{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,5]],"date-time":"2026-05-05T11:12:37Z","timestamp":1777979557059,"version":"3.51.4"},"reference-count":66,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2026,5,5]],"date-time":"2026-05-05T00:00:00Z","timestamp":1777939200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background\/Objectives: Placental abruption remains one of the leading causes of maternal morbidity, and the development of disseminated intravascular coagulation (DIC) significantly worsens outcomes. We sought to develop and internally validate a prediction model\u2014the Placental Abruption DIC (PAD) Score\u2014using parameters routinely collected at presentation. Methods: We conducted a retrospective cohort study at a tertiary referral center in Istanbul, Turkey (January 2019\u2013December 2024). Women with singleton pregnancies \u226522 weeks diagnosed with placental abruption were eligible. The primary outcome was overt disseminated intravascular coagulation (DIC) within 24 h of admission, adjudicated using the original International Society on Thrombosis and Haemostasis (ISTH) overt DIC scoring algorithm; a total score of \u22655 was considered compatible with overt DIC. We built a multivariable logistic regression model with bootstrap internal validation (1000 resamples). Robustness was evaluated through prespecified sensitivity analyses including complete-case analysis, single imputation, Firth-penalized logistic regression, exclusion of patients transferred from external facilities, a four-variable model excluding preeclampsia, and alternative score threshold grouping. Comparative discrimination against the admission ISTH overt DIC score, the Erez pregnancy-modified DIC score, and the Kobayashi obstetrical DIC score were evaluated using the area under the receiver operating characteristic curve and DeLong testing. Results: Of 237 women, 54 (22.8%) developed DIC. The final model retained five predictors: fibrinogen concentration, shock index, platelet count, placental separation percentage, and chronic hypertension\/preeclampsia. The optimism-corrected area under the receiver operating characteristic curve (AUC) was 0.916, with calibration slope 0.96 and Brier score 0.12. DIC incidence was 2.9% in low-risk (0\u20134 points), 7.6% in moderate-risk (5\u20138 points), and 86.0% in high-risk (\u22659 points) patients. Discrimination remained stable across complete-case (AUC 0.909), single-imputation (0.913), Firth-penalized (0.914), transfer-excluded (0.902), four-variable (0.892), reduced three-predictor (0.842, excluding fibrinogen and platelet count), pathology-confirmed subgroups (0.887) and composite clinical outcome (0.801) analyses, and exceeded that of the ISTH (0.812), Erez (0.848) and Kobayashi (0.793) comparator scores. Conclusions: The PAD Score offers a straightforward method for stratifying DIC risk in placental abruption. External validation in independent cohorts is needed before clinical implementation.<\/jats:p>","DOI":"10.3390\/jcm15093524","type":"journal-article","created":{"date-parts":[[2026,5,5]],"date-time":"2026-05-05T10:01:30Z","timestamp":1777975290000},"page":"3524","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["PAD Score: A Clinical Prediction Tool for Disseminated Intravascular Coagulation in Placental Abruption"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0009-0002-7221-0042","authenticated-orcid":false,"given":"Resat","family":"Misirlioglu","sequence":"first","affiliation":[{"name":"Department of Obstetrics and Gynecology, Haseki Training and Research Hospital, University of Health Sciences, Istanbul 34668, T\u00fcrkiye"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4577-3368","authenticated-orcid":false,"given":"Filiz","family":"Yarsilikal Guleroglu","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Haseki Training and Research Hospital, University of Health Sciences, Istanbul 34668, T\u00fcrkiye"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ali","family":"Cetin","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Haseki Training and Research Hospital, University of Health Sciences, Istanbul 34668, T\u00fcrkiye"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2026,5,5]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1005","DOI":"10.1097\/01.AOG.0000239439.04364.9a","article-title":"Placental abruption","volume":"108","author":"Oyelese","year":"2006","journal-title":"Obstet. Gynecol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"140","DOI":"10.1111\/j.1600-0412.2010.01030.x","article-title":"Placental abruption: Epidemiology, risk factors and consequences","volume":"90","author":"Tikkanen","year":"2011","journal-title":"Acta Obstet. Gynecol. Scand."