Duke AI Health, Durham, North Carolina.
Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, North Carolina.
JAMA. 2023 Jan 24;329(4):306-317. doi: 10.1001/jama.2022.24683.
IMPORTANCE: Stroke is the fifth-highest cause of death in the US and a leading cause of serious long-term disability with particularly high risk in Black individuals. Quality risk prediction algorithms, free of bias, are key for comprehensive prevention strategies. OBJECTIVE: To compare the performance of stroke-specific algorithms with pooled cohort equations developed for atherosclerotic cardiovascular disease for the prediction of new-onset stroke across different subgroups (race, sex, and age) and to determine the added value of novel machine learning techniques. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study on combined and harmonized data from Black and White participants of the Framingham Offspring, Atherosclerosis Risk in Communities (ARIC), Multi-Ethnic Study for Atherosclerosis (MESA), and Reasons for Geographical and Racial Differences in Stroke (REGARDS) studies (1983-2019) conducted in the US. The 62 482 participants included at baseline were at least 45 years of age and free of stroke or transient ischemic attack. EXPOSURES: Published stroke-specific algorithms from Framingham and REGARDS (based on self-reported risk factors) as well as pooled cohort equations for atherosclerotic cardiovascular disease plus 2 newly developed machine learning algorithms. MAIN OUTCOMES AND MEASURES: Models were designed to estimate the 10-year risk of new-onset stroke (ischemic or hemorrhagic). Discrimination concordance index (C index) and calibration ratios of expected vs observed event rates were assessed at 10 years. Analyses were conducted by race, sex, and age groups. RESULTS: The combined study sample included 62 482 participants (median age, 61 years, 54% women, and 29% Black individuals). Discrimination C indexes were not significantly different for the 2 stroke-specific models (Framingham stroke, 0.72; 95% CI, 0.72-073; REGARDS self-report, 0.73; 95% CI, 0.72-0.74) vs the pooled cohort equations (0.72; 95% CI, 0.71-0.73): differences 0.01 or less (P values >.05) in the combined sample. Significant differences in discrimination were observed by race: the C indexes were 0.76 for all 3 models in White vs 0.69 in Black women (all P values <.001) and between 0.71 and 0.72 in White men and between 0.64 and 0.66 in Black men (all P values ≤.001). When stratified by age, model discrimination was better for younger (<60 years) vs older (≥60 years) adults for both Black and White individuals. The ratios of observed to expected 10-year stroke rates were closest to 1 for the REGARDS self-report model (1.05; 95% CI, 1.00-1.09) and indicated risk overestimation for Framingham stroke (0.86; 95% CI, 0.82-0.89) and pooled cohort equations (0.74; 95% CI, 0.71-0.77). Performance did not significantly improve when novel machine learning algorithms were applied. CONCLUSIONS AND RELEVANCE: In this analysis of Black and White individuals without stroke or transient ischemic attack among 4 US cohorts, existing stroke-specific risk prediction models and novel machine learning techniques did not significantly improve discriminative accuracy for new-onset stroke compared with the pooled cohort equations, and the REGARDS self-report model had the best calibration. All algorithms exhibited worse discrimination in Black individuals than in White individuals, indicating the need to expand the pool of risk factors and improve modeling techniques to address observed racial disparities and improve model performance.
重要性:在美国,中风是第五大死因,也是导致严重长期残疾的主要原因,黑人的风险尤其高。无偏差的高质量风险预测算法是综合预防策略的关键。 目的:比较特定于中风的算法与针对动脉粥样硬化性心血管疾病开发的 pooled cohort equations 在不同亚组(种族、性别和年龄)中新发中风的预测性能,并确定新的机器学习技术的附加值。 设计、设置和参与者:对来自 Framingham Offspring、Atherosclerosis Risk in Communities (ARIC)、Multi-Ethnic Study for Atherosclerosis (MESA) 和 Reasons for Geographical and Racial Differences in Stroke (REGARDS) 研究的黑人和白人参与者的合并和协调数据进行回顾性队列研究(1983-2019 年),这些研究在美国进行。基线时纳入的 62482 名参与者年龄至少为 45 岁,且无中风或短暂性脑缺血发作史。 暴露:Framingham 和 REGARDS 的特定于中风的算法(基于自我报告的危险因素)以及针对动脉粥样硬化性心血管疾病的 pooled cohort equations 加上 2 种新开发的机器学习算法。 主要结果和测量:设计模型以估计新发中风(缺血性或出血性)的 10 年风险。在 10 年内评估了预期与观察到的事件发生率之比的判别协方差指数(C 指数)和校准比。分析按种族、性别和年龄组进行。 结果:合并研究样本包括 62482 名参与者(中位数年龄 61 岁,54%为女性,29%为黑人)。2 种特定于中风的模型(Framingham 中风,0.72;95%CI,0.72-073;REGARDS 自我报告,0.73;95%CI,0.72-0.74)与 pooled cohort equations(0.72;95%CI,0.71-0.73)的判别 C 指数没有显著差异:差异在 0.01 或更小(P 值>.05)。在合并样本中观察到显著的种族差异:3 种模型在白人中的 C 指数为 0.76,而在黑人女性中为 0.69(所有 P 值均<.001),在白人男性中为 0.71-0.72,在黑人男性中为 0.64-0.66(所有 P 值均≤.001)。按年龄分层,对于年龄小于 60 岁的黑人或白人个体,模型的判别能力优于年龄大于或等于 60 岁的个体。REGARDS 自我报告模型的观察到的与预期的 10 年中风发生率之比最接近 1.05(95%CI,1.00-1.09),表明风险高估,Framingham 中风(0.86;95%CI,0.82-0.89)和 pooled cohort equations(0.74;95%CI,0.71-0.77)。当应用新的机器学习算法时,性能没有显著提高。 结论和相关性:在这项对来自美国 4 个队列的无中风或短暂性脑缺血发作的黑人和白人个体的分析中,与 pooled cohort equations 相比,现有的特定于中风的风险预测模型和新的机器学习技术并没有显著提高新发中风的判别准确性,而 REGARDS 自我报告模型的校准效果最好。所有算法在黑人个体中的判别能力均低于白人个体,表明需要扩大风险因素池,并改进建模技术,以解决观察到的种族差异并提高模型性能。
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