Zhou / Sun / Pennello | Statistical Methods in Diagnostic Medicine | Buch | 978-1-394-22021-2 | www.sack.de

Buch, Englisch, 576 Seiten, Format (B × H): 182 mm x 256 mm, Gewicht: 1210 g

Zhou / Sun / Pennello

Statistical Methods in Diagnostic Medicine


3. Auflage 2026
ISBN: 978-1-394-22021-2
Verlag: Wiley John + Sons

Buch, Englisch, 576 Seiten, Format (B × H): 182 mm x 256 mm, Gewicht: 1210 g

ISBN: 978-1-394-22021-2
Verlag: Wiley John + Sons


The definitive resource for ensuring diagnostic tests meet the highest standards of statistical rigor and clinical effectiveness

Statistical Methods in Diagnostic Medicine, 3rd Edition by Xiao-Hua Zhou, Jiarui Sun, Gene A. Pennello, Nancy A. Obuchowski and Donna K. McClish delivers the most comprehensive treatment of statistical methodologies for diagnostic test evaluation available today. The authors of the 2nd Edition – Peking University PKU Distinguished Chair Professor Zhou, Cleveland Clinic Professor Obuchowski, and Virginia Commonwealth University Professor Donna McClish – team with U.S. Food and Drug Administration senior mathematical statistician Pennello and doctoral researcher Sun to address a critical challenge facing medical professionals: ensuring that diagnostic tests used in clinical practice are accurate, methodologically sound, free from bias, and effective.

This edition provides practitioners and researchers with the statistical foundation necessary to design, analyze, and validate diagnostic studies that can withstand regulatory scrutiny and clinical demands. The book has been thoroughly revised to incorporate the latest advances in diagnostic test methodology, featuring significant expansions in biomarker evaluation and benefit-risk assessment. The authors have restructured content to improve cohesion through integrated case studies that span multiple chapters, while updating each section with contemporary methods and streamlining discussions of older techniques to focus on the most relevant approaches for today’s diagnostic challenges.

Readers will also find: - Three entirely new chapters covering statistical methods for risk prediction, quantitative imaging biomarkers, and efficacy and effectiveness of biomarkers and other tests.
- Enhanced coverage of sample size calculations, accuracy estimation methods, and comparative analysis techniques for competing diagnostic tests
- Advanced analytical approaches including methods for comparing correlated ROC curves in multi-reader studies and techniques for correcting verification bias
- Comprehensive treatment of regression analysis applications in diagnostic accuracy research with updated methodological guidance
- Integrated case studies that demonstrate real-world application of statistical methods across different diagnostic scenarios and study designs

Perfect for biostatisticians, applied statisticians, clinical researchers, and regulatory professionals working in diagnostic medicine, Statistical Methods in Diagnostic Medicine will also benefit graduate students and researchers interested in gaining the statistical expertise needed to design robust diagnostic studies.

Zhou / Sun / Pennello Statistical Methods in Diagnostic Medicine jetzt bestellen!