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Ananth, C.V., Keyes, K.M., Hamilton, A., Gissler, M., Wu, C., Liu, S., Luque-Fernandez, M.A., Skj\u00e6rven, R., Williams, M.A., and Tikkanen, M. (2015). An international contrast of rates of placental abruption: An age-period-cohort analysis. PLoS ONE, 10.","DOI":"10.1371\/journal.pone.0125246"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"935","DOI":"10.1055\/s-0037-1599149","article-title":"Maternal, labor, delivery, and perinatal outcomes associated with placental abruption: A systematic review","volume":"34","author":"Downes","year":"2017","journal-title":"Am. J. Perinatol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"21","DOI":"10.2147\/JBM.S273047","article-title":"DIC in Pregnancy\u2014Pathophysiology, Clinical Characteristics, Diagnostic Scores, and Treatments","volume":"13","author":"Erez","year":"2022","journal-title":"J. Blood Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"149","DOI":"10.1016\/S0889-8588(02)00102-8","article-title":"Disseminated intravascular coagulation current concepts of etiology, pathophysiology, diagnosis, and treatment","volume":"17","author":"Bick","year":"2003","journal-title":"Hematol. Oncol. Clin."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"341","DOI":"10.1016\/S1701-2163(16)35214-8","article-title":"Acute disseminated intravascular coagulation in obstetrics: A tertiary centre population review (1980 to 2009)","volume":"34","author":"Rattray","year":"2012","journal-title":"J. Obstet. Gynaecol. Can."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"452","DOI":"10.1016\/j.ajog.2015.03.054","article-title":"Disseminated intravascular coagulation in pregnancy: Insights in pathophysiology, diagnosis and management","volume":"213","author":"Erez","year":"2015","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"999","DOI":"10.1097\/AOG.0000000000001110","article-title":"Disseminated intravascular coagulation syndromes in obstetrics","volume":"126","author":"Cunningham","year":"2015","journal-title":"Obstet. Gynecol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"167","DOI":"10.1016\/j.blre.2009.04.002","article-title":"Disseminated intravascular coagulation in obstetric disorders and its acute haematological management","volume":"23","author":"Thachil","year":"2009","journal-title":"Blood Rev."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"411","DOI":"10.1093\/bja\/aex181","article-title":"Viscoelastometric-guided early fibrinogen concentrate replacement during postpartum haemorrhage: OBS2, a double-blind randomized controlled trial","volume":"119","author":"Collins","year":"2017","journal-title":"Br. J. Anaesth."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1327","DOI":"10.1055\/s-0037-1616068","article-title":"Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation","volume":"86","author":"Taylor","year":"2001","journal-title":"Thromb. Haemost."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Erez, O., Novack, L., Beer-Weisel, R., Dukler, D., Press, F., Zlotnik, A., Than, N.G., Tomer, A., and Mazor, M. (2014). DIC score in pregnant women\u2014A population based modification of the International Society on Thrombosis and Hemostasis score. PLoS ONE, 9.","DOI":"10.1371\/journal.pone.0093240"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1500","DOI":"10.1111\/jog.12426","article-title":"Obstetrical disseminated intravascular coagulation score","volume":"40","author":"Kobayashi","year":"2014","journal-title":"J. Obstet. Gynaecol. Res."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"845","DOI":"10.1182\/blood-2017-10-804096","article-title":"How I treat disseminated intravascular coagulation","volume":"131","author":"Levi","year":"2018","journal-title":"Blood"},{"key":"ref_16","first-page":"1","article-title":"The role of massive transfusion protocol (MTP)s in obstetrics","volume":"30","author":"Pacheco","year":"2013","journal-title":"Am. J. Perinatol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"b604","DOI":"10.1136\/bmj.b604","article-title":"Prognosis and prognostic research: Developing a prognostic model","volume":"338","author":"Royston","year":"2009","journal-title":"BMJ"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1025","DOI":"10.1080\/14767058.2017.1306050","article-title":"Risk for postpartum hemorrhage, transfusion, and hemorrhage-related morbidity at low, moderate, and high volume hospitals","volume":"31","author":"Merriam","year":"2018","journal-title":"J. Matern.