WST UWE MA Graphic Arts group 22mar11

Will Stahl-Timmins
22nd Mar 2011

Associate Research Fellow:
Visual Presentation of Environment and Human
Health Data and Information

European Centre for Environment and Human Health

PhD research intro

A journey (MA)

A journey (PhD)

Current work

Opportunities

what is a PhD?
PhD research intro

A journey (MA)

A journey (PhD)

Current work

Opportunities

what is a PhD?
PhD research intro

research training A journey (MA)

A journey (PhD)
large original research project
Current work

Opportunities

what is a PhD?
PhD research intro

research training A journey (MA)

A journey (PhD)
large original research project
Current work

3-4 years full time Opportunities

5+ years part time?

PhD research intro

A journey (MA)

A journey (PhD)

Current work

Opportunities

+ defence

PhD research intro

Also see: A journey (MA)
Stahl, W. 2009. Branding and Presentation of
Smart Clothing Products to Consumers in A journey (PhD)
Smart Clothes and Wearable Technology Eds.
McCann, J & Bryson, D. Woodhead: Current work
Cambridge, UK.
Opportunities

HTA PhD research intro

A journey (MA)

A journey (PhD)
Health Technology Current work
Assessment Opportunities

countries with ‘universal’ health care:

PhD research intro

A journey

My PhD (so far)

Opportunities

Health Policy

Medical
Practice PhD research intro

A journey (MA)
EBM A journey (PhD)

Current work
HTA
Opportunities

Scientific
Evidence

PhD research intro

A journey

My PhD (so far)

Opportunities

TAR review

• 50 reports reviewed PhD research intro

• content analysis A journey (MA)

A journey (PhD)
• graphics categorised
Current work

Opportunities

OTHER
LINE 353

301 PhD research intro
AREA A journey (MA)
/POSITION

FLOW 187
A journey (PhD)
124
Current work

102 124 37 38 78 41 5 88 55 44 331 22
Opportunities
BAR CHART

SCATTER PLOT

FOREST PLOT
STATE TRANSITION
THRESHOLD ANALYSIS

DECISON TREE
TIME SERIES

CEAC

OTHER

OTHER

OTHER

OTHER

Assessed for eligibility
(n = 253)

Excluded (n = 44)
Declined to participate
Randomized (n = 44)
(n = 209)

Allocated to brachytherapy Allocated to stent placement
(n = 101) (n = 108)
PhD research intro
Did not receive allocated
intervention (n = 6)
intervention (n = 3)
1 died before treatment
3 had problems during
endoscopy
2 died before treatment
1 was un t for treatment A journey (MA)
2 did not ful ll inclusion
criteria

A journey (PhD)
Centers (n = 9) performing
Centers (n = 9) performing

Current work
the intervention
the intervention
Number of patients treated
by each center (median = 5
by each center (median = 6
[IQR: 1–10]; min = 0,
[IQR: 1–9]; min = 1,
max = 60)
max = 64)

Opportunities

Lost to follow-up (n = 0) Lost to follow-up (n = 0)
Discontinued intervention Discontinued intervention
Received stent (n = 45) Received brachytherapy
Received second (n = 2)
brachytherapy (n = 3) Received second stent
treatment (n = 24)

Analyzed (n = 101)
Analyzed (n = 108)

Assessed for eligibility
(n = 253)

Excluded (n = 44)
Randomized Declined to participate
(n = 209) (n = 44)

PhD research intro
Allocated to brachytherapy Allocated to stent placement
(n = 101) (n = 108)

A journey (MA)
intervention (n = 6) Did not receive allocated
1 died before treatment intervention (n = 3)
3 had problems during 2 died before treatment
endoscopy
2 did not fulfill inclusion 70
1 was unfit for treatment
A journey (PhD)
criteria
70 60 Centers (n = 9) performing
60 50 the stent placement
Centers (n = 9) performing the
brachytherapy.
50

40
40

30
by each center (median = 6 Current work
Number of patients treated 20
[IQR: 1–9]; min = 1,
30
by each center (median = 5 max = 64)
20 10
[IQR: 1–10]; min = 0,
Opportunities
10 0
max = 60)
0