Weitere Infos & Material


Preface xiv

Acknowledgments xvi

Part I Basic Concepts and Methods 1

1 Introduction 3

1.1 Diagnostic Test Accuracy Studies 3

1.2 Case Studies 5

1.2.1 Case Study 1: Parathyroid Disease 5

1.2.2 Case Study 2: Colon Cancer Detection 6

1.2.3 Case Study 3: Carotid Artery Stenosis 7

1.3 Software 8

1.4 Topics Not Covered in This Book 8

2 Measures of Diagnostic Accuracy 9

2.1 Sensitivity and Specificity 9

2.1.1 Basic Measures of Test Accuracy: Case Study 2 11

2.1.2 Diagnostic Tests with Continuous Results: The Artificial Heart Valve Example 12

2.1.3 Diagnostic Tests with Ordinal Results: Case Study 1 13

2.1.4 Effect of Prevalence and Spectrum of Disease 14

2.1.5 Analogy to a and ß Statistical Errors 14

2.2 Combined Measures of Sensitivity and Specificity 15

2.2.1 Problems Comparing Two or More Tests: Case Study 1 15

2.2.2 Probability of a Correct Test Result 15

2.2.3 Odds Ratio and Youden’s Index 16

2.3 ROC Curve 17

2.3.1 ROC Curves: Artificial Heart Valve and Case Study 1 17

2.3.2 ROC Curve Assumption 18

2.3.3 Smooth, Fitted ROC Curves 19

2.3.4 Advantages of ROC Curves 19

2.4 Area Under the ROC Curve 20

2.4.1 Interpretation of the Area Under the ROC Curve 20

2.4.2 Magnitudes of the Area Under the ROC Curve 21

2.4.3 Area Under the ROC Curve: Case Study 1 21

2.4.4 Misinterpretations of the Area Under the ROC Curve 23

2.5 Sensitivity at Fixed FPR 25

2.6 Partial Area Under the ROC Curve 25

2.7 Likelihood Ratios 26

2.7.1 Three Examples to Illustrate Likelihood Ratios 27

2.7.2 Limitations of Likelihood Ratios 28

2.7.3 Proper and Improper ROC Curves 29

2.8 ROC Analysis When the True Diagnosis Is Not Binary 30

2.9 C-statistics and Other Measures to Compare Prediction Models 32

2.10 Detection and Localization of Multiple Lesions 33

2.11 Positive and Negative Predictive Values, Bayes’ Theorem, and Case Study 2 35

2.11.1 Bayes’ Theorem 36

2.12 Optimal Decision Threshold on the ROC Curve 38

2.12.1 Optimal Thresholds for Maximizing Classification 38

2.12.2 Optimal Threshold for Minimizing Cost 39

2.12.3 Optimal Decision Threshold: Rapid Eye Movement as a Marker for Depression Example 39

2.13 Interpreting the Results of Multiple Tests 40

2.13.1 Parallel Testing 40

2.13.2 Serial, or Sequential, Testing 41

3 Design of Diagnostic Accuracy Studies 45

3.1 Establish the Objective of the Study 45

3.2 Identify the Target Patient Population 49

3.3 Select a Sampling Plan for Patients 50

3.3.1 Phase I: Exploratory Studies 50

3.3.2 Phase II: Challenge Studies 50

3.3.3 Phase III: Clinical Studies 52

3.4 Select the Gold Standard 56

3.5 Choose a Measure of Accuracy 61

3.6 Identify Target Reader Population 63

3.7 Select Sampling Plan for Readers 64

3.8 Plan Data Collection 64

3.8.1 Format for Test Results 64

3.8.2 Data Collection for Reader Studies 65

3.8.3 Reader Training 71

3.9 Plan Data Analyses 72

3.9.1 Statistical Hypotheses 72

3.9.2 Planning for Covariate Adjustment 73

3.9.3 Reporting Test Results 75

3.10 Determine Sample Size 77

4 Estimation and Hypothesis Testing in a Single Sample 79

4.1 Binary-scale Data 80

4.1.1 Sensitivity and Specificity 80

4.1.2 Predictive Value of a Positive or Negative 82

4.1.3 Sensitivity, Specificity, and Predictive Values with Clustered Binary-scale Data 84

4.1.4 Likelihood Ratio 86

4.1.5 Odds Ratio 88

4.2 Ordinal-scale Data 89

4.2.1 Empirical ROC Curve 90

4.2.2 Fitting a Smooth Curve 90

4.2.3 Estimation of Sensitivity at a Particular FPR 95

4.2.4 Area and Partial Area Under the ROC Curve (Parametric Methods) 97

4.2.5 ci Estimation 99

4.2.6 Area and Partial Area Under the ROC Curve (Nonparametric Methods) 102

4.2.7 Nonparametric Analysis of Clustered Data 105

4.2.8 Degenerate Data 106

4.2.9 Choosing Between Parametric, Semi-parametric, and Nonparametric Methods 108

