EXAMPLE OF HEALTH PROMOTION AT THE ALFRED

Shower & locker facilities for cyclists.

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ACTIVITY TRACKER APPS??

CatchPokemon Motivationtogetoutsidetohuntem.
Hatcheggs Motivationtowalk2km,5kmor10km
incubateandhatcheggs.

Eviehaswalked400+kmsinceJulyplayingPokemon!

MONASH 10,000STEPS

CELEBRITIES MAKING LOGISTIC REGRESSION

AND BREAST RECONSTRUCTION SEXY
PennyRobinson
BBioMed Sc (Hons),MBiostat,GCAP
SchoolofPublicHealthandPreventiveMedicine
Email:Penny.Robinson@monash.edu
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Twitter:@PennyRobaus

OBJECTIVES

Attheendofthislecture,youwillbeableto:
Explaintheimportanceoflogisticregressioninpublichealth.
Describewhenlogisticregressionisappropriate.
Describethecomponentsofthelogisticregressionequation.
Interpretlogisticregressionoutput.

WHAT WELL COVER TODAY

Linearregressionrefresher

Logisticregression(example:breastreconstruction)

TheAngelinaJolieeffect

Anexampleofconfounding

Modelprediction

Modelevaluation

LINEAR REGRESSION REFRESHER

Generalequation:

y 0 1 x1
BW=0.05957 OL+2.183

Numerical
continuous

Numerical: continuous

EXAMPLE USED IN THE LECTURE

Dataset:BUPAHealthFoundationHealthandWellbeingafter
BreastCancerStudy.
Studyquestion:Whatfactorsinfluenceawomansdecisionto
have/nothaveabreastreconstructionaftermastectomyfor
breastcancer?

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SURGERY OPTIONS TO TREAT BREAST CANCER

Some women have a breast reconstruction.

Double mastectomy = both breasts removed.

Breastreconstructioncanbeanimplant,orcanbemuscle/skin
flapsfromelsewhereonthebody(back,stomach).
http://www.cancer.org/cancer/breastcancer/overviewguide/breast-cancer-overview-treating-surgery

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WHO WAS INCLUDED IN THE ANALYSIS?

Completedthe2nd followupquestionnaire(FQ2).

Onaverage2.8yearsafterdiagnosis.

Noactivediseaseorrecurrenceofbreastcancerbythen.
Hadamastectomyononeside(unilateral).
i.e.Womenwhohadadoublemastectomywerenotincluded.
Womenwhohadalumpectomywerenotincluded.

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FLOW CHART OF WOMEN WHO HAD A UNILATERAL MASTECTOMY

Whattypeofvariableishadabreastreconstruction(Y/N)?
Categorical binary

Isbreastreconstructiontheoutcomeorexposure?

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INTRODUCTION TO LOGISTIC REGRESSION

Outcome:Categorical binary
i.e.Didtheoutcomeoccur Yes/No?
Logisticregressionisverycommonlyused inpublichealth.

Exposure:

CanbeCategoricalorContinuous(sameaslinearregression)

Logofoddsofoutcome:

Probability(orrisk,)

0 1 x1

log

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GENERAL LOGISTIC REGRESSION EQUATION

ln
0 1 x1
1
e

ln

e
y
0 1 x1
1 e

e 0 1x1

1 e
e

1 e

0 1 x1

0 1 x1

0 1 x1

0 1 x1

e 0 1x1

e 0 1 x1

Generallogisticregression:
0 1 x1

e 0 1x1

0 1 x1

e 0 1x1

1 e 0 1 x1

yrangesfrom0to1.

Oddsofdisease=exp(1)
Exp()ofteninoutputnot.

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STEP 1
CATEGORICAL
%TABLES
UNIVARIABLE
LOGISTIC
REGRESSION

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STEP 1
CATEGORICAL
%TABLES
UNIVARIABLE
LOGISTIC REGRESSION

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STEP 2 MULTIVARIABLE LOGISTIC REGRESSION

Whichfactorsareassociatedwithanincreased rateofbreastreconstruction?
AnythingwithOR>1:Postsecondaryschool,privatehealth.
Whichfactorsareassociatedwithadecreased rateofbreastreconstruction?
AnythingwithOR<1:Age,Nonmetro,Dependentchild,Radiotherapy.
InterprettheNagelkerke r2.(SimilartoR2 forlinearregression)
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41.1%ofthevariationinbreastreconstructionexplainedbythe6factorsinthe
model.

