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Shi Y, Mahdian S, Blanchet J, Glynn P, Shin AY, Scheinker D. Surgical scheduling via optimization and machine learning with long-tailed data : Health care management science, in press. Health Care Manag Sci 2023; 26:692-718. [PMID: 37665543 DOI: 10.1007/s10729-023-09649-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 06/07/2023] [Indexed: 09/05/2023]
Abstract
Using data from cardiovascular surgery patients with long and highly variable post-surgical lengths of stay (LOS), we develop a modeling framework to reduce recovery unit congestion. We estimate the LOS and its probability distribution using machine learning models, schedule procedures on a rolling basis using a variety of optimization models, and estimate performance with simulation. The machine learning models achieved only modest LOS prediction accuracy, despite access to a very rich set of patient characteristics. Compared to the current paper-based system used in the hospital, most optimization models failed to reduce congestion without increasing wait times for surgery. A conservative stochastic optimization with sufficient sampling to capture the long tail of the LOS distribution outperformed the current manual process and other stochastic and robust optimization approaches. These results highlight the perils of using oversimplified distributional models of LOS for scheduling procedures and the importance of using optimization methods well-suited to dealing with long-tailed behavior.
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Affiliation(s)
- Yuan Shi
- Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | | | | | - Peter Glynn
- Stanford University, Stanford, CA, 94305, USA
| | - Andrew Y Shin
- Stanford University, Stanford, CA, 94305, USA
- Lucile Packard Children's Hospital, Palo Alto, CA, 94304, USA
| | - David Scheinker
- Stanford University, Stanford, CA, 94305, USA.
- Lucile Packard Children's Hospital, Palo Alto, CA, 94304, USA.
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Optimization of Tree-Based Machine Learning Models to Predict the Length of Hospital Stay Using Genetic Algorithm. JOURNAL OF HEALTHCARE ENGINEERING 2023; 2023:9673395. [PMID: 36824405 PMCID: PMC9943622 DOI: 10.1155/2023/9673395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 12/01/2022] [Accepted: 01/17/2023] [Indexed: 02/16/2023]
Abstract
The length of hospital stay (LOS) is a significant indicator of the quality of patient care, hospital efficiency, and operational resilience. Considering the importance of LOS in hospital resource management, this research aims to improve the accuracy of LOS prediction using hyperparameter optimization (HPO). Expert physicians and related studies were reviewed to determine the variables affecting LOS. The electronic medical records of 200 patients in the department of internal medicine of a hospital in Iran were collected randomly. As the performance of machine learning (ML) models can vary based on the characteristics of the features, several models were applied and evaluated in this study. In particular, k-nearest neighbors (KNN), multivariate regression, decision tree (DT), random forest (RF), artificial neural network (ANN), and XGBoost have been evaluated and improved. The genetic algorithm (GA) was applied to optimize the tree-based models. In addition, the dummy coding technique, sometimes called the One-Hot encoding, was used to encode categorical features to increase prediction accuracy. Compared with other algorithms, the XGBoost model optimized by GA (XGB_GA) achieved higher accuracy and better prediction performance. The mean and median of absolute errors in the test dataset for this model were 1.54 and 1.14 days, respectively. In other words, the XGB_GA model reduced the mean absolute error by 37%, which is beneficial in the reliable design of a clinical decision support system.
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Bushnell J, Connelly C, Algaze CA, Bailly DK, Koth A, Mafla M, Presnell L, Shin AY, McCammond AN. Team Communication and Expectations Following Pediatric Cardiac Surgery: A Multi-Disciplinary Survey. Pediatr Cardiol 2022; 44:908-914. [PMID: 36436004 DOI: 10.1007/s00246-022-03059-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 11/16/2022] [Indexed: 11/28/2022]
Abstract
Patients and families desire an accurate understanding of the expected recovery following congenital cardiac surgery. Variation in knowledge and expectations within the care team may be under-recognized and impact communication and care delivery. Our objective was to assess knowledge of common postoperative milestones and perceived efficacy of communication with patients and families and within the care team. An 18-question survey measuring knowledge of expected milestones for recovery after four index operations and team communication in the postoperative period was distributed electronically to multidisciplinary care team members at 16 academic pediatric heart centers. Answers were compared to local median data for each respondent's heart center to assess accuracy and stratified by heart center role and years of experience. We obtained 874 responses with broad representation of disciplines. More than half of all respondent predictions (55.3%) did not match their local median data. Percent matching did not vary by care team role but improved with increasing experience (35.8% < 2 years vs. 46.4% > 10 years, p = 0.2133). Of all respondents, 62.7% expressed confidence discussing the anticipated postoperative course, 78.6% denoted confidence discussing postoperative complications, and 55.3% conveyed that not all members of their care team share a common expectation for typical postoperative recovery. Most respondents (94.6%) stated that increased knowledge of local data would positively impact communication. Confidence in communication exceeded accuracy in predicting the timing of postoperative milestones. Important variation in knowledge and expectations for postoperative recovery in pediatric cardiac surgery exists and may impact communication and clinical effectiveness.
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Affiliation(s)
- Julie Bushnell
- Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Chloe Connelly
- University of Cincinnati School of Medicine, Cincinnati Children's Hospital and James M. Anderson Center for Health Systems Excellence, Cincinnati, OH, USA
| | - Claudia A Algaze
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - David K Bailly
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Andrew Koth
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Monica Mafla
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Laura Presnell
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Andrew Y Shin
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Amy N McCammond
- Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, CA, USA.
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Yan YM, Gao J, Jin PL, Lu JJ, Yu ZH, Hu Y. C-reactive protein as a non-linear predictor of prolonged length of intensive care unit stay after gastrointestinal cancer surgery. World J Clin Cases 2022; 10:11381-11390. [PMID: 36387784 PMCID: PMC9649545 DOI: 10.12998/wjcc.v10.i31.11381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 09/26/2022] [Accepted: 10/09/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The relationship between C-reactive protein (CRP) levels and prolonged intensive care unit (ICU) length of stay (LoS) has not been well defined.
AIM To explore the association between CRP levels at ICU admission and prolonged ICU LoS in gastrointestinal cancer (GC) patients after major surgery.
