학술논문
Overtriage, Undertriage, and Value of Care after Major Surgery: An Automated, Explainable Deep Learning-Enabled Classification System.
Document Type
Academic Journal
Author
Loftus TJ; From the University of Florida Intelligent Critical Care Center, Gainesville, FL (Loftus, Ruppert, Shickel, Ozrazgat-Baslanti, Balch, Hu, Rashidi, Bihorac).; Departments of Surgery (Loftus, Balch, Hu, Efron, Upchurch, Bihorac), University of Florida Health, Gainesville, FL.; Ruppert MM; From the University of Florida Intelligent Critical Care Center, Gainesville, FL (Loftus, Ruppert, Shickel, Ozrazgat-Baslanti, Balch, Hu, Rashidi, Bihorac).; Medicine (Ruppert, Shickel, Ozrazgat-Baslanti, Bihorac), University of Florida Health, Gainesville, FL.; Shickel B; From the University of Florida Intelligent Critical Care Center, Gainesville, FL (Loftus, Ruppert, Shickel, Ozrazgat-Baslanti, Balch, Hu, Rashidi, Bihorac).; Medicine (Ruppert, Shickel, Ozrazgat-Baslanti, Bihorac), University of Florida Health, Gainesville, FL.; Ozrazgat-Baslanti T; From the University of Florida Intelligent Critical Care Center, Gainesville, FL (Loftus, Ruppert, Shickel, Ozrazgat-Baslanti, Balch, Hu, Rashidi, Bihorac).; Medicine (Ruppert, Shickel, Ozrazgat-Baslanti, Bihorac), University of Florida Health, Gainesville, FL.; Balch JA; From the University of Florida Intelligent Critical Care Center, Gainesville, FL (Loftus, Ruppert, Shickel, Ozrazgat-Baslanti, Balch, Hu, Rashidi, Bihorac).; Departments of Surgery (Loftus, Balch, Hu, Efron, Upchurch, Bihorac), University of Florida Health, Gainesville, FL.; Biomedical Engineering (Balch, Rashidi), University of Florida, Gainesville, FL.; Computer and Information Science and Engineering (Balch, Rashidi), University of Florida, Gainesville, FL.; Electrical and Computer Engineering (Balch, Rashidi), University of Florida, Gainesville, FL.; Hu D; From the University of Florida Intelligent Critical Care Center, Gainesville, FL (Loftus, Ruppert, Shickel, Ozrazgat-Baslanti, Balch, Hu, Rashidi, Bihorac).; Departments of Surgery (Loftus, Balch, Hu, Efron, Upchurch, Bihorac), University of Florida Health, Gainesville, FL.; Javed A; Departments of Emergency Medicine (Javed, Guirgis), University of Florida College of Medicine, Jacksonville, FL.; Critical Care Medicine (Javed), University of Florida College of Medicine, Jacksonville, FL.; Madbak F; Surgery (Madbak, Skarupa), University of Florida College of Medicine, Jacksonville, FL.; Skarupa DJ; Surgery (Madbak, Skarupa), University of Florida College of Medicine, Jacksonville, FL.; Guirgis F; Departments of Emergency Medicine (Javed, Guirgis), University of Florida College of Medicine, Jacksonville, FL.; Efron PA; Departments of Surgery (Loftus, Balch, Hu, Efron, Upchurch, Bihorac), University of Florida Health, Gainesville, FL.; Tighe PJ; Anesthesiology (Tighe), University of Florida Health, Gainesville, FL.; Orthopedics (Tighe), University of Florida Health, Gainesville, FL.; Information Systems/Operations Management (Tighe), University of Florida Health, Gainesville, FL.; Hogan WR; Department of Health Outcomes and Biomedical Informatics, College of Medicine (Hogan), University of Florida, Gainesville, FL.; Rashidi P; From the University of Florida Intelligent Critical Care Center, Gainesville, FL (Loftus, Ruppert, Shickel, Ozrazgat-Baslanti, Balch, Hu, Rashidi, Bihorac).; Biomedical Engineering (Balch, Rashidi), University of Florida, Gainesville, FL.; Computer and Information Science and Engineering (Balch, Rashidi), University of Florida, Gainesville, FL.; Electrical and Computer Engineering (Balch, Rashidi), University of Florida, Gainesville, FL.; Upchurch GR Jr; Departments of Surgery (Loftus, Balch, Hu, Efron, Upchurch, Bihorac), University of Florida Health, Gainesville, FL.; Bihorac A; From the University of Florida Intelligent Critical Care Center, Gainesville, FL (Loftus, Ruppert, Shickel, Ozrazgat-Baslanti, Balch, Hu, Rashidi, Bihorac).; Departments of Surgery (Loftus, Balch, Hu, Efron, Upchurch, Bihorac), University of Florida Health, Gainesville, FL.; Medicine (Ruppert, Shickel, Ozrazgat-Baslanti, Bihorac), University of Florida Health, Gainesville, FL.
Source
Publisher: Lippincott Williams & Wilkins, Inc Country of Publication: United States NLM ID: 9431305 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1879-1190 (Electronic) Linking ISSN: 10727515 NLM ISO Abbreviation: J Am Coll Surg Subsets: MEDLINE
Subject
Language
English
Abstract
Background: In single-institution studies, overtriaging low-risk postoperative patients to ICUs has been associated with a low value of care; undertriaging high-risk postoperative patients to general wards has been associated with increased mortality and morbidity. This study tested the reproducibility of an automated postoperative triage classification system to generating an actionable, explainable decision support system.
Study Design: This longitudinal cohort study included adults undergoing inpatient surgery at two university hospitals. Triage classifications were generated by an explainable deep learning model using preoperative and intraoperative electronic health record features. Nearest neighbor algorithms identified risk-matched controls. Primary outcomes were mortality, morbidity, and value of care (inverted risk-adjusted mortality/total direct costs).
Results: Among 4,669 ICU admissions, 237 (5.1%) were overtriaged. Compared with 1,021 control ward admissions, overtriaged admissions had similar outcomes but higher costs ($15.9K [interquartile range $9.8K to $22.3K] vs $10.7K [$7.0K to $17.6K], p < 0.001) and lower value of care (0.2 [0.1 to 0.3] vs 1.5 [0.9 to 2.2], p < 0.001). Among 8,594 ward admissions, 1,029 (12.0%) were undertriaged. Compared with 2,498 control ICU admissions, undertriaged admissions had longer hospital length-of-stays (6.4 [3.4 to 12.4] vs 5.4 [2.6 to 10.4] days, p < 0.001); greater incidence of hospital mortality (1.7% vs 0.7%, p = 0.03), cardiac arrest (1.4% vs 0.5%, p = 0.04), and persistent acute kidney injury without renal recovery (5.2% vs 2.