title: A simple method to adjust clinical prediction models to local circumstances.
abstract: BACKGROUND
  Clinical prediction models estimate the risk of having or developing a particular outcome or disease. Researchers often develop a new model when a previously developed model is validated and the performance is poor. However, the model can be adjusted (updated) using the new data. The updated model is then based on both the development and validation data. We show how a simple updating method may suffice to update a clinical prediction model.
  
  
  METHODS
  A prediction model that preoperatively predicts the risk of severe postoperative pain was developed with multivariable logistic regression from the data of 1944 surgical patients in the Academic Medical Center Amsterdam, the Netherlands. We studied the predictive performance of the model in 1,035 new patients, scheduled for surgery at a later time in the University Medical Center Utrecht, the Netherlands. We assessed the calibration (agreement between predicted risks and the observed frequencies of an outcome) and discrimination (ability of the model to distinguish between patients with and without postoperative pain). When the incidence of the outcome is different, all predicted risks may be systematically over- or underestimated. Hence, the intercept of the model can be adjusted (updating).
  
  
  RESULTS
  The predicted risks were systematically higher than the observed frequencies, corresponding to a difference in the incidence of postoperative pain between the development (62%) and validation set (36%). The updated model resulted in better calibration.
  
  
  CONCLUSIONS
  When a clinical prediction model in new patients does not show adequate performance, an alternative to developing a new model is to update the prediction model with new data. The updated model will be based on more patient data, and may yield better risk estimates.
authors.affiliation: Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Str 6.131, P.O. Box 85500, 3508 GA Utrecht, The Netherlands. K.J.M.Janssen@umcutrecht.nl
authors.forename: Kristel J M
authors.initials: KJ
authors.lastname: Janssen
authors.forename: Yvonne
authors.initials: Y
authors.lastname: Vergouwe
authors.forename: Cor J
authors.initials: CJ
authors.lastname: Kalkman
authors.forename: Diederick E
authors.initials: DE
authors.lastname: Grobbee
authors.forename: Karel G M
authors.initials: KG
authors.lastname: Moons
mesh_terms: D000758:Anesthesia; D019540:Area Under Curve; D002138:Calibration; D006801:Humans; D015233:Models, Statistical; D010147:Pain Measurement; D010149:Postoperative Pain / Q000453:epidemiology; D019990:Perioperative Care / Q000706:statistics & numerical data*; D011183:Postoperative Complications / Q000453:epidemiology; D011237:Predictive Value of Tests; D012307:Risk Factors; D016896:Treatment Outcome