4.3 Continuous-scale Data 108

4.3.1 Empirical ROC Curve 109

4.3.2 Fitting a Smooth ROC Curve – Parametric, Semi-parametric, and Nonparametric Methods 110

4.3.3 Confidence Bands Around the Estimated ROC Curve 115

4.3.4 Area and Partial Area Under the ROC Curve – Parametric, Nonparametric, and Semi-parametric Methods 116

4.3.5 CIs for the Area Under the ROC Curve 117

4.3.6 Fixed FPR – Sensitivity and the Decision Threshold 119

4.3.7 Choosing the Optimal Operating Point and Decision Threshold 122

4.3.8 Choosing Between Parametric, Semi-parametric, and Nonparametric Methods 125

4.4 Testing the Hypothesis that the ROC Curve Area or Partial Area Is a Specific Value 126

4.4.1 Testing Whether MRA Has Any Ability to Detect Significant Carotid Stenosis 127

5 Comparing the Accuracy of Two Diagnostic Tests 129

5.1 Binary-scale Data 130

5.1.1 Sensitivity and Specificity 130

5.1.2 Sensitivity and Specificity of Clustered Binary Data 132

5.1.3 Predictive Probability of a Positive or Negative 134

5.2 Ordinal- and Continuous-scale Data 136

5.2.1 Testing the Equality of Two ROC Curves 137

5.2.2 Comparing ROC Curves at a Particular Point 140

5.2.3 Determining the Range of FPRs for Which TPRs Differ 141

5.2.4 Comparison of the Area or Partial Area 143

5.3 Tests of Equivalence 148

5.3.1 Testing Whether ROC Curve Areas Are Equivalent: Case Study 3 150

6 Sample Size Calculations 153

6.1 Studies Estimating the Accuracy of a Single Test 153

6.1.1 Sample Size Calculations for Estimating Sensitivity and/or Specificity – Case Study 1 153

6.1.2 Sample Size for Estimating the Area Under the ROC Curve – Case Study 2 155

6.1.3 Studies with Clustered Data 157

6.1.4 Testing the Hypothesis That the ROC Area Is Equal to a Particular Value 158

6.1.5 Sample Size for Estimating Sensitivity at Fixed FPR – Case Study 2 158

6.1.6 Sample Size for Estimating the Partial Area Under the ROC Curve – Case Study 2 160

6.2 Sample Size for Detecting a Difference in Accuracies of Two Tests 161

6.2.1 Sample Size Software 161

6.2.2 Sample Size for Comparing Tests’ Sensitivity and/or Specificity – Case Study 1 161

6.2.3 Sample Size for Comparing Tests’ Positive and Negative Predictive Values – Case Study 1 163

6.2.4 Sample Size for Comparing Tests’ Area Under the ROC Curve – Case Study 2 164

6.2.5 Sample Size for Comparing Tests with Clustered Data 165

6.2.6 Sample Size for Comparing Tests’ Sensitivity at Fixed FPR – Case Study 2 166

6.2.7 Sample Size for Comparing Tests’ Partial Area Under the ROC Curve – Case Study 2 167

6.3 Sample Size for Assessing Non-inferiority or Equivalency of Two Tests 169

6.4 Sample Size for Determining a Suitable Cutoff Value 172

6.5 Sample Size Determination for Multi-reader Studies 173

6.5.1 MRMC Sample Size Software 173

6.5.2 MRMC Sample Size Calculations with No Pilot Data 174

6.5.3 MRMC Sample Size Calculations with Pilot Data 179

6.6 Alternative to Sample Size Formulae 180

7 Introduction to Meta-analysis for Diagnostic Accuracy Studies 181

7.1 Objectives 182

7.2 Retrieval of the Literature 182

7.2.1 Literature Search: Meta-analysis of Ultrasound for PAD 186

7.3 Inclusion/Exclusion Criteria 186

7.3.1 Inclusion/Exclusion Criteria: Meta-analysis of Ultrasound for PAD 188

7.4 Extracting Information from the Literature 188

7.4.1 Data Abstraction: Meta-analysis of Ultrasound for PAD 190

7.5 Statistical Analysis 190

7.5.1 Binary-scale Data 190

7.5.2 Ordinal- or Continuous-scale Data 191

7.5.3 Area Under the ROC Curve 200

7.5.4 Other Methods 202

7.6 Public Presentation 202

7.6.1 Presentation of Results: Meta-analysis of Ultrasound for PAD 204

Part II Advanced Methods 205

8 Regression Analysis for Independent ROC Data 207

8.1 Four Clinical Studies 208

8.1.1 Surgical Lesion in a Carotid Vessel Example 208