Discontinued intervention,
receiving brachytherapy (n = 2)
Discontinued intervention, receiving
second brachytherapy (n = 3) Discontinued intervention, receiving
second stent treatment (n = 24)
Discontinued intervention,
receiving stent (n = 45)

Lost to follow-up (n = 0)

Lost to follow-up (n = 0) Analyzed (n = 108)
Analyzed (n = 101)

jul 08: Info Vis 08 conference:
Health Technology Assessment as an area of
application for Information Graphics.

jan 09: International Journal of
Technology Assessment in PhD research intro
Health Care:
M. Pitt, W. Stahl-Timmins, R. Anderson, and A journey (MA)
K. Stein. Using information graphics in health
technology assessment: Toward a structured A journey (PhD)
approach. Int.J.Technol.Assess.Health Care
25 (04):555-563, 2009. Current work

Opportunities
jun 09: Data Designed for Decisions
(DD4D) conference:
NICE graphics: Empirical evidence of the
beneﬁts of graphical display.

feb 10: Information Design Journal:
Graphical Presentation of Data for Health Policy
Decisions: An Exploratory Online Decision Task
Experiment to Measure Effectiveness

measurements test (experiment)

online decision gradually increasing
task study decision complexity
(subgroups)
sample: general
PhD research intro
internet-using measurements:
public - respondent decision accuracy, A journey (MA)
-driven sample time & preference
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Current work

Opportunities

numerical presentation graphical presentation


(subgroups)
sample: general
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A journey (PhD)
http://
Current work
www.pms.ac.uk/
Opportunities
infographics/


(subgroups)
sample: general
PhD research intro
A journey (PhD)

Current work

seed 1 Opportunities

seed 2
25+ participants...

seed 3


(subgroups)
sample: general
PhD research intro
A journey (PhD)

Current work

increasing complexity Opportunities

single group males and females low, medium, high risk
males and females


(subgroups)
sample: general
PhD research intro
A journey (PhD)

Current work

Opportunities

measurements test
(findings)
PhD research intro

A journey (MA)

A journey (PhD)

Current work

Opportunities

measurements test
(findings)
Study Duration: PhD research intro
36 days (15th June - 21st July
2009) A journey (MA)

A journey (PhD)

Current work

Opportunities

measurements test
(findings)

244 entries were recorded during A journey (PhD)
this time.
Current work

Opportunities

measurements test
(findings)

this time.
Current work
48 excluded as possible Opportunities
duplicates, leaving 196 for the
analysis

measurements test
(findings)

this time.
Current work
48 excluded as possible Opportunities
duplicates, leaving 196 for the
analysis
99 participants received the
graphical presentation first.
97 received the numerical one first.

Randomised to receive:
Numerical first (N=97) Graphical first (N=99)
did not did not
complete complete
task 1 (N=19) task 1 (N=22)
Task 1

did not complete did not complete
task 2 (N=7) Task 2 task 2 (N=7)

task 3 (N=3) Task 3 task 3 (N=2)
PhD research intro
details collection Details details collection
(N=6)
collection
(N=2)
A journey (MA)
task 4 (N=7)
Task 4 task 4 (N=2)
A journey (PhD)
did not complete
Task 5 task 5 (N=2) Current work
did not complete
task 6 (N=2) Task 6
did not complete
task 6 (N=2) Opportunities
did not give
preference (N=2) Preference did not give
preference (N=5)
collection

38 people gave a 25 people liked 43 people gave a
preference for the the displays preference for the
numerical display equally graphical display

Average Deaths (mean)
Numerical - Graphical group
7787 7787 7787
Graphical - Numerical group

Max. Possible Deaths 7224 7224 7224

95% confidence
5920
mean (g-n group)

mean (n-g group)
5466
95% confidence

Min. Possible Deaths 5074 5114
5015

4748

Y1 Y2 Y3 Y4 Y5 Y6
N=78 N=71 N=69 N=65 N=63 N=61
N=77 N=70 N=67 N=54 N=54 N=52

NICE technical advisors
telephone interviews - needs assessment

• 5 interviews PhD research intro

• ~30 minutes A journey (MA)

• gist transcribed A journey (PhD)

