Department of Biostatistics

Introduction: We performed a systematic review and meta-analysis to identify predictors of serious clinical outcomes after an acute-care evaluation for syncope.

Methods: We identified studies that assessed for predictors of short-term (≤30 days) serious clinical events after an emergency department (ED) visit for syncope. We performed a MEDLINE search (January 1, 1990 - July 1, 2017) and reviewed reference lists of retrieved articles. The primary outcome was the occurrence of a serious clinical event (composite of mortality, arrhythmia, ischemic or structural heart disease, major bleed, or neurovascular event) within 30 days. We estimated the sensitivity, specificity, and likelihood ratio of findings for the primary outcome. We created summary estimates of association on a variable-by-variable basis using a Bayesian random-effects model.

Results: We reviewed 2,773 unique articles; 17 met inclusion criteria. The clinical findings most predictive of a short-term, serious event were the following: 1) An elevated blood urea nitrogen level (positive likelihood ratio [LR+]: 2.86, 95% confidence interval [CI] [1.15, 5.42]); 2); history of congestive heart failure (LR+: 2.65, 95%CI [1.69, 3.91]); 3) initial low blood pressure in the ED (LR+: 2.62, 95%CI [1.12, 4.9]); 4) history of arrhythmia (LR+: 2.32, 95%CI [1.31, 3.62]); and 5) an abnormal troponin value (LR+: 2.49, 95%CI [1.36, 4.1]). Younger age was associated with lower risk (LR-: 0.44, 95%CI [0.25, 0.68]). An abnormal electrocardiogram was mildly predictive of increased risk (LR+ 1.79, 95%CI [1.14, 2.63]).

Conclusion: We identified specific risk factors that may aid clinical judgment and that should be considered in the development of future risk-prediction tools for serious clinical events after an ED visit for syncope.

Introduction: We sought to compare three hospital cost estimation models for patients undergoing evaluation for unexplained syncope with hospital cost data. Developing such a model would allow researchers to assess the value of novel clinical algorithms for syncope management.

Methods: Complete health services data, including disposition, testing, and length of stay (LOS), were collected on 67 adult patients (age 60 years and older) who presented to the Emergency Department (ED) with syncope at a single hospital. Patients were excluded if a serious medical condition was identified. Three hospital cost estimation models were created to estimate facility costs: V1, unadjusted Medicare payments for observation and/or hospital admission, V2: modified Medicare payment, prorated by LOS in calendar days, and, V3: modified Medicare payment, prorated by LOS in hours. Total hospital costs included unadjusted Medicare payments for diagnostic testing and estimated facility costs. These estimates were plotted against actual cost data from the hospital finance department. Correlation and regression analyses were performed.

Results: Of the three models, V3 consistently outperformed the others with regard to correlation and goodness of fit. The Pearson correlation coefficient for V3 was 0.88 (95% Confidence Interval 0.81, 0.92) with an R-square value of 0.77 and a linear regression coefficient of 0.87 (95% Confidence Interval 0.76, 0.99).

Conclusion: Using basic health services data, it is possible to accurately estimate hospital costs for older adults undergoing a hospital-based evaluation for unexplained syncope. This methodology could help assess the potential economic impact of implementing novel clinical algorithms for ED syncope. 

Introduction: The emergency department (ED) is an inherently high-risk setting. Risk scores can help practitioners understand the risk of ED patients for developing poor outcomes after discharge. Our objective was to develop two risk scores that predict either general inpatient admission or death/intensive care unit (ICU) admission within seven days of ED discharge.

Methods: We conducted a retrospective cohort study of patients age > 65 years using clinical data from a regional, integrated health system for years 2009-2010 to create risk scores to predict two outcomes, a general inpatient admission or death/ICU admission. We used logistic regression to predict the two outcomes based on age, body mass index, vital signs, Charlson comorbidity index (CCI), ED length of stay (LOS), and prior inpatient admission.

Results: Of 104,025 ED visit discharges, 4,638 (4.5%) experienced a general inpatient admission and 531 (0.5%) death or ICU admission within seven days of discharge. Risk factors with the greatest point value for either outcome were high CCI score and a prolonged ED LOS. The C-statistic was 0.68 and 0.76 for the two models.

Conclusion: Risk scores were successfully created for both outcomes from an integrated health system, inpatient admission or death/ICU admission. Patients who accrued the highest number of points and greatest risk present to the ED with a high number of comorbidities and require prolonged ED evaluations.

Americans have differing opinions on whether greater regulation of firearms results in improved public safety. One area that seems to enjoy broad support is to limit firearm access in specific locations. “Bar Ban” laws—which prohibit firearms where alcohol is served—represent one such approach, yet their effectiveness remains largely unexamined nationally. This paper provides the first comprehensive evaluation of the impact of Bar Ban laws on shootings near alcohol-related establishments. Using a geospatial panel dataset of over 1.6 million alcohol vendors active across the United States between January 2019 and January 2025, we analyze the relationship between restrictions on carrying a gun where alcohol is served and gun violence. Results show that shootings occur close to alcohol-serving establishments: across 263,464 shooting incidents, the median distance to the nearest alcohol vendor was 222 meters. To assess the effectiveness of Bar Ban laws, we employ a stacked difference-in-differences design examining monthly shooting exposure rates of alcohol vendors across counties in five states (Hawaii, Maryland, New York, New Jersey, South Dakota) that adopted Bar Ban laws during our study period. Our findings reveal a policy puzzle: while spatial analyses confirm that shootings routinely occur near alcohol establishments, Bar Ban laws targeting these locations show no discernible effect on reducing shooting incidents. Thus, states adopting these restrictions saw no substantial change in county-level shooting exposure rates near alcohol vendors.