METHODS A retrospective study was performed to quantify serum CRP levels and to establish their association with prolonged ICU LoS (≥ 72 h) in GC patients admitted to the ICU. Univariate and multivariate regression analyses were conducted, and restricted cubic spline curves with four knots (5%, 35%, 65%, 95%) were used to explore non-linearity assumptions.
RESULTS A total of 408 patients were enrolled. Among them, 83 (20.3%) patients had an ICU LoS longer than 72 h. CRP levels were independently associated with the risk of prolonged ICU LoS [odds ratio (OR) 1.47, 95% confidence interval (CI) 1.00–2.17]. Restricted cubic spline analysis revealed a non-linear relationship between CRP levels and OR for the prolonged ICU LoS (P = 0.035 for non-linearity). After the cut-off of 2.6 (log transformed mg/L), the OR for prolonged ICU LoS significantly increased with CRP levels. The adjusted regression coefficient was 0.70 (95%CI 0.31–1.57, P = 0.384) for CRP levels less than 2.6, whereas it was 2.43 (95%CI 1.39–4.24, P = 0.002) for CRP levels higher than 2.6.
CONCLUSION Among the GC patients, CRP levels at ICU admission were non-linearly associated with prolonged ICU LoS in survivors. An admission CRP level > 2.6 (log transformed mg/L) was associated with increased risk of prolonged ICU LoS.
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Affiliation(s)
- Ya-Min Yan
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jian Gao
- Department of Nutrition, Zhongshan Hospital, Fudan University, Shanghai 200032, China
- Center of Clinical Epidemiology and Evidence-based Medicine, Fudan University, Shanghai 200032, China
| | - Pei-Li Jin
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jing-Jing Lu
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Zheng-Hong Yu
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yan Hu
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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Multilayer dynamic ensemble model for intensive care unit mortality prediction of neonate patients. J Biomed Inform 2022; 135:104216. [DOI: 10.1016/j.jbi.2022.104216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 09/25/2022] [Accepted: 09/28/2022] [Indexed: 12/26/2022]
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Patel R, Dhanda AK, Georges K, Cohen DA, Patel P, Eloy JA. Length of Stay in Patients Undergoing Tracheoplasty: A NSQIP Study. Laryngoscope 2022. [PMID: 36214517 DOI: 10.1002/lary.30424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/21/2022] [Accepted: 09/15/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Prolonged length of stay (LOS) has been associated with increased morbidity and resource utilization in various surgical procedures. We aim to determine factors associated with increased hospital stay in patient undergoing tracheoplasty. METHODS The 2012-2018 National Surgical Quality Improvement Program (NSQIP) database was queried for patients undergoing tracheoplasty. Patient LOS was the primary clinical outcome. A LOS >75th percentile was considered as prolonged and was utilized for bivariate analysis of demographic, comorbidity, and operative characteristics. LOS was utilized as a continuous variable for multivariate linear regression analysis. RESULTS A total of 252 patients were queried. The majority of patients were female (67.5%), white (82.4%), and over the age of 65 (77.0%). Patients had a median LOS of 7 days with the 75th percentile cutoff being defined at 10 days. On bivariate analysis of associated comorbidities, patients with prolonged LOS were more commonly obese (72.4% vs. 53.1%, p = 0.009), diabetic (37.9% vs. 16.5%, p < 0.001), dyspneic (58.6% vs. 40.7%, p = 0.016), and had chronic steroid use (25.9% vs. 12.9%, p = 0.018). Multivariable logistic regression analysis demonstrated significant associations between prolonged LOS and both chronic obstructive pulmonary disorder (COPD) (OR: 3.43, p = 0.020) and chronic steroid use (OR: 3.81, p = 0.018). CONCLUSIONS This study elucidates factors associated with prolonged LOS in patients undergoing tracheoplasty. Patients with COPD and chronic steroid use were significantly associated with prolonged LOS. LEVEL OF EVIDENCE 4 Laryngoscope, 2022.
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Affiliation(s)
- Rushi Patel
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Aatin K Dhanda
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Kirolos Georges
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - David A Cohen
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Prayag Patel
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Jean Anderson Eloy
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, USA.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA.,Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, New Jersey, USA.,Department of Otolaryngology and Facial Plastic Surgery, Cooperman Barnabas Medical Center - RWJ Barnabas Health, Livingston, New Jersey, USA
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Wang K, Yan LZ, Li WZ, Jiang C, Wang NN, Zheng Q, Dong NG, Shi JW. Comparison of Four Machine Learning Techniques for Prediction of Intensive Care Unit Length of Stay in Heart Transplantation Patients. Front Cardiovasc Med 2022; 9:863642. [PMID: 35800164 PMCID: PMC9253610 DOI: 10.3389/fcvm.2022.863642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPost-operative heart transplantation patients often require admission to an intensive care unit (ICU). Early prediction of the ICU length of stay (ICU-LOS) of these patients is of great significance and can guide treatment while reducing the mortality rate among patients. However, conventional linear models have tended to perform worse than non-linear models.Materials and MethodsWe collected the clinical data of 365 patients from Wuhan Union Hospital who underwent heart transplantation surgery between April 2017 and August 2020. The patients were randomly divided into training data (N = 256) and test data (N = 109) groups. 84 clinical features were collected for each patient. Features were validated using the Least Absolute Shrinkage and Selection Operator (LASSO) regression’s fivefold cross-validation method. We obtained Shapley Additive explanations (SHAP) values by executing package “shap” to interpret model predictions. Four machine learning models and logistic regression algorithms were developed. The area under the receiver operating characteristic curve (AUC-ROC) was used to compare the prediction performance of different models. Finally, for the convenience of clinicians, an online web-server was established and can be freely accessed via the website https://wuhanunion.shinyapps.io/PredictICUStay/.ResultsIn this study, 365 consecutive patients undergoing heart transplantation surgery for moderate (NYHA grade 3) or severe (NYHA grade 4) heart failure were collected in Wuhan Union Hospital from 2017 to 2020. The median age of the recipient patients was 47.2 years, while the median age of the donors was 35.58 years. 330 (90.4%) of the donor patients were men, and the average surgery duration was 260.06 min. Among this cohort, 47 (12.9%) had renal complications, 25 (6.8%) had hepatic complications, 11 (3%) had undergone chest re-exploration and 19 (5.2%) had undergone extracorporeal membrane oxygenation (ECMO). The following six important clinical features were selected using LASSO regression, and according to the result of SHAP, the rank of importance was (1) the use of extracorporeal membrane oxygenation (ECMO); (2) donor age; (3) the use of an intra-aortic balloon pump (IABP); (4) length of surgery; (5) high creatinine (Cr); and (6) the use of continuous renal replacement therapy (CRRT). The eXtreme Gradient Boosting (XGBoost) algorithm presented significantly better predictive performance (AUC-ROC = 0.88) than other models [Accuracy: 0.87; sensitivity: 0.98; specificity: 0.51; positive predictive value (PPV): 0.86; negative predictive value (NPV): 0.93].ConclusionUsing the XGBoost classifier with heart transplantation patients can provide an accurate prediction of ICU-LOS, which will not only improve the accuracy of clinical decision-making but also contribute to the allocation and management of medical resources; it is also a real-world example of precision medicine in hospitals.