• framework analysis Current work

• Looking for instances of: Opportunities

- complexity
- summary/overview needed
- comparison needed
- time limited
- selective focussing needed

technical leads 1.01 interview 1
technical advisors 1.02
interview 2
committee members 1.03

lead team 1.04
interview 3
scoping 1.05 interview 4
evidence submission 1.06
interview 5
pre-meeting briefing / overview 1.07

slide presentation / committee meetings 1.08

complexity / overwhelming volume of data 2.01

condensing / summarising / one page only 2.02

comparison 2.03

limited time 2.04

disaggregation / selective focussing 2.05

magnitude 2.06

background of condition 3.01

clinical effectiveness (general) 3.02

survival 3.03

quality of life / utilities 3.04

multiple outcomes 3.05

subgroup analysis 3.06

costs 3.07

economic analysis / cost-effectiveness (general) 3.08

model / model structure 3.09

sensitivity analysis 3.10

probabilistic sensitivity analysis (PSA) 3.11

cost-effectiveness acceptablility curves (CEACs) 3.12

incremental cost-effectiveness ratio (ICER) 3.13

multiple comparisons 3.14

sequencial treatments 3.15

absent information 3.16

changing assumptions at committee 3.17

how informed are decision-makers? 3.18

methodology 3.19

base case assumptions 3.20

uncertainty 3.21

belief/trust 3.22

current use of graphics 3.23

multiple vs single technology assessments 3.24

different backgrounds of committee members 3.25

face validity of results 3.26

scenario analyses 3.27

quality of evidence 3.28

interim analysis 3.29

discrete event simulation 3.30

pair-wise comparisons 3.31

large volume of trials 3.32

quality adjusted life years (QALYs) 3.33

mixed treatment comparisons 3.34

probability in decision-making 3.35

licensing 3.36

When asked if time was limited (in any
part of the appraisal process),
PhD research intro
interviewees responded:
A journey (MA)
“Time is always limited”
A journey (PhD)
or Current work

“Yes, is the short answer!” Opportunities

All five interviewees stated that time was
always limited for decision-makers to
familiarise themselves with the necessary
information before an appraisal
committee.


PhD research intro

A journey (MA)

The most commonly mentioned type of A journey (PhD)
data that needed to be compared to
another was the ICER, the overall Current work
measure of the cost-effectiveness of an Opportunities
intervention.


Complexity was related to clinical PhD research intro
effectiveness by three of the five
A journey (MA)
interviewees. The data presented in
systematic reviews of clinical A journey (PhD)
effectiveness was reported to be quite
problematic to present. This is likely to be Current work
the case particularly where there are Opportunities
different subgroups of people that are of
interest in the analysis, or where the trials
reviewed used a large number of different
outcome measures.

10 information graphics
The Friday Information Graphic

09
16th Oct 2009

Link diagrams for showing PhD research intro
connections between search
strategies in multiple systematic reviews
A journey (MA)

A journey (PhD)

Current work

Opportunities

Peninsula Technology Information Graphics in
Assessment Group Health Technology Assessment

www.pms.ac.uk/pentag www.pms.ac.uk/infographics

Noy Scott House Will Stahl-Timmins
Barrack Road wstahl-timmins@pms.ac.uk
Exeter EX2 5DW +44 (0) 1392 406 967 1

COGS (Clinical effectiveness
Overview Graphical Summary

PhD research intro

A journey

My PhD (so far)

Opportunities

EFFECTIVENESS AND COST-EFFECTIVENESS OF COCHLEAR IMPLANTS CLINICAL EFFECTIVENESS – CHILDREN
Table 15 Summary of study characteristics unilateral cochlear implants vs. acoustic hearing aids – children
Study ID
Mildner et al 2006
125
Design
Cross-sectional
Intervention group
N = 29
Control group
N = 20 PhD research intro
Croatia Age yrs: mean 11.6 (7-15)
Length of follow up: n/a Degree of deafness: profound >98 Degree of deafness: profound
dBHL
N = 49 Mean age (yrs: months) at
implant: 8.2 (2-12)
> 98 dBHL
A journey (MA)
Mean time (yrs) between
deafness and implantation:
Not reported