Extended methodological details for the uncertainty quantification procedure, technical proofs for theorems, a simulation study to examine the impact of resampling on efficiency scores, and detailed variable selection procedures for the fairness analyses are included in this file. R code implementing the proposed method is available both in the Supplementary Material and at https://github.com/amofrad/Kidney-Exchange-DEA. Kidney exchange programs have substantially increased transplantation rates but also raise critical concerns about fairness in organ allocation. We propose a novel framework leveraging Data Envelopment Analysis (DEA) to evaluate multiple dimensions of fairness—Priority, Access, and Outcome—within a unified model. This approach captures complexities often missed in single-metric analyses. Using data from the United Network for Organ Sharing, we separately quantify fairness across these dimensions: Priority Fairness through waitlist durations, Access Fairness via the Living Kidney Donor Profile Index (LKDPI) scores, and Outcome Fairness based on graft lifespan. We then apply our conditional DEA model with covariate adjustment to demonstrate significant disparities in kidney allocation efficiency across ethnic groups. To quantify uncertainty, we employ conformal prediction within a novel reference frontier mapping (RFM) framework, yielding group-conditional prediction intervals with finite-sample coverage guarantees. Our findings show notable differences in efficiency distributions between ethnic groups. Our study provides a rigorous framework for evaluating fairness in complex resource allocation systems with resource scarcity and mutual compatibility constraints.

ABSTRACT Air pollution remains a major environmental risk factor that is often associated with adverse health outcomes. However, quantifying and evaluating its effects on human health is challenging due to the complex nature of exposure data. Recent technological advances have led to the collection of various indicators of air pollution at increasingly high spatial‐temporal resolutions (e.g., daily averages of pollutant levels at spatial locations referenced by latitude‐longitude). However, health outcomes are typically aggregated over several spatial‐temporal coordinates (e.g., annual prevalence for a county) to comply with survey regulations. This article develops a Bayesian hierarchical model to analyze such spatially‐temporally misaligned exposure and health outcome data. We develop Bayesian predictive stacking for spatially and temporally misaligned data to optimally combine inference from multiple predictive spatial‐temporal models. Stacking allows us to avoid iterative estimation algorithms such as Markov chain Monte Carlo that struggle due to convergence issues inflicted by the presence of weakly identified parameters. We apply our proposed method to study the effects of ozone on asthma in the state of California.

B cells play a crucial role in humoral immunity, acting as sentinels against viral infections by using their B cell receptors (BCRs) to recognize viral proteins. This recognition typically triggers a response leading to the production of neutralizing antibodies against viral surface proteins, such as the viral envelope proteins. However, recent studies have revealed a surprising dual role for BCRs, showing that some enveloped viruses and viral vectors, such as Dengue virus and lentiviral vectors, can exploit anti-viral BCRs as their attachment and entry receptors to infect/transduce B cells. While these viruses use a simple low-pH-dependent fusion mechanism for entry, it remained unclear whether BCRs could facilitate the entry of viruses with more complex fusion requirements, such as HIV-1 and SARS-CoV-2, which rely on their cognate receptors to activate their fusion machinery. In this study, we investigated the ability of BCRs to mediate viral entry for HIV-1 and SARS-CoV-2, which require specific host receptors (CD4 and ACE2, respectively) to activate their fusion machinery. We found that while anti-HIV-1 envelope protein BCRs can mediate viral attachment, they are unable to facilitate viral fusion and entry. In contrast, anti-SARS-CoV-2 Spike (S) protein BCRs not only mediate attachment but also enable viral entry in the absence of the ACE2 receptor. Our findings demonstrate that the ability of anti-viral BCRs to mediate viral fusion/entry is not universal but depends on the specific viral envelope protein. This novel entry pathway has important implications for both viral replication and the development of B cell-mediated immunity.

Building spatial process models that capture nonstationary behavior while delivering computationally efficient inference is challenging. Nonstationary spatially varying kernels (see, e.g., Paciorek, 2003) offer flexibility and richness, but computation is impeded by high-dimensional parameter spaces resulting from spatially varying process parameters. Matters are exacerbated if the number of locations recording measurements is massive. With limited theoretical tractability, obviating computational bottlenecks requires synergy between model construction and algorithm development. We build a class of scalable nonstationary spatial process models using spatially varying covariance kernels. We implement a Bayesian modeling framework using Hybrid Monte Carlo with nested interweaving. We conduct experiments on synthetic data sets to explore model selection and parameter identifiability, and assess inferential improvements accrued from nonstationary modeling. We illustrate strengths and pitfalls with a data set on remote sensed normalized difference vegetation index.

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The kidney paired donation (KPD) program provides an innovative solution to overcome incompatibility challenges in kidney transplants by matching incompatible donor-patient pairs and facilitating kidney exchanges. To address unequal access to transplant opportunities, there are two widely used fairness criteria: group fairness and individual fairness. However, these criteria do not consider protected patient features, which refer to characteristics legally or ethically recognized as needing protection from discrimination, such as race and gender. Motivated by the calibration principle in machine learning, we introduce a new fairness criterion: the matching outcome should be conditionally independent of the protected feature, given the sensitization level. We integrate this fairness criterion as a constraint within the KPD optimization framework and propose a computationally efficient solution using linearization strategies and column-generation methods. Theoretically, we analyze the associated price of fairness using random graph models. Empirically, we compare our fairness criterion with group fairness and individual fairness through both simulations and a real-data example.