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Affiliation(s)
- Kan Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Li Zhao Yan
- Department of Hand Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wang Zi Li
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chen Jiang
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ni Ni Wang
- Department of Nurse, Jianshi County People's Hospital, Enshi, China
| | - Qiang Zheng
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Nian Guo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jia Wei Shi
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Ehrmann D, Harish V, Morgado F, Rosella L, Johnson A, Mema B, Mazwi M. Ignorance Isn't Bliss: We Must Close the Machine Learning Knowledge Gap in Pediatric Critical Care. Front Pediatr 2022; 10:864755. [PMID: 35620143 PMCID: PMC9127438 DOI: 10.3389/fped.2022.864755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/18/2022] [Indexed: 12/02/2022] Open
Abstract
Pediatric intensivists are bombarded with more patient data than ever before. Integration and interpretation of data from patient monitors and the electronic health record (EHR) can be cognitively expensive in a manner that results in delayed or suboptimal medical decision making and patient harm. Machine learning (ML) can be used to facilitate insights from healthcare data and has been successfully applied to pediatric critical care data with that intent. However, many pediatric critical care medicine (PCCM) trainees and clinicians lack an understanding of foundational ML principles. This presents a major problem for the field. We outline the reasons why in this perspective and provide a roadmap for competency-based ML education for PCCM trainees and other stakeholders.
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Affiliation(s)
- Daniel Ehrmann
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada.,Temerty Centre for Artificial Intelligence Research and Education in Medicine, University of Toronto, Toronto, ON, Canada
| | - Vinyas Harish
- Temerty Centre for Artificial Intelligence Research and Education in Medicine, University of Toronto, Toronto, ON, Canada.,MD/PhD Program, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Felipe Morgado
- Temerty Centre for Artificial Intelligence Research and Education in Medicine, University of Toronto, Toronto, ON, Canada.,MD/PhD Program, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Medical Biophysics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Laura Rosella
- MD/PhD Program, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Alistair Johnson
- MD/PhD Program, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
| | - Briseida Mema
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Mjaye Mazwi
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada.,MD/PhD Program, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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[Predicting prolonged length of intensive care unit stay via machine learning]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2021; 53. [PMID: 34916699 PMCID: PMC8695140 DOI: 10.19723/j.issn.1671-167x.2021.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To construct length of intensive care unit (ICU) stay (LOS-ICU) prediction models for ICU patients, based on three machine learning models support vector machine (SVM), classification and regression tree (CART), and random forest (RF), and to compare the prediction perfor-mance of the three machine learning models with the customized simplified acute physiology score Ⅱ(SAPS-Ⅱ) model. METHODS We used medical information mart for intensive care (MIMIC)-Ⅲ database for model development and validation. The primary outcome was prolonged LOS-ICU(pLOS-ICU), defined as longer than the third quartile of patients' LOS-ICU in the studied dataset. The recursive feature elimination method was used to do feature selection for three machine learning models. We utilized 5-fold cross validation to evaluate model prediction performance. The Brier value, area under the receiver operation characteristic curve (AUROC), and estimated calibration index (ECI) were used as perfor-mance measures. Performances of the four models were compared, and performance differences between the models were assessed using two-sided t test. The model with the best prediction performance was employed to generate variable importance ranking, and the identified top five important predictors were pre-sented. RESULTS The final cohort in our study consisted of 40 200 eligible ICU patients, of whom 23.7% were with pLOS-ICU. The proportion of the male patients was 57.6%, and the age of all the ICU patients was (61.9±16.5) years.Results showed that the three machine learning models outperformed the customized SAPS-Ⅱ model in terms of all the performance measures with statistical significance (P < 0.01). Among the three machine learning models, the RF model achieved the best overall performance (Brier value, 0.145), discrimination (AUROC, 0.770) and calibration (ECI, 7.259). The calibration curve showed that the RF model slightly overestimated the risk of pLOS-ICU in high-risk ICU patients, but underestimated the risk of pLOS-ICU in low-risk ICU patients. Top five important predictors for pLOS-ICU identified by the RF model included age, heart rate, systolic blood pressure, body tempe-rature, and ratio of arterial oxygen tension to the fraction of inspired oxygen(PaO2/FiO2). CONCLUSION The RF algorithm-based pLOS-ICU prediction model had a best prediction performance in this study. It lays a foundation for future application of the RF-based pLOS-ICU prediction model in ICU clinical practice.