A journey (PhD)
Tomblin et al126 1999 Non-randomised controlled N = 29 N = 29
U SA Prospective trial with Age yrs mean (SD): 10 (2.9) Age yrs mean (SD): 9 (3.65)
Length of follow up: 5 yrs
N = 58
cross-overs allowed Degree of deafness: profound
Pr e-l i ngu all y deaf
Mean (SD) age (yrs) at implant:
Degree of
Pre-lingually deaf Current work
4.76 (1.57, 2-13)
Mean time (yrs) between

Osberger et al127 1999 Pre/Post prospective
deafness and implantation: NR
Participants
N = 58
Opportunities
USA Repeated measures Age mean yrs: 5.4

COGS test

Task-based cognitive interviewing
PhD research intro
9 expert users (HTA systematic
A journey (MA)
reviewers)
A journey (PhD)
Randomised, sequencial comparison
Current work
to report
Opportunities
Quantitative results (time and
accuracy)

Qualitative results (actions and words
of participants - framework analysis)

Task 4: Can you tell me about selection
bias in the Peters et al. (2007) trial please?

COGS display report section

1 4 5 8 9 2 3 6 7

6.9%
9.3%
12.0% 12.3%
13.5%
16.4% 17.0%
17.9%

24.1%

Task 8: Of the unilateral cochlear implants
vs non-technological support trials, which
reported at least one significant outcome
measure, and which measures were
these?

report section COGS display

1 4 5 8 9 2 3 6 7

5.4% 5.1%
6.3%
7.9%

13.3%
15.0% 15.1%
18.2%

32.4%

stated preference for COGS
key stated preference for report
did not state preference during task

using
report display 1 using
COGS
familiar-
isation 1
task 1

task 2

task 3

task 4
general
reliability 1 PhD research intro
display 2
familiar- A journey (MA)
isation 2
task 5

task 6 Thematic category 7: A journey (PhD)
Preference
task 7

Current work
task 8
general
reliability 2

display 3 Opportunities
familiar-
isation 3
task 9

task 10

task 11

task 12

probe

general questions
useful for
this review?
useful for
other reviews?
validate tasks

interactive version

outcome measures used
no. of design, size baseline study cog func be glo
author location centres & follow-up MMSE sex ages quality

ADCS-ADL

ADCS-CGIC
ADAS-cog

other

other

other
CIBIC
MMSE

DAD
PDS

CDR

QoL
SIB

NPI

GDS
0yr 1 2 0 10 20 30 55 75 95

Donepezil 1mg N = 42 M F
Rogers & Rand
Donepezil 3mg N = 40 M F
? N = 161 Donepezil 5mg N = 39 M F
Char
Blind
Analy
1mg
3mg
1996 F
Placebo N = 40 M 5mg

Donepezil 5mg N = 154
M F 5mg
Rogers et al. Rand
M F Char 10
Donepezil 10mg N = 157 Blind mg
1998 (A) N = 473 Analy
M F
Placebo N = 162
M F 5mg
Rogers et al. Rand
M F Char 10
Donepezil 10mg N = 158 mg
Blind
1998 (B) N = 468 Analy
M F
Placebo N = 153
M F 5mg
Burns et al. Rand
M F Char 10mg
Donepezil 10mg N = 273 Blind
1999 Analy
N = 818 M F
Placebo N = 274

Greenberg Donepezil 5mg (D)
Rand
et al. group 1 (p-D-p-p) N=30 M F Char
group 2 (p-p-D-p) N=30 M F Blind
N = 60 Analy
2000 Placebo (p)

Homma et al. M F Rand
Char
Blind
2000 N = 268 M F Analy
Placebo N = 129

Mohs et al. M F Rand
Char

ADCS-CGIC
ADCS-ADL
Blind

ADAS-cog
2001 N = 431 M F Analy

MMSE

CIBIC
Placebo N = 217

DAD
other

other

other

CDR
GDS
PDS

QoL
NPI
SIB
0yr 1 2 0 10 20 30 55 75 95 cog func be glo

SOC (State Occupancy Chart)

PhD research intro

A journey (MA)

A journey (PhD)