-Fetal Neonatal Med."},{"key":"ref_19","first-page":"155","article-title":"National partnership for maternal safety: Consensus bundle on obstetric hemorrhage","volume":"126","author":"Main","year":"2015","journal-title":"Obstet. Gynecol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"g7594","DOI":"10.1136\/bmj.g7594","article-title":"Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD): The TRIPOD statement","volume":"350","author":"Collins","year":"2015","journal-title":"BMJ"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"W1","DOI":"10.7326\/M14-0698","article-title":"Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD): Explanation and elaboration","volume":"162","author":"Moons","year":"2015","journal-title":"Ann. Intern. Med."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1373","DOI":"10.1016\/S0895-4356(96)00236-3","article-title":"A simulation study of the number of events per variable in logistic regression analysis","volume":"49","author":"Peduzzi","year":"1996","journal-title":"J. Clin. Epidemiol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"710","DOI":"10.1093\/aje\/kwk052","article-title":"Relaxing the rule of ten events per variable in logistic and Cox regression","volume":"165","author":"Vittinghoff","year":"2007","journal-title":"Am. J. Epidemiol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"m441","DOI":"10.1136\/bmj.m441","article-title":"Calculating the sample size required for developing a clinical prediction model","volume":"368","author":"Riley","year":"2020","journal-title":"BMJ"},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"van Smeden, M., de Groot, J.A., Moons, K.G., Collins, G.S., Altman, D.G., Eijkemans, M.J., and Reitsma, J.B. (2016). No rationale for 1 variable per 10 events criterion for binary logistic regression analysis. BMC Med. Res. Methodol., 16.","DOI":"10.1186\/s12874-016-0267-3"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"268","DOI":"10.1111\/1471-0528.13206","article-title":"Shock index: An effective predictor of outcome in postpartum haemorrhage?","volume":"122","author":"Nathan","year":"2015","journal-title":"BJOG Int. J. Obstet. Gynaecol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"253","DOI":"10.1016\/j.ijgo.2013.08.020","article-title":"Use of the obstetric shock index as an adjunct in identifying significant blood loss in patients with massive postpartum hemorrhage","volume":"124","author":"Chandraharan","year":"2014","journal-title":"Int. J. Gynaecol. Obstet."},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"El Ayadi, A.M., Nathan, H.L., Seed, P.T., Butrick, E.A., Hezelgrave, N.L., Shennan, A.H., and Miller, S. (2016). Vital sign prediction of adverse maternal outcomes in women with hypovolemic shock: The role of shock index. PLoS ONE, 11.","DOI":"10.1371\/journal.pone.0148729"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1198","DOI":"10.1080\/01621459.1988.10478722","article-title":"A test of missing completely at random for multivariate data with missing values","volume":"83","author":"Little","year":"1988","journal-title":"J. Am. Stat. Assoc."},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"van Buuren, S. (2018). Flexible Imputation of Missing Data, CRC Press. [2nd ed.].","DOI":"10.1201\/9780429492259"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1002\/sim.4067","article-title":"Multiple imputation using chained equations: Issues and guidance for practice","volume":"30","author":"White","year":"2011","journal-title":"Stat. Med."},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Steyerberg, E.W. (2019). Clinical Prediction Models: A Practical Approach to Development, Validation, and Updating, Springer. [2nd ed.].","DOI":"10.1007\/978-3-030-16399-0"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"361","DOI":"10.1002\/(SICI)1097-0258(19960229)15:4<361::AID-SIM168>3.0.CO;2-4","article-title":"Multivariable prognostic models: Issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors","volume":"15","author":"Harrell","year":"1996","journal-title":"Stat. Med."