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Abd-Elrazek MA, Eltahawi AA, Abd Elaziz MH, Abd-Elwhab MN. Predicting length of stay in hospitals intensive care unit using general admission features. AIN SHAMS ENGINEERING JOURNAL 2021; 12:3691-3702. [DOI: 10.1016/j.asej.2021.02.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Wu J, Lin Y, Li P, Hu Y, Zhang L, Kong G. Predicting Prolonged Length of ICU Stay through Machine Learning. Diagnostics (Basel) 2021; 11:diagnostics11122242. [PMID: 34943479 PMCID: PMC8700580 DOI: 10.3390/diagnostics11122242] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 11/22/2021] [Accepted: 11/24/2021] [Indexed: 12/12/2022] Open
Abstract
This study aimed to construct machine learning (ML) models for predicting prolonged length of stay (pLOS) in intensive care units (ICU) among general ICU patients. A multicenter database called eICU (Collaborative Research Database) was used for model derivation and internal validation, and the Medical Information Mart for Intensive Care (MIMIC) III database was used for external validation. We used four different ML methods (random forest, support vector machine, deep learning, and gradient boosting decision tree (GBDT)) to develop prediction models. The prediction performance of the four models were compared with the customized simplified acute physiology score (SAPS) II. The area under the receiver operation characteristic curve (AUROC), area under the precision-recall curve (AUPRC), estimated calibration index (ECI), and Brier score were used to measure performance. In internal validation, the GBDT model achieved the best overall performance (Brier score, 0.164), discrimination (AUROC, 0.742; AUPRC, 0.537), and calibration (ECI, 8.224). In external validation, the GBDT model also achieved the best overall performance (Brier score, 0.166), discrimination (AUROC, 0.747; AUPRC, 0.536), and calibration (ECI, 8.294). External validation showed that the calibration curve of the GBDT model was an optimal fit, and four ML models outperformed the customized SAPS II model. The GBDT-based pLOS-ICU prediction model had the best prediction performance among the five models on both internal and external datasets. Furthermore, it has the potential to assist ICU physicians to identify patients with pLOS-ICU risk and provide appropriate clinical interventions to improve patient outcomes.
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Affiliation(s)
- Jingyi Wu
- National Institute of Health Data Science, Peking University, Beijing 100191, China; (J.W.); (L.Z.)
- Advanced Institute of Information Technology, Peking University, Hangzhou 311215, China;
| | - Yu Lin
- Department of Medicine and Therapeutics, LKS Institute of Health Science, The Chinese University of Hong Kong, Hong Kong, China;
| | - Pengfei Li
- Advanced Institute of Information Technology, Peking University, Hangzhou 311215, China;
| | - Yonghua Hu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing 100191, China;
- Medical Informatics Center, Peking University, Beijing 100191, China
| | - Luxia Zhang
- National Institute of Health Data Science, Peking University, Beijing 100191, China; (J.W.); (L.Z.)
- Advanced Institute of Information Technology, Peking University, Hangzhou 311215, China;
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Beijing 100034, China
| | - Guilan Kong
- National Institute of Health Data Science, Peking University, Beijing 100191, China; (J.W.); (L.Z.)
- Advanced Institute of Information Technology, Peking University, Hangzhou 311215, China;
- Correspondence: ; Tel.: +86-18710098511
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Capone F, Molinari L, Noale M, Previato L, Giannini S, Vettore G, Fabris F, Saller A. Admission criteria for a cardiovascular short stay unit: a retrospective analysis on a pilot unit. Intern Emerg Med 2021; 16:2087-2095. [PMID: 33770369 PMCID: PMC8563614 DOI: 10.1007/s11739-021-02700-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 03/05/2021] [Indexed: 11/29/2022]
Abstract
Rapid intensive observation (RIO) units have been created to guarantee high standards of care in a sustainable health-care system. Within short stay units (SSUs), which are a subgroup of RIOs, only rapidly manageable patients should be admitted. Physicians are unable to predict the length of stay (LOS) as objective criteria to make such a prediction are missing. A retrospective observational study was carried out to identify the objective criteria for admission within a cardiovascular care-oriented SSU. Over a period of 317 days, 340 patients (age 69.4 ± 14.7 years) were admitted to a pilot SSU within our internal medicine department. The most frequent diagnoses were chest pain (45.9%), syncope (12.9%), and supraventricular arrhythmias (11.2%). The median LOS was 4 days (quartile 1:3; quartile 3:7). Predictors of LOS ≤ 96 h were age < 80, hemoglobin > 115 g/L, estimated glomerular filtration rate > 45 mL/min/1.73 m2, Charlson Comorbidity Index < 3, Barthel Index > 40, diagnosis of chest pain, syncope, supraventricular arrhythmias, or acute heart failure. The HEART (history, ECG, age, risk factors, troponin) score was found to be excellent in risk stratification of patients admitted for chest pain. Blood tests and anamnestic variables can be used to predict the LOS and thus SSU admission. The HEART score may help in the classification of patients with chest pain admitted to an SSU.
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Affiliation(s)
- Federico Capone
- Department of Medicine, University of Padova Medical School, University of Padua, Padua, Italy.
| | - Leonardo Molinari
- Department of Medicine, University of Padova Medical School, University of Padua, Padua, Italy
| | - Marianna Noale
- Neuroscience Institute, Aging Branch, National Research Council (CNR), Padua, Italy
| | - Lorenzo Previato
- Department of Medicine, University of Padova Medical School, University of Padua, Padua, Italy
| | - Sandro Giannini
- Department of Medicine, University of Padova Medical School, University of Padua, Padua, Italy
| | - Gianna Vettore
- Department of Urgent and Emergency Care, University of Padova, Padua, Italy
| | - Fabrizio Fabris
- Department of Medicine, University of Padova Medical School, University of Padua, Padua, Italy
| | - Alois Saller
- Department of Medicine, University of Padova Medical School, University of Padua, Padua, Italy
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Lequertier V, Wang T, Fondrevelle J, Augusto V, Duclos A. Hospital Length of Stay Prediction Methods: A Systematic Review. Med Care 2021; 59:929-938. [PMID: 34310455 DOI: 10.1097/mlr.0000000000001596] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This systematic review sought to establish a picture of length of stay (LOS) prediction methods based on available hospital data and study protocols designed to measure their performance. MATERIALS AND METHODS An English literature search was done relative to hospital LOS prediction from 1972 to September 2019 according to the PRISMA guidelines. Articles were retrieved from PubMed, ScienceDirect, and arXiv databases. Information were extracted from the included papers according to a standardized assessment of population setting and study sample, data sources and input variables, LOS prediction methods, validation study design, and performance evaluation metrics. RESULTS Among 74 selected articles, 98.6% (73/74) used patients' data to predict LOS; 27.0% (20/74) used temporal data; and 21.6% (16/74) used the data about hospitals. Overall, regressions were the most popular prediction methods (64.9%, 48/74), followed by machine learning (20.3%, 15/74) and deep learning (17.6%, 13/74). Regarding validation design, 35.1% (26/74) did not use a test set, whereas 47.3% (35/74) used a separate test set, and 17.6% (13/74) used cross-validation. The most used performance metrics were R2 (47.3%, 35/74), mean squared (or absolute) error (24.4%, 18/74), and the accuracy (14.9%, 11/74). Over the last decade, machine learning and deep learning methods became more popular (P=0.016), and test sets and cross-validation got more and more used (P=0.014). CONCLUSIONS Methods to predict LOS are more and more elaborate and the assessment of their validity is increasingly rigorous. Reducing heterogeneity in how these methods are used and reported is key to transparency on their performance.