Current work

Opportunities

Temozolomide model QALYs SOC (state occupancy chart) Temozolomide model costs SOC (state occupancy chart)
Length of bars show state occupancy. Colours show QALYs experienced by the simulated cohort. Length of bars show state occupancy. Colours show costs incurred.

placebo arm
colours show QALYs experienced
comparative
incremental state occupancy and
TMZ arm
colours show QALYs experienced in £300k £0 £300k £600k-900k £9m
in one model state in placebo arm incremental QALYs experienced in each state one model state in temozolomide arm incurred in placebo arm a state with no cost incurred in temozolomide arm
20 10 0 4 (placebo) 0 4 (TMZ) 20 10 0 placebo arm incremental temozolomide arm
state occupancy and absolute costs state occupancy and incremental costs state occupancy and absolute costs
0 250 500 750 1000 stable progressive death 0 250 500 750 1000 0 250 500 750 1000 stable progressive death 0 250 500 750 1000

week week week week
13 13 13 13

week week week week
26 26 26 26

week week week week
39 39 39 39

week week week week
52 52 52 52

week week week week
65 65 65 65

week week week week
78 78 78 78

week week week week
91 91 91 91

week week week week
104 104 104 104

week week week week
117 117 117 117

week week week week
130 130 130 130

week week week week
143 143 143 143

week week week week
156 156 156 156

week week week week
169 169 169 169

week week week week
182 182 182 182

week week week week
195 195 195 195

week week week week
208 208 208 208

week week week week
221 221 221 221

week week week week
234 234 234 234

week week week week
247 247 247 247

week week week week
260 260 260 260

State Occupancy & Absolute Quality of Life 2 State Occupancy & Absolute Costs Per Person 3
placebo arm treatment arm placebo arm treatment arm
0% 25% 50% 75% 100% 0% 25% 50% 75% 100%
week 1 surgery 0% 25% 50% 75% 100% 0% 25% 50% 75% 100% week 1 week 1 surgery week 1
week 2 week 2
weeks 2-6 post-op recovery weeks 2-6 post-op recovery
week 7 week 7
weeks 7-12 radiotherapy weeks 7-12 radiotherapy
week week
week 13+ stable/progressive/death 13 week 13+ stable/progressive/death 13
week week week week
26 26 26 26
is information graphic shows is information graphic shows
the absolute quality of life week week the absolute costs incurred per week week
experienced by the simulated 39 39 person in the model, on a scale 39 39
patients in the model. e week week from black (£3000 per person) week week
shades of grey provide a scale 52 52 to white (£0 per person). 52 52
from black (a utility of 1 per
week week week week
person) to white (a utility of 0 65 65 ese shades of grey are 65 65
per person). presented in bars whose length
week week correspond to the number week week
78 78 of people incurring that cost 78 78
ese shades of grey are
presented in bars whose length in that state in the model, as in
week week week week
correspond to the number 91 91 graphic 1 — State Occupancy. 91 91
of people in that state in the week week week week
model during that week, as in 104 104 e small dark bars appearing 104 104
graphic 1 — State Occupancy. between the progressive and
week week death states represent the week week
117 117 one-o costs assigned to death 117 117
e slowly lightening e ect in
in the model. e length of
the progressive state is caused week week week week
130 130 these bars is again proportional 130 130
by the gradual decomposition
to the number of people dying
of utility values in this state in week week during that week of the model. week week
the model. e simulated 143 143 143 143
patients experience less quality Similar dark boxes appear
week week week week
of life the longer they spend in 156 156 between the stable and 156 156
this state. e values presented progressive states to indicate
here are the average (mean) of week week the higher costs assigned week week
the utility scores experienced 169 169 169 169
to a patient’s rst week in the
by the cohort in that week of week week progressive state. week week
the model. 182 182 182 182
Costs for surgery in week
week week week week
195 195 1 are o the scale at £5953 per 195 195
person, but this cost is identical
utility of 1 week week week week
(per person) 208 208 in both arms of the model. 208 208

week week week week
221 221 221 221
£3000 per person
utility of 0.5 week week week week
234 234 234 234
£1500 per person
week week week week
247 247 247 247
utility of 0 week week
£0 per person week week
260 260 260 260

