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Inverse optimization on hierarchical networks: an application to breast cancer clinical pathways


Clinical pathways are standardized processes that outline the steps required for managing a specific disease. However, patient pathways often deviate from clinical pathways. Measuring the concordance of patient pathways to clinical pathways is important for health system monitoring and informing quality improvement initiatives. In this paper, we develop an inverse optimization-based approach to measuring pathway concordance in breast cancer, a complex disease. We capture this complexity in a hierarchical network that models the patient’s journey through the health system. A novel inverse shortest path model is formulated and solved on this hierarchical network to estimate arc costs, which are used to form a concordance metric to measure the distance between patient pathways and shortest paths (i.e., clinical pathways). Using real breast cancer patient data from Ontario, Canada, we demonstrate that our concordance metric has a statistically significant association with survival for all breast cancer patient subgroups. We also use it to quantify the extent of patient pathway discordances across all subgroups, finding that patients undertaking additional clinical activities constitute the primary driver of discordance in the population.

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The authors thank the Editor-in-Chief (Gregory S. Zaric), an anonymous associate editor, and three anonymous referees for their valuable comments and suggestions that significantly improved the paper. The authors also thank Grace Bannerman and Sarah Bastedo for their project management support. This study was conducted with the support of Ontario Health (Cancer Care Ontario) through funding provided by the Ontario Ministry of Health and funding from the Ontario Institute for Cancer Research. Parts of this material are based on data and information provided by Ontario Health (Cancer Care Ontario). The opinions, results, views, and conclusions reported in this publication are those of the authors and do not necessarily reflect those of Ontario Health (Cancer Care Ontario). No endorsement by Ontario Health (Cancer Care Ontario) is intended or should be inferred.

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Correspondence to Nasrin Yousefi.

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Appendix A: Pathway requirements for subgroups 3-9

Table 8 Clinical pathway requirements for subgroup 3
Table 9 Clinical pathway requirements for subgroup 4
Table 10 Clinical pathway requirements for subgroup 5
Table 11 Clinical pathway requirements for subgroup 6
Table 12 Clinical pathway requirements for subgroup 7
Table 13 Clinical pathway requirements for subgroup 8
Table 14 Clinical pathway requirements for subgroup 9

Appendix B: Supplementary figures and tables

Fig. 7
figure 7

Distribution of difference in concordance scores between a bootstrapped sample and the original model

Table 15 Risk of mortality associated with concordance score (ω) for subgroups when patient data are swapped in model (4)

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Chan, T.C.Y., Forster, K., Habbous, S. et al. Inverse optimization on hierarchical networks: an application to breast cancer clinical pathways. Health Care Manag Sci (2022).

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  • Operations research
  • Inverse optimization
  • Hierarchical network
  • Clinical pathway concordance
  • Breast cancer
  • Survival analysis