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Affiliation(s)
- Vincent Lequertier
- Research on Healthcare Performance (RESHAPE), Université Claude Bernard Lyon 1, INSERM U1290
- Health Data Department, Lyon University Hospital, Lyon
- Univ Lyon, INSA Lyon, Université Claude Bernard Lyon 1, Univ Lumière Lyon 2, DISP, EA4570, 69621 Villeurbanne, France
| | - Tao Wang
- University of Lyon, INSA Lyon, Université Claude Bernard Lyon 1, Univ Lumière Lyon 2, UJM-Saint-Etienne, Decision and Information Systems for Production systems (DISP), Villeurbanne Cedex
| | - Julien Fondrevelle
- Univ Lyon, INSA Lyon, Université Claude Bernard Lyon 1, Univ Lumière Lyon 2, DISP, EA4570, 69621 Villeurbanne, France
| | - Vincent Augusto
- Mines Saint-Etienne, University of Clermont Auvergne, CNRS, UMR 6158 LIMOS, Centre CIS, Saint-Etienne, France
| | - Antoine Duclos
- Research on Healthcare Performance (RESHAPE), Université Claude Bernard Lyon 1, INSERM U1290
- Health Data Department, Lyon University Hospital, Lyon
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Huang K, Gray TF, Romero-Brufau S, Tulsky JA, Lindvall C. Using nursing notes to improve clinical outcome prediction in intensive care patients: A retrospective cohort study. J Am Med Inform Assoc 2021; 28:1660-1666. [PMID: 33880557 PMCID: PMC8324216 DOI: 10.1093/jamia/ocab051] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/08/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Electronic health record documentation by intensive care unit (ICU) clinicians may predict patient outcomes. However, it is unclear whether physician and nursing notes differ in their ability to predict short-term ICU prognosis. We aimed to investigate and compare the ability of physician and nursing notes, written in the first 48 hours of admission, to predict ICU length of stay and mortality using 3 analytical methods. MATERIALS AND METHODS This was a retrospective cohort study with split sampling for model training and testing. We included patients ≥18 years of age admitted to the ICU at Beth Israel Deaconess Medical Center in Boston, Massachusetts, from 2008 to 2012. Physician or nursing notes generated within the first 48 hours of admission were used with standard machine learning methods to predict outcomes. RESULTS For the primary outcome of composite score of ICU length of stay ≥7 days or in-hospital mortality, the gradient boosting model had better performance than the logistic regression and random forest models. Nursing and physician notes achieved area under the curves (AUCs) of 0.826 and 0.796, respectively, with even better predictive power when combined (AUC, 0.839). DISCUSSION Models using only nursing notes more accurately predicted short-term prognosis than did models using only physician notes, but in combination, the models achieved the greatest accuracy in prediction. CONCLUSIONS Our findings demonstrate that statistical models derived from text analysis in the first 48 hours of ICU admission can predict patient outcomes. Physicians' and nurses' notes are both uniquely important in mortality prediction and combining these notes can produce a better predictive model.
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Affiliation(s)
- Kexin Huang
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Tamryn F Gray
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Santiago Romero-Brufau
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
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15
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ICU Days-to-Discharge Analysis with Machine Learning Technology. Artif Intell Med 2021. [DOI: 10.1007/978-3-030-77211-6_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Uysal E, Acar YA, Celik R, Nasuhbeyoglu N. PLASMA INTERLEUKIN-6 LEVELS MAY BE ASSOCIATED WITH THE LENGTH OF STAY TIME OF ADULT HYPERGLYCEMIC PATIENTS IN AN INTENSIVE CARE UNIT. ACTA ENDOCRINOLOGICA-BUCHAREST 2020; 16:311-315. [PMID: 33363652 DOI: 10.4183/aeb.2020.311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Context Estimation of intensive care unit (ICU) length of stay time (LOS) may be challenging, and pro-inflammatory cytokines can be used as a marker for this purpose. Objective The current study aimed to investigate the association between pro-inflammatory cytokine levels and LOS in hyperglycemic patients admitted to adult ICU. Design This is a prospective observational study. Subjects and Methods All adult ICU patients with a blood glucose level higher than 250 mg/dL, during the study period were included. Hospitalization day demographics were recorded, and plasma IL-6, IL1-ß, and TNF-α concentrations were measured. Results A total of 74 patients were enrolled in the study. Diabetic ketoacidosis (DKA) was positive in 31 patients, and the remaining 43 were in the non-DKA (NDKA) group. There was no difference between the two groups in terms of age, gender, LOS, hemoglobin, hematocrit, lactate levels, and platelets count. IL-6, IL-1ß, and TNF-α levels did not show any difference between DKA and NDKA groups (p=0.784, 0.413, and 0.288, respectively). There was a positive correlation between IL-6 levels and LOS (n=74, Pearson correlation=0.330; p=0.004). Conclusions Among pro-inflammatory cytokines, IL-6 showed a better performance for the prediction of LOS than IL-1ß, TNF-α, and CRP.