},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Harrell, F.E. (2015). Regression Modeling Strategies: With Applications to Linear Models, Logistic and Ordinal Regression, and Survival Analysis, Springer. [2nd ed.].","DOI":"10.1007\/978-3-319-19425-7"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"128","DOI":"10.1097\/EDE.0b013e3181c30fb2","article-title":"Assessing the performance of prediction models: A framework for some traditional and novel measures","volume":"21","author":"Steyerberg","year":"2010","journal-title":"Epidemiology"},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Van Calster, B., McLernon, D.J., van Smeden, M., Wynants, L., and Steyerberg, E.W. (2019). Calibration: The Achilles heel of predictive analytics. BMC Med., 17.","DOI":"10.1186\/s12916-019-1466-7"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"565","DOI":"10.1177\/0272989X06295361","article-title":"Decision curve analysis: A novel method for evaluating prediction models","volume":"26","author":"Vickers","year":"2006","journal-title":"Med. Decis. Mak."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"i6","DOI":"10.1136\/bmj.i6","article-title":"Net benefit approaches to the evaluation of prediction models, molecular markers, and diagnostic tests","volume":"352","author":"Vickers","year":"2016","journal-title":"BMJ"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1631","DOI":"10.1002\/sim.1742","article-title":"Presentation of multivariate data for clinical use: The Framingham Study risk score functions","volume":"23","author":"Sullivan","year":"2004","journal-title":"Stat. Med."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"266","DOI":"10.1111\/j.1538-7836.2007.02297.x","article-title":"The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage","volume":"5","author":"Charbit","year":"2007","journal-title":"J. Thromb. Haemost."},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Hosmer, D.W., Lemeshow, S., and Sturdivant, R.X. (2013). Applied Logistic Regression, John Wiley & Sons. [3rd ed.].","DOI":"10.1002\/9781118548387"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"337","DOI":"10.1097\/AOG.0000000000000107","article-title":"Amniotic fluid embolism","volume":"123","author":"Clark","year":"2014","journal-title":"Obstet. Gynecol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"339","DOI":"10.1016\/j.bpobgyn.2009.11.010","article-title":"Coagulation in pregnancy","volume":"24","author":"Thornton","year":"2010","journal-title":"Best Pract. Res. Clin. Obstet. Gynaecol."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"409","DOI":"10.1016\/j.thromres.2004.08.004","article-title":"Haemostatic changes in pregnancy","volume":"114","author":"Brenner","year":"2004","journal-title":"Thromb. Res."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"42","DOI":"10.1186\/s12959-016-0117-x","article-title":"Proposal for new diagnostic criteria for DIC from the Japanese Society on Thrombosis and Hemostasis","volume":"14","author":"Asakura","year":"2016","journal-title":"Thromb. J."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"354","DOI":"10.1111\/anae.12180","article-title":"Design and internal validation of an obstetric early warning score","volume":"68","author":"Carle","year":"2013","journal-title":"Anaesthesia"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"771","DOI":"10.1111\/1552-6909.12504","article-title":"The maternal early warning criteria: A proposal from the national partnership for maternal safety","volume":"43","author":"Mhyre","year":"2014","journal-title":"J. Obstet. Gynecol. Neonatal Nurs."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1111\/j.1365-2044.2011.06896.x","article-title":"A validation study of the CEMACH recommended modified early obstetric warning system (MEOWS)","volume":"67","author":"Singh","year":"2012","journal-title":"Anaesthesia"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"120","DOI":"10.1097\/AOG.0b013e3182941c78","article-title":"Clinical validation of risk stratification criteria for peripartum hemorrhage","volume":"122","author":"Dilla","year":"2013","journal-title":"Obstet. Gynecol."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"46","DOI":"10.1111\/1471-0528.16379","article-title":"Predicting risk of postpartum haemorrhage: A systematic review","volume":"128","author":"Neary","year":"2021","journal-title":"BJOG Int. J. Obstet. Gynaecol."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"935","DOI":"10.1097\/AOG.0000000000003759","article-title":"Machine Learning and Statistical Models to Predict Postpartum Hemorrhage","volume":"135","author":"Venkatesh","year":"2020","journal-title":"Obstet. Gynecol."