8.1.2 Pancreatic Cancer Example 208

8.1.3 Hearing Test Example 208

8.1.4 Staging of Prostate Cancer Example 209

8.2 Regression Models for Continuous-scale Tests 210

8.2.1 Indirect Regression Models for ROC Curves 211

8.2.2 Direct Regression Models for ROC Curves 214

8.3 Regression Models for Ordinal-scale Tests 228

8.3.1 Indirect Regression Models for Latent Smooth ROC Curves 228

8.3.2 Direct Regression Model for Latent Smooth ROC Curves 230

8.3.3 Detection of Periprostatic Invasion with Ultrasound 232

8.4 Covariate AROC Curves of Continuous-scale Tests 233

9 Analysis of Multiple Reader and/or Multiple Test Studies 235

9.1 Studies Comparing Multiple Tests with Covariates 235

9.1.1 Two Clinical Studies 235

9.1.2 Indirect Regression Models for Ordinal-scale Tests 236

9.1.3 Direct Regression Models for Continuous-scale Tests 241

9.2 Studies with Multiple Readers and Multiple Tests 245

9.2.1 Three MRMC Studies 245

9.2.2 Statistical Methods for Analyzing MRMC Studies 246

9.2.3 Analysis of the Interstitial Disease Example 254

9.2.4 Comparisons Between MRMC Methods 254

10 Methods for Correcting Verification Bias 257

10.1 Examples 258

10.1.1 Hepatic Scintigraph 258

10.1.2 Screening Tests for Dementia Disorder Example 258

10.1.3 Fever of Uncertain Origin 259

10.1.4 CT and MRI for Staging Pancreatic Cancer Example 259

10.1.5 NACC MDS on AD 259

10.2 Impact of Verification Bias 260

10.3 A Single Binary-scale Test 261

10.3.1 Correction Methods Under the MAR Assumption 261

10.3.2 Correction Methods Without the MAR Assumption 263

10.3.3 Analysis of Hepatic Scintigraph Example, Continued 265

10.4 Correlated Binary-scale Tests 267

10.4.1 ml Approach Without Any Covariates 267

10.4.2 Analysis of Two Screening Tests for Dementia Disorder Example 272

10.4.3 ml Approach with Covariates 273

10.4.4 Analysis of Two Screening Tests for Dementia Disorder Example, Continued 275

10.5 A Single Ordinal-scale Test 276

10.5.1 ML Approach Without Covariates 276

10.5.2 Analysis of Fever of Uncertain Origin Example 280

10.5.3 ML Approach with Covariates 280

10.5.4 Analysis of New Screening Test for Dementia Disorder 284

10.6 Correlated Ordinal-scale Tests 286

10.6.1 Weighted Estimating Equation Approaches for Latent Smooth ROC Curves 287

10.6.2 Likelihood-based Approach for ROC Areas 291

10.6.3 Analysis of CT and MRI for Staging Pancreatic Cancer 295

10.7 Continuous-scale Tests 296

10.7.1 Estimation of ROC Curves and Their Areas Under the MAR Assumption 297

10.7.2 Estimation of ROC Curves and Areas Under a Non-MAR Process 303

11 Methods for Correcting Imperfect Gold Standard Bias 313

11.1 Examples 314

11.1.1 Binary Stool Test for Strongyloides Infection 314

11.1.2 Binary Tine Test for Tuberculosis 314

11.1.3 Binary-scale X-rays for Pleural Thickening 314

11.1.4 Bioassays for HIV 315

11.1.5 Ordinal-scale Evaluation by Pathologists for Detecting Carcinoma In Situ of the Uterine Cervix 315

11.1.6 Ordinal-scale and Continuous-scale MRA for Carotid Artery Stenosis 315

11.2 Impact of Imperfect Gold Standard Bias 315

11.3 One Single Binary Test in a Single Population 317

11.3.1 Conditions for Model Identifiability 318

11.3.2 The Frequentist-based ML Method Under an Identifiable Model 319

11.3.3 Bayesian Methods Under a Non-identifiable Model 320

11.3.4 Analysis of Strongyloides Infection Example 322

11.4 One Single Binary Test in G Populations 324

11.4.1 Estimation Methods 324

11.4.2 Tuberculosis Example 327

11.5 Multiple Binary Tests in One Single Population 329

11.5.1 Checking for Model Identifiability 329

11.5.2 ml Estimates Under the CIA 330

11.5.3 Assessment of Pleural Thickening Example 331

11.5.4 ml Approaches Under Identifiable Conditional Dependence Models 331

11.5.5 Bioassays for HIV Example 336