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Affiliation(s)
- E Uysal
- Bagcilar Training and Research Hospital - Department of Emergency Medicine, Istanbul, Turkey
| | - Y A Acar
- University of Health Sciences, Gulhane School of Medicine - Emergency Medicine, Ankara Turkey
| | - R Celik
- Bagcilar Training and Research Hospital - Department of Internal Medicine, Istanbul, Turkey
| | - N Nasuhbeyoglu
- Bagcilar Training and Research Hospital - Department of Microbiology and Clinical Microbiology, Istanbul, Turkey
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17
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Zhang Y, Zhu S, Yuan Z, Li Q, Ding R, Bao X, Zhen T, Fu Z, Fu H, Xing K, Yuan H, Chen T. Risk factors and socio-economic burden in pancreatic ductal adenocarcinoma operation: a machine learning based analysis. BMC Cancer 2020; 20:1161. [PMID: 33246424 PMCID: PMC7694304 DOI: 10.1186/s12885-020-07626-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 11/10/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Surgical resection is the major way to cure pancreatic ductal adenocarcinoma (PDAC). However, this operation is complex, and the peri-operative risk is high, making patients more likely to be admitted to the intensive care unit (ICU). Therefore, establishing a risk model that predicts admission to ICU is meaningful in preventing patients from post-operation deterioration and potentially reducing socio-economic burden. METHODS We retrospectively collected 120 clinical features from 1242 PDAC patients, including demographic data, pre-operative and intra-operative blood tests, in-hospital duration, and ICU status. Machine learning pipelines, including Supporting Vector Machine (SVM), Logistic Regression, and Lasso Regression, were employed to choose an optimal model in predicting ICU admission. Ordinary least-squares regression (OLS) and Lasso Regression were adopted in the correlation analysis of post-operative bleeding, total in-hospital duration, and discharge costs. RESULTS SVM model achieved higher performance than the other two models, resulted in an AU-ROC of 0.80. The features, such as age, duration of operation, monocyte count, and intra-operative partial arterial pressure of oxygen (PaO2), are risk factors in the ICU admission. The protective factors include RBC count, analgesic pump dexmedetomidine (DEX), and intra-operative maintenance of DEX. Basophil percentage, duration of the operation, and total infusion volume were risk variables for staying in ICU. The bilirubin, CA125, and pre-operative albumin were associated with the post-operative bleeding volume. The operation duration was the most important factor for discharge costs, while pre-lymphocyte percentage and the absolute count are responsible for less cost. CONCLUSIONS We observed that several new indicators such as DEX, monocyte count, basophil percentage, and intra-operative PaO2 showed a good predictive effect on the possibility of admission to ICU and duration of stay in ICU. This work provided an essential reference for indication in advance to PDAC operation.
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Affiliation(s)
- Yijue Zhang
- Department of Anesthesiology, South Campus, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Sibo Zhu
- School of Life Sciences, Fudan University, Shanghai, China
| | - Zhiqing Yuan
- Department of General Surgery, South Campus, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Qiwei Li
- Department of General Surgery, South Campus, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Ruifeng Ding
- School of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | | | | | | | - Hailong Fu
- Department of Anesthesiology, Changzheng Hospital, Second Military Medical University, No.415 Fengyang Road, Shanghai, 200003 China
| | | | - Hongbin Yuan
- Department of Anesthesiology, Changzheng Hospital, Second Military Medical University, No.415 Fengyang Road, Shanghai, 200003 China
| | - Tao Chen
- Department of Anesthesiology, South Campus, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 2000 Jiangyue Road, Pujin Street, Minhang District, Shanghai, 201100 China
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Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2020. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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Affiliation(s)
- Guillermo Gutierrez
- Pulmonary, Critical Care and Sleep Medicine Division, The George Washington University, Washington, DC, USA.
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19
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Can We Improve Prediction of Adverse Surgical Outcomes? Development of a Surgical Complexity Score Using a Novel Machine Learning Technique. J Am Coll Surg 2019; 230:43-52.e1. [PMID: 31672674 DOI: 10.1016/j.jamcollsurg.2019.09.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 07/15/2019] [Accepted: 09/16/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND An optimal method to quantify surgical complexity using patient comorbidities derived from administrative billing data is lacking. We sought to develop a novel, easy-to-use surgical Complexity Score to accurately predict adverse outcomes among patients undergoing elective surgery. STUDY DESIGN A novel surgical Complexity Score was developed using 100% Medicare Inpatient and Outpatient Standard Analytic Files (SAFs) from years 2012 to 2016 (n = 1,049,160). Comorbid conditions were entered into a machine learning algorithm to assign weights to maximize the correlation with multiple postoperative outcomes including morbidity, readmission, mortality, and postoperative super-use. Predictive ability was compared against 3 of the most commonly used risk adjustment indices: the Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Index (ECI), and the Centers for Medicare and Medicaid Service's Hierarchical Condition Category (CMS-HCC). RESULTS Patients underwent colectomy (12.6%), abdominal aortic aneurysm repair (4.4%), coronary artery bypass grafting (13.0%), total hip replacement (22.0%), total knee replacement (43.0%), or lung resection (5.0%). The Complexity Score had a good to very good predictive ability for all adverse outcomes. The Complexity Score had the highest accuracy in predicting perioperative morbidity (area under the curve [AUC]: 0.868, 95% CI 0.866 to 0.869); this performed better than the CCI (AUC: 0.717, 95% CI 0.715 to 0.719), ECI (AUC: 0.799, 95% CI 0.797 to 0.800), and similar to the CMS-HCC (AUC: 0.862, 95% CI 0.861 to 0.863). Similarly, the Complexity Score outperformed each of the 3 other comorbidity indices in predicting 90-day readmission (AUC: 0.707, 95% CI 0.705 to 0.709), 30-day readmission (AUC: 0.717, 95% CI 0.715 to 0.720), and postoperative super-use (AUC: 0.817, 95% CI 0.814 to 0.820). CONCLUSIONS Compared with the most commonly used comorbidity and surgical risk scores, the novel surgical Complexity Score outperformed the CCI, ECI, and CMS-HCC in predicting postoperative morbidity, 30-day readmission, 90-day readmission, and postoperative super-use.
