A practical approach to a multi-level analysis with a sparse binary outcome within a large surgical trial

Objectives: To assess the potential source of variation that surgeon may add to patient outcome in a clinical trial of surgical procedures. Methods: Two large (n = 1380) parallel multicentre randomized surgical trials were undertaken to compare laparoscopically assisted hysterectomy with conventional methods of abdominal and vaginal hysterectomy; involving 43 surgeons. The primary end point of the trial was the occurrence of at least one major complication. Patients were nested within surgeons giving the data set a hierarchical structure. A total of 10% of patients had at least one major complication, that is, a sparse binary outcome variable. A linear mixed logistic regression model (with logit link function) was used to model the probability of a major complication, with surgeon fitted as a random effect. Models were fitted using the method of maximum likelihood in SAS((R)). Results: There were many convergence problems. These were resolved using a variety of approaches including; treating all effects as fixed for the initial model building; modelling the variance of a parameter on a logarithmic scale and centring of continuous covariates. The initial model building process indicated no significant 'type of operation' across surgeon interaction effect in either trial, the 'type of operation' term was highly significant in the abdominal trial, and the 'surgeon' term was not significant in either trial. Conclusions: The analysis did not find a surgeon effect but it is difficult to conclude that there was not a difference between surgeons. The statistical test may have lacked sufficient power, the variance estimates were small with large standard errors, indicating that the precision of the variance estimates may be questionable.

An agent based approach to distributed task modeling for co-operative task support

This paper describes the design and implementation of an agent based network for the support of collaborative switching tasks within the control room environment of the National Grid Company plc. This work includes aspects from several research disciplines, including operational analysis, human computer interaction, finite state modelling techniques, intelligent agents and computer supported co-operative work. Aspects of these procedures have been used in the analysis of collaborative tasks to produce distributed local models for all involved users. These models have been used as the basis for the production of local finite state automata. These automata have then been embedded within an agent network together with behavioural information extracted from the task and user analysis phase. The resulting support system is capable of task and communication management within the transmission despatch environment.