11.5.6 Bayesian Methods Under Conditional Dependence Models 339

11.5.7 Analysis of the MRA for Carotid Stenosis Example 340

11.6 Multiple Binary Tests in G Populations 341

11.6.1 ml Approaches Under the CIA 342

11.6.2 ml Approach Without the CIA Assumption 343

11.7 Multiple Ordinal-scale Tests in One Single Population 343

11.7.1 Nonparametric Estimation of ROC Curves Under the CIA 343

11.7.2 Estimation of ROC Curves Under Some Conditional Dependence Models 345

11.7.3 Analysis of Ordinal-scale Tests for Detecting Carcinoma In Situ of the Uterine Cervix 346

11.8 Multiple-scale Tests in One Single Population 347

11.8.1 Reanalysis of the Accuracy of Continuous-scale MRA for Detection of Significant Carotid Stenosis 351

12 Location-specific ROC Methods for Diagnostic Imaging 353

12.1 Examples 353

12.1.1 Example One: A Clinical Study of Computer-aided Detection of Mammographic Masses 353

12.1.2 Example Two: A Clinical Study of Pulmonary Computer-aided Diagnosis Medical Software 354

12.1.3 Example Three: A Clinical Study of 3D Magnetic Resonance Angiography 354

12.2 LROC Approach 355

12.2.1 Swensson’s Parametric Model 356

12.2.2 Nonparametric LROC Approach 358

12.2.3 Analysis of Example One 359

12.3 FROC Approach 360

12.3.1 FROC-type Curves 361

12.3.2 Radiological Search Model 367

12.3.3 Resampling Methods 368

12.3.4 FROC Analysis Method in MRMC Study 369

12.3.5 Analysis of Example Two 373

12.4 ROI Approach 377

12.4.1 Nonparametric ROI Analysis Method 377

12.4.2 iROI Paradigm 379

12.4.3 Analysis of Example Two 382

12.4.4 Analysis of Example Three 382

12.5 Comparison Between Location-specific ROC Methods 383

13 Technical Performance (“Accuracy”) of Quantitative Imaging Biomarkers 385

13.1 Quantitative Imaging Biomarkers 385

13.1.1 Definitions 385

13.1.2 Technical Performance Characteristics 385

13.1.3 Illustrative Example of QIBs for Nonalcoholic Fatty Liver Disease 387

13.2 Technical Performance Characteristics of a QIB 387

13.2.1 Basic Model 387

13.2.2 Limits of Detection and Quantitation 388

13.3 Precision 389

13.3.1 Study Design for Measuring Precision of QIBs 389

13.3.2 Precision Metrics and Their Estimation 392

13.3.3 Sample Size Considerations for Precision Studies 396

13.3.4 Precision Profile 398

13.4 Bias and Linearity 398

13.4.1 Study Design for Assessing Bias 398

13.4.2 Bias Metrics and Their Estimation 401

13.4.3 Sample Size Considerations for Bias Studies 404

13.4.4 Bias Profile 404

13.5 Other Metrics of QIB Performance 405

13.5.1 Limits of Agreement 405

13.5.2 Coverage Probability 406

13.5.3 Total Deviation Index 406

13.5.4 Mean Squared Deviation 407

13.6 Clinical Performance 407

13.6.1 Integrated Biomarkers 408

13.6.2 Integral Biomarkers 409

13.6.3 Multi-parametric Applications 411

14 Medical Test Efficacy and Effectiveness 413

14.1 General Notation 414

14.2 Prognostic Effects 416

14.3 Predictive Effects 416

14.4 Test Strategies for Assigning Treatments 417

14.5 Explanatory Versus Pragmatic Trials of Tests 417

14.6 Explanatory Trial Designs 418

14.6.1 Stratified Design 418

14.6.2 Enrichment (Targeted) Design 418

14.6.3 Discordant Pairs Design 419

14.7 Pragmatic Trial Designs 420

14.7.1 Test Strategy Design 420

14.7.2 Comparative Test Strategy Design 422

14.8 Adaptive Treatment Strategy Trial Designs 423

14.9 Treatment Selection Tests 424

14.10 Follow-on Treatment Selection Tests 425

14.10.1 Bridging Studies 425

14.10.2 Concordance Study and Indirect Estimation of Drug Efficacy 427

14.11 Bibliographic Notes 428

14.11.1 Biomarkers and Markers 428

14.11.2 Prognostic and Predictive Factors 428

14.11.3 Medical Test Trial Design Literature 429

14.11.4 Stratified Trial Design 429

14.11.5 Enrichment Design 430

14.11.6 Causal Effects of Testing 430

15 Statistical Analysis for Meta-analysis 433