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20
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Joynt GM, Gopalan PD, Argent A, Chetty S, Wise R, Lai VKW, Hodgson E, Lee A, Joubert I, Mokgokong S, Tshukutsoane S, Richards GA, Menezes C, Mathivha LR, Espen B, Levy B, Asante K, Paruk F. The Critical Care Society of Southern Africa Consensus Guideline on ICU Triage and Rationing (ConICTri). SOUTHERN AFRICAN JOURNAL OF CRITICAL CARE 2019; 35:10.7196/SAJCC.2019.v35i1b.380. [PMID: 37719328 PMCID: PMC10503493 DOI: 10.7196/sajcc.2019.v35i1b.380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2019] [Indexed: 11/08/2022] Open
Abstract
Background In South Africa (SA), administrators and intensive care practitioners are faced with the challenge of resource scarcity as well as an increasing demand for intensive care unit (ICU) services. ICU services are expensive, and practitioners in low- to middle-income countries experience the consequences of limited resources daily. Critically limited resources necessitate that rationing and triage (prioritisation) decisions are routinely necessary in SA, particularly in the publicly funded health sector. Purpose The purpose of this guideline is to utilise the relevant recommendations of the associated consensus meeting document and other internationally accepted principles to develop a guideline to inform frontline triage policy and ensure the best utilisation of adult intensive care in SA, while maintaining the fair distribution of available resources. Recommendations An overall conceptual framework for the triage process was developed. The components of the framework were developed on the basis that patients should be admitted preferentially when the likely incremental medical benefit derived from ICU admission justifies admission. An estimate of likely resource use should also form part of the triage decision, with those patients requiring relatively less resources to achieve substantial benefit receiving priority for admission. Thus, the triage system should maximise the benefits obtained from ICU resources available for the community. Where possible, practical examples of what the consensus group agreed would be considered appropriate practice under specified South African circumstances were provided, to assist clinicians with practical decision-making. It must be stressed that this guideline is not intended to be prescriptive for individual hospital or regional practice, and hospitals and regions are encouraged to develop specified local guidelines with locally relevant examples. The guideline should be reviewed and revised if appropriate within 5 years. Conclusion In recognition of the absolute need to limit patient access to ICU because of the lack of sufficient intensive care resources in public hospitals, this guideline has been developed to guide policy-making and assist frontline triage decision-making in SA. This document is not a complete plan for quality practice, but rather a template to support frontline clinicians, guide administrators and inform the public regarding appropriate triage decision-making.
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Affiliation(s)
- G M Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong
| | - P D Gopalan
- Department of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - A Argent
- Department of Paediatrics and Child Health, University of Cape Town, South Africa
| | - S Chetty
- Department of Anaesthesiology and Critical Care, Stellenbosch University, Cape Town, South Africa
| | - R Wise
- Department of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, and Edendale Hospital,
Pietermaritzburg, South Africa
| | - V K W Lai
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong
| | - E Hodgson
- Department of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, and Inkosi Albert Luthuli
Central Hospital, Durban, South Africa
| | - A Lee
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong
| | - I Joubert
- Department of Anaesthesia and Peri-operative Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - S Mokgokong
- Department of Neurosurgery, University of Pretoria, South Africa
| | - S Tshukutsoane
- Chris Hani Baragwanath Academic Hospital, Soweto, Johannesburg, South Africa
| | - G A Richards
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - C Menezes
- Chris Hani Baragwanath Academic Hospital, Soweto, Johannesburg, South Africa
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - L R Mathivha
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - B Espen
- Centre for Health Professions Education, Stellenbosch University, Cape Town, South Africa
| | - B Levy
- Netcare Rosebank Hospital, Johannesburg, South Africa
| | - K Asante
- African Organization for Research and Training in Cancer, Cape Town, South Africa
| | - F Paruk
- Department of Critical Care, University of Pretoria, South Africa
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Lee DS, Lee JS, Schull MJ, Borgundvaag B, Edmonds ML, Ivankovic M, McLeod SL, Dreyer JF, Sabbah S, Levy PD, O’Neill T, Chong A, Stukel TA, Austin PC, Tu JV. Prospective Validation of the Emergency Heart Failure Mortality Risk Grade for Acute Heart Failure. Circulation 2019; 139:1146-1156. [DOI: 10.1161/circulationaha.118.035509] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Douglas S. Lee
- ICES, Toronto, Ontario, Canada (D.S.L., M.J.S., T.O., A.C., T.A.S., P.C.A., J.V.T.)
- Peter Munk Cardiac Centre and University Health Network, Toronto, Ontario, Canada (D.S.L., S.S.)
- University of Toronto, Ontario, Canada (D.S.L., J.S.L., M.J.S., B.B., S.L.M., S.S., T.A.S., P.C.A., J.V.T.)
| | - Jacques S. Lee
- University of Toronto, Ontario, Canada (D.S.L., J.S.L., M.J.S., B.B., S.L.M., S.S., T.A.S., P.C.A., J.V.T.)
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.S.L., M.J.S., J.V.T.)
| | - Michael J. Schull
- ICES, Toronto, Ontario, Canada (D.S.L., M.J.S., T.O., A.C., T.A.S., P.C.A., J.V.T.)
- University of Toronto, Ontario, Canada (D.S.L., J.S.L., M.J.S., B.B., S.L.M., S.S., T.A.S., P.C.A., J.V.T.)
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.S.L., M.J.S., J.V.T.)
| | - Bjug Borgundvaag
- University of Toronto, Ontario, Canada (D.S.L., J.S.L., M.J.S., B.B., S.L.M., S.S., T.A.S., P.C.A., J.V.T.)
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada (B.B., S.L.M.)
| | | | - Maria Ivankovic
- Trillium Health Partners, Mississauga, Ontario, Canada (M.I.)
| | - Shelley L. McLeod
- University of Toronto, Ontario, Canada (D.S.L., J.S.L., M.J.S., B.B., S.L.M., S.S., T.A.S., P.C.A., J.V.T.)
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada (B.B., S.L.M.)
| | | | - Sam Sabbah
- Peter Munk Cardiac Centre and University Health Network, Toronto, Ontario, Canada (D.S.L., S.S.)
- University of Toronto, Ontario, Canada (D.S.L., J.S.L., M.J.S., B.B., S.L.M., S.S., T.A.S., P.C.A., J.V.T.)
| | - Phillip D. Levy
- Department of Emergency Medicine and Integrative Biosciences Center, Wayne State University, Detroit, MI (P.D.L.)
| | - Tara O’Neill
- ICES, Toronto, Ontario, Canada (D.S.L., M.J.S., T.O., A.C., T.A.S., P.C.A., J.V.T.)
| | - Alice Chong
- ICES, Toronto, Ontario, Canada (D.S.L., M.J.S., T.O., A.C., T.A.S., P.C.A., J.V.T.)
| | - Therese A. Stukel
- ICES, Toronto, Ontario, Canada (D.S.L., M.J.S., T.O., A.C., T.A.S., P.C.A., J.V.T.)
