title: Risk prediction models: II. External validation, model updating, and impact assessment.
abstract: Clinical prediction models are increasingly used to complement clinical reasoning and decision-making in modern medicine, in general, and in the cardiovascular domain, in particular. To these ends, developed models first and foremost need to provide accurate and (internally and externally) validated estimates of probabilities of specific health conditions or outcomes in the targeted individuals. Subsequently, the adoption of such models by professionals must guide their decision-making, and improve patient outcomes and the cost-effectiveness of care. In the first paper of this series of two companion papers, issues relating to prediction model development, their internal validation, and estimating the added value of a new (bio)marker to existing predictors were discussed. In this second paper, an overview is provided of the consecutive steps for the assessment of the model's predictive performance in new individuals (external validation studies), how to adjust or update existing models to local circumstances or with new predictors, and how to investigate the impact of the uptake of prediction models on clinical decision-making and patient outcomes (impact studies). Each step is illustrated with empirical examples from the cardiovascular field.
authors.affiliation: Julius Centre for Health Sciences and Primary Care, UMC Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands. k.g.m.moons@umcutrecht.nl
authors.forename: Karel G M
authors.initials: KG
authors.lastname: Moons
authors.forename: Andre Pascal
authors.initials: AP
authors.lastname: Kengne
authors.forename: Diederick E
authors.initials: DE
authors.lastname: Grobbee
authors.forename: Patrick
authors.initials: P
authors.lastname: Royston
authors.forename: Yvonne
authors.initials: Y
authors.lastname: Vergouwe
authors.forename: Douglas G
authors.initials: DG
authors.lastname: Altman
authors.forename: Mark
authors.initials: M
authors.lastname: Woodward
mesh_terms: D002318:Cardiovascular Diseases / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy; D003657:Decision Making; D003695:Delivery of Health Care / Q000458:organization & administration*; D006801:Humans; D008962:Models, Theoretical; D011379:Prognosis; D015203:Reproducibility of Results; D018570:Risk Assessment / Q000379:methods*