15.1 Binary-scale Data 433

15.1.1 Random Effects Model: Meta-analysis of Ultrasound for PAD 434

15.2 Ordinal- or Continuous-scale Data 435

15.2.1 Random Effects Model 435

15.2.2 Bivariate Approach 436

15.2.3 Binary Regression Model 438

15.2.4 Hierarchical SROC Curve 439

15.2.5 Other Methods 441

15.3 ROC Curve Area 441

15.3.1 EB Method: Meta-analysis of DST 443

15.4 Publication Bias 443

16 Risk Prediction 449

16.1 Risk Calculators 451

16.1.1 Breast Cancer Calculators 451

16.1.2 The Gail Model 452

16.1.3 Framingham Heart Study Risk Calculator 453

16.2 Calibration 454

16.2.1 Definitions of Calibration 454

16.2.2 Log-logistic Regression 455

16.2.3 Cox Proportional Hazards 456

16.2.4 Predictiveness Curve 457

16.2.5 Calibration Plot 458

16.2.6 Goodness-of-fit Tests 459

16.2.7 Testing for Equivalence 461

16.2.8 Brier Score 463

16.2.9 Model-based ROC Curve 463

16.3 Discrimination 464

16.3.1 Risk Distribution 465

16.3.2 Time-dependent Predictive Values 466

16.3.3 Time-dependent ROC Curves 467

16.4 Appendix 16-A: Survival Analysis 469

16.4.1 Structure of Survival Data 470

16.4.2 Basic Concepts in Survival Analysis 471

16.4.3 Estimation 472

16.5 Appendix 16-B: Survival Analysis for Competing Risks 475

16.5.1 Competing Risk Survival Analysis 475

16.5.2 Survival Analysis for Competing Risks 476

16.5.3 Estimation 478

16.5.4 Kaplan–Meier Estimator of Pure Risk 478

16.5.5 Aalen–Johansen Estimator of Absolute Risk 479

16.6 Appendix 16-C: Stochastic Processes for Survival Analysis 480

16.7 Appendix 16-D: Bibliographic Notes 481

16.7.1 Bibliographic Notes for Section 16.3 481

16.7.2 Bibliographic Notes for Section 16.5 481

Appendix-A: Case Studies and Chapter 8 Data 485

Appendix-B: Jackknife and Bootstrap Methods of Estimating Variances and Confidence Intervals 513

Bibliography 517

Index 555


Xiao-Hua Zhou, fellow of the American Association for the Advancement of Science, fellow of the American Statistical Association, fellow of Institute of Mathematical Statistics, is PKU Distinguished Chair Professor and Chair of the Department of Biostatistics at Peking University, Beijing, China. His research focuses on statistical methods for diagnostic medicine, causal inference, and clinical trials, with extensive experience in regulatory statistics and biomedical research methodology. He has published more than 290 referred papers in those areas.

Jiarui Sun is Senior Biostatistician in Shanghai Shengdi Pharmaceutical Co., Ltd. and received his Ph.D from the School of Mathematical Science at Peking University, Beijing, China. His research interests include statistical methods for diagnostic accuracy studies, biomarker evaluation, and computational approaches to medical statistics and diagnostic test validation.

Gene A. Pennello, fellow of the American Statistical Association, is a statistical reviewer and research Mathematical Statistician at the U.S. Food and Drug Administration (FDA) in Silver Spring, Maryland. He specializes in statistical methods for medical device evaluation, diagnostic test assessment, and regulatory review processes for medical technologies.

Nancy A. Obuchowski, fellow of the American Statistical Association, Professor of Medicine at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, has extensive experience in the design, analysis, and development of new statistical methodology for the evaluation of diagnostic and screening tests and quantitative imaging biomarkers.

Donna K. McClish, PhD, is Associate Professor and Graduate Program Director in Biostatistics at Virginia Commonwealth University. She has written more than 100 journal articles on statistical methods in epidemiology, diagnostic medicine, and health services research.



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