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"298e1","DOI":"10.1016\/j.ajog.2017.01.017","article-title":"Reduction of severe maternal morbidity from hemorrhage using a state perinatal quality collaborative","volume":"216","author":"Main","year":"2017","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"135","DOI":"10.1016\/j.ijoa.2010.12.002","article-title":"Standard haemostatic tests following major obstetric haemorrhage","volume":"20","author":"Bovington","year":"2011","journal-title":"Int. J. Obstet. Anesth."},{"key":"ref_54","first-page":"CD007871","article-title":"Thromboelastography (TEG) or thromboelastometry (ROTEM) to monitor haemostatic treatment versus usual care in adults or children with bleeding","volume":"8","author":"Wetterslev","year":"2016","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"166","DOI":"10.1111\/anae.12859","article-title":"Introduction of an algorithm for ROTEM-guided fibrinogen concentrate administration in major obstetric haemorrhage","volume":"70","author":"Mallaiah","year":"2015","journal-title":"Anaesthesia"},{"key":"ref_56","doi-asserted-by":"crossref","unstructured":"Pacagnella, R.C., Souza, J.P., Durocher, J., Perel, P., Blum, J., Winikoff, B., and G\u00fclmezoglu, A.M. (2013). A systematic review of the relationship between blood loss and clinical signs. PLoS ONE, 8.","DOI":"10.1371\/annotation\/4db90e4b-ae29-4931-9049-3ef5e5c9eeee"},{"key":"ref_57","doi-asserted-by":"crossref","unstructured":"Qiu, X., Nair, M.G., Jaroszewski, L., and Godzik, A. (2024). Deciphering Abnormal Platelet Subpopulations in COVID-19, Sepsis and Systemic Lupus Erythematosus through Machine Learning and Single-Cell Transcriptomics. Int. J. Mol. Sci., 25.","DOI":"10.3390\/ijms25115941"},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"1347","DOI":"10.1056\/NEJMra1814259","article-title":"Machine learning in medicine","volume":"380","author":"Rajkomar","year":"2019","journal-title":"N. Engl. J. Med."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1016\/j.jclinepi.2019.02.004","article-title":"A systematic review shows no performance benefit of machine learning over logistic regression for clinical prediction models","volume":"110","author":"Christodoulou","year":"2019","journal-title":"J. Clin. Epidemiol."},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"1216","DOI":"10.1056\/NEJMp1606181","article-title":"Predicting the future\u2014Big data, machine learning, and clinical medicine","volume":"375","author":"Obermeyer","year":"2016","journal-title":"N. Engl. J. Med."},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"2199","DOI":"10.1001\/jama.2018.17163","article-title":"Clinical decision support in the era of artificial intelligence","volume":"320","author":"Shortliffe","year":"2018","journal-title":"JAMA"},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"761","DOI":"10.1111\/jth.12155","article-title":"Guidance for diagnosis and treatment of disseminated intravascular coagulation from harmonization of the recommendations from three guidelines","volume":"11","author":"Wada","year":"2013","journal-title":"J. Thromb. Haemost."},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"279","DOI":"10.1016\/j.jclinepi.2014.06.018","article-title":"A new framework to enhance the interpretation of external validation studies of clinical prediction models","volume":"68","author":"Debray","year":"2015","journal-title":"J. Clin. Epidemiol."},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"h391","DOI":"10.1136\/bmj.h391","article-title":"The stepped wedge cluster randomised trial: Rationale, design, analysis, and reporting","volume":"350","author":"Hemming","year":"2015","journal-title":"BMJ"},{"key":"ref_65","doi-asserted-by":"crossref","unstructured":"Ancker, J.S., Edwards, A., Nosal, S., Hauser, D., Mauer, E., Kaushal, R., and HITEC Investigators (2017). Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system. BMC Med. Inform. Decis. Mak., 17.","DOI":"10.1186\/s12911-017-0430-8"},{"key":"ref_66","doi-asserted-by":"crossref","first-page":"1093","DOI":"10.1001\/jama.2016.12195","article-title":"Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: Second panel on cost-effectiveness in health and medicine","volume":"316","author":"Sanders","year":"2016","journal-title":"JAMA"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/9\/3524\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,5]],"date-time":"2026-05-05T10:30:10Z","timestamp":1777977010000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/9\/3524"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,5]]},"references-count":66,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2026,5]]}},"alternative-id":["jcm15093524"],"URL":"https:\/\/doi.org\/10.3390\/jcm15093524","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,5]]}}}