .
ATHEROSCLEROSIS, 2006, 187 (02) :415-422
[10]   Aortic stiffness is an independent predictor of primary coronary events in hypertensive patients - A longitudinal study [J].
Boutouyrie, P ;
Tropeano, AI ;
Asmar, R ;
Gautier, I ;
Benetos, A ;
Lacolley, P ;
Laurent, S .
HYPERTENSION, 2002, 39 (01) :10-15