SOC test
Task-based cognitive
interviewing
PhD research intro
6 expert users (HTA A journey (MA)
mathematical modellers)
A journey (PhD)

Single group study Current work

Opportunities
Quantitative results (time
and accuracy)

Qualitative results
(actions and words of
participants - framework
analysis)

Tasks for validation
Task 4: Where do the costs tend to come
from in each arm of the model? PhD research intro

A journey (MA)

participants must consider both A journey (PhD)
length and colour of bars
treatment arm Current work
0% 25% 50% 75% 100%
surgery = £5.9m week 1
week 2 Opportunities
week 7
radiotherapy = £5.4m
week
13
week
drug course 26
(weeks 17– 40) = £5.4m
week
39

Tasks for validation

value value
(placebo arm) (treatment arm)

surgery £5.9m £5.9m
radiotherapy
(weeks 7–12) £1.6m £5.4m
drug course £0.2m £5.1m
(weeks 17–40)
progressive
disease £6.7m £5.9m

death £3.1m £3.1m

1 2 3 4 5 6

39s

109s 100s
119s
166s

240s

mentioned by potential times mentioned
participants: functions (overall)
5 complexity 1
condensing 0
3 4 5 comparison 5
3 6 limited time 2
selective focussing 0

modelling
1 2 3 4 5 6 states 45
1 2 3 4 5 ICER 16
1 2 3 4 5 6 costs 44
PhD research intro
1 2 3 4 5 6 quality of life 55
4 6 other methods 6

2 3 4
6
6
discounting
model validation
2
10
A journey (MA)
interpretation
1 2 3 4 5 uncertainty 23 A journey (PhD)
1 3 4 5 6 transformation 11
6 overview 1
1 sizing 1 Current work
1 2 learning 5
1 5 obviousness 4
3 4 cognitive load 2 Opportunities
2 5 6 orientation 4
1 2 3 4 6 units 12
4 5 6 memory 3

actions
1 3 4 5 focussing aids 6
2 3 angling 3
3 5 6 peering 5
6 bookmarking 1

1 3 6
design
production 3
Qualitative
2 3 4 5 6 media 8
1
1
2
2
4
5 6

5
detail
alternatives
suggestions
13
4
3
results

Question 3: Do you think this kind of display
would be useful or confusing for a decision-
maker at NICE?

The most common idea mentioned (by PhD research intro
participants 1, 4 and 6) was that the graphic
A journey (MA)
would give decision-makers an idea of what was
A journey (PhD)
‘driving’ the model, and why the costs per QALY
(or ICER) were high or not. Participant 3 thought Current work

that giving the decision makers an idea of how Opportunities
costs and QALYs were accrued over time was
something that they were not currently able to
see.
Qualitative
results

Conclusions
measurements test (findings)

PhD research intro

A journey (MA)

A journey (PhD)

Current work

Opportunities

Conclusions

Design of information graphics in HTA
Start with user needs
Iterative design PhD research intro

Formal and informal testing A journey (MA)

A journey (PhD)

Current work

Opportunities

Conclusions



A journey (PhD)
Production of information graphics in HTA
Current work
Researchers produce with standard spreadsheet software
Develop specialist software for new HTA information graphics Opportunities
Production by design on individual basis

Conclusions



A journey (PhD)
Production of information graphics in HTA
Current work
Researchers produce with standard spreadsheet software
Develop specialist software for new HTA information graphics Opportunities
Production by design on individual basis

Use of information graphics in HTA
Assess complexity of data on health intervention being considered
Search for creative solutions appropriate to communicate that data

COMPARATIVE
pilot STUDY
testing redesign
informal may be
needed
advice

INFORMATION initial design work real data incorporation
NEEDS

SPECIFICATION PROTOTYPE DEPLOY MONITOR

INDIVIDUAL
STUDY

informal
conversations

needs
research
studies

research research research
outputs outputs outputs

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Boyce, T. & Lewis, J. (Eds.) 2009. Climate Change

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Thank you
Will Stahl-Timmins
w.stahl-timmins@exeter.ac.uk

European Centre for Environment and Human Health

WST UWE MA Graphic Arts group 22mar11

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