BREAST RECONSTRUCTION PAPER TABLE 4,95%CIAS A GRAPH

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LOGISTIC REGRESSION GRAPHICALLY (AGE ONLY)

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LOGISTIC REGRESSION GRAPHICALLY (AGE +PRIVATE HEALTH)

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http://time.com/3450368/
theangelinaeffect/

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BREAST RECONSTRUCTION IN THE MEDIA (@ELLI_IZRAILOV)

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http://www.heraldsun.com.au/lifestyle/health/angelina-jolies-celebrity-mastectomycoverage-improves-awareness/story-fni0diac-1227547459215

CONFOUNDING

Age (yrs)
Dependent
child < 12 yrs

Univariable OR = 1.65

Breast
reconstruction

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CONFOUNDING

Age (yrs)
Dependent
child < 12 yrs

Univariable OR = 1.65
Multivariable OR = 0.29

Breast
reconstruction

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MODEL PREDICTION THERES AN APP FOR THAT!

Modelpredictionmorecomplexthanlinear!
y

0 1 x1 ... p x p

1 e

0 1 x1 ... p x p

AusSCORE II (Google Play)

https://play.google.com/store/apps/details?id=com.telerik.AusSCOREII

EuroSCORE online calculator

http://www.euroscore.org/calc.html

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BACKGROUND TO PHONE APPS

Linearregressionmodelpredictionisstraightforward.
Modelpredictionusinglogisticregressionismorecomplex.

Thereareafewmortalitymodelsforcardiacsurgery,incl:
EuroSCORE(DevelopedinEuropein1999)
http://ejcts.oxfordjournals.org/content/16/1/9.short
EuroSCOREII(DevelopedinEuropein2012)
Aus SCORE(DevelopedbyMonashSPHPMin2009)
Aus SCOREII(DevelopedbyMonashSPHPMin2014)
http://www.sciencedirect.com/science/article/pii/S0022522314001871

Thesemodelsincludeanadditivemodel(usingOddsRatiosasestimates)and
multiplicativemodel(usinglogisticmodelequation).

Cardiacsurgeonsneedbackofenvelopemodeltopredictmortalityriskand
explainrisktopatients.Hencephoneappshavebeendeveloped.

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Question:Ifyouwereabusycardiacsurgeon,whatwould
appeal toyouabouthavingtheApp?

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AUSSCORE IIAPP

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http://dx.doi.org/10.1016/j.jtcvs.2014.02.027

CASE 1

Woman, Elective surgery, No dialysis, No previous MI.

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CASE 2

Woman, Emergency surgery, No dialysis, No previous MI.

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CASE 3

Woman, Emergency surgery, Yes dialysis, No previous MI.

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CASE 4

Woman, Emergency surgery, Yes dialysis, Yes previous MI.

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Question:Ifyouwereabusycardiacsurgeon,whatwould
appeal toyouabouthavingtheApp?

Cheap(appisFREE)
Quick
Easy(appcalculatesadditive&logisticmodel)

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WAYS TO EVALUATE A LOGISTIC REGRESSION MODEL

HosmerLemeshow goodnessoffitstatistic

Measureofmodelcalibration.

ApproximatedbythePearsons2 statistic.
Comparestheobservedandexpectedfrequenciesofoutcome(Y/N)
acrossdecilesofrisk.

Interpretingthe2 value

Alow2 value=highpvalue>0.05.Themodelfitsthedatawell.

Ahigh2 value=lowpvalue<0.05.Themodelisapoorfittothedata.

ReceiverOperatorCharacteristic(ROC)curveandcindex
Howwelldoesthemodeldiscriminatebetweenpatientswhodevelop/
donotdeveloptheoutcomeofinterest accordingtoprediction.
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Acutoffrisk(valueofy)isspecifiedaspartoftheanalysis.

RECEIVER OPERATOR CHARACTERISTIC (ROC)CURVE AND CINDEX

Sensitivity(yaxis)vs1 Specificity(xaxis)plottedonagraph.

c-index = 0.725
Good fit

c-index = 0.884
Very good fit

Cindex:TheareaundertheROCcurve.

cindex=1.0Perfectaccuracy
cindex>0.8Verygoodfit
cindex0.7to0.8Goodfit
cindex<0.7Poorfit
cindex0.5Nobetterthanchance

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SOMETIMES A DEVELOPED MODEL HAS NO EXTERNAL VALIDITY

Creationdataset=datathatisusedtocreatethemodel.
Validationdataset=datausedtocheckthemodel.
MyHonoursthesis(2005):Themodelwasgoodinthecreation
dataset,butpoorinthevalidationone.

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SUMMARY OF WEEK 10LECTURE

Logisticregressionisverycommonlyusedinpublichealth.

Outcome:Categorical binary.(Yes 1;No 0)

Exposure(s):Categoricalorcontinuous

Generalform:
y

0 1 x1 ... p x p

1 e

0 1 x1 ... p x p

exp()=OR.Oftengiveninoutputinsteadof.

Modelpredictionismorecomplexthanlinearregression.

Modelevaluation

HosmerLemeshow goodnessoffit

ReceiverOperatorCharacteristic(ROC)curve

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