- University of Toronto, Ontario, Canada (D.S.L., J.S.L., M.J.S., B.B., S.L.M., S.S., T.A.S., P.C.A., J.V.T.)
| | - Peter C. Austin
- ICES, Toronto, Ontario, Canada (D.S.L., M.J.S., T.O., A.C., T.A.S., P.C.A., J.V.T.)
- University of Toronto, Ontario, Canada (D.S.L., J.S.L., M.J.S., B.B., S.L.M., S.S., T.A.S., P.C.A., J.V.T.)
| | - Jack V. Tu
- ICES, Toronto, Ontario, Canada (D.S.L., M.J.S., T.O., A.C., T.A.S., P.C.A., J.V.T.)
- University of Toronto, Ontario, Canada (D.S.L., J.S.L., M.J.S., B.B., S.L.M., S.S., T.A.S., P.C.A., J.V.T.)
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.S.L., M.J.S., J.V.T.)
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Cuadrado D, Riaño D, Gómez J, Bodí M, Sirgo G, Esteban F, García R, Rodríguez A. Pursuing Optimal Prediction of Discharge Time in ICUs with Machine Learning Methods. Artif Intell Med 2019. [DOI: 10.1007/978-3-030-21642-9_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Weissman GE, Hubbard RA, Ungar LH, Harhay MO, Greene CS, Himes BE, Halpern SD. Inclusion of Unstructured Clinical Text Improves Early Prediction of Death or Prolonged ICU Stay. Crit Care Med 2018; 46:1125-1132. [PMID: 29629986 PMCID: PMC6005735 DOI: 10.1097/ccm.0000000000003148] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Early prediction of undesired outcomes among newly hospitalized patients could improve patient triage and prompt conversations about patients' goals of care. We evaluated the performance of logistic regression, gradient boosting machine, random forest, and elastic net regression models, with and without unstructured clinical text data, to predict a binary composite outcome of in-hospital death or ICU length of stay greater than or equal to 7 days using data from the first 48 hours of hospitalization. DESIGN Retrospective cohort study with split sampling for model training and testing. SETTING A single urban academic hospital. PATIENTS All hospitalized patients who required ICU care at the Beth Israel Deaconess Medical Center in Boston, MA, from 2001 to 2012. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among eligible 25,947 hospital admissions, we observed 5,504 (21.2%) in which patients died or had ICU length of stay greater than or equal to 7 days. The gradient boosting machine model had the highest discrimination without (area under the receiver operating characteristic curve, 0.83; 95% CI, 0.81-0.84) and with (area under the receiver operating characteristic curve, 0.89; 95% CI, 0.88-0.90) text-derived variables. Both gradient boosting machines and random forests outperformed logistic regression without text data (p < 0.001), whereas all models outperformed logistic regression with text data (p < 0.02). The inclusion of text data increased the discrimination of all four model types (p < 0.001). Among those models using text data, the increasing presence of terms "intubated" and "poor prognosis" were positively associated with mortality and ICU length of stay, whereas the term "extubated" was inversely associated with them. CONCLUSIONS Variables extracted from unstructured clinical text from the first 48 hours of hospital admission using natural language processing techniques significantly improved the abilities of logistic regression and other machine learning models to predict which patients died or had long ICU stays. Learning health systems may adapt such models using open-source approaches to capture local variation in care patterns.
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Affiliation(s)
- Gary E. Weissman
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, PA
- Palliative and Advanced Illness Research Center, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Rebecca A. Hubbard
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lyle H. Ungar
- Department of Computer and Information Science, University of Pennsylvania, Philadelphia, PA
| | - Michael O. Harhay
- Palliative and Advanced Illness Research Center, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, PA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Casey S. Greene
- Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA
- Institute for Translational Medicine and Therapeutics, University of Pennsylvania, Philadelphia, PA
- Institute for Biomedical Informatics, University of Pennsylvania, Philadelphia, PA
| | - Blanca E. Himes
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Institute for Biomedical Informatics, University of Pennsylvania, Philadelphia, PA
| | - Scott D. Halpern
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, PA
- Palliative and Advanced Illness Research Center, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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24
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Durstenfeld MS, Saybolt MD, Praestgaard A, Kimmel SE. Physician predictions of length of stay of patients admitted with heart failure. J Hosp Med 2016; 11:642-5. [PMID: 27187036 DOI: 10.1002/jhm.2605] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 04/07/2016] [Accepted: 04/19/2016] [Indexed: 11/08/2022]
Abstract
Physicians' ability to predict length of stay is understudied, particularly for patients with heart failure (HF) admissions. The objective of this prospective, observational cohort study was to measure the accuracy of inpatient physicians' predictions of length of stay at the time of admission of patients admitted to an academic tertiary care hospital with HF and to determine whether level of experience improves accuracy. The patients included 165 adults consecutively admitted with heart failure, about whom 415 predictions were made within 24 hours of admission. Mean and median lengths of stay were 10.9 and 8 days, respectively. The mean difference between predicted and actual length of stay was statistically significant for all groups: interns, -5.9 days (95% confidence interval [CI]: -8.2 to -3.6, P < 0.0001); residents, -4.3 days (95% CI: -6.0 to -2.7, P = 0.0001); attending cardiologists, -3.5 days (95% CI: -5.1 to -2.0, P < 0.0001). There were no differences in accuracy by level of experience (P = 0.61). Physicians, regardless of experience, underestimate length of stay of patients admitted with HF. Journal of Hospital Medicine 2016;11:642-645. © 2016 Society of Hospital Medicine.
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Affiliation(s)
| | - Matthew D Saybolt
- Department of Medicine, Cardiovascular Division, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amy Praestgaard
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen E Kimmel
- Department of Medicine, Cardiovascular Division, University of Pennsylvania, Philadelphia, Pennsylvania.
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania.
- Center for Clinical Epidemiology and Biostatistics and Center for Therapeutic Effectiveness Research, University of Pennsylvania, Philadelphia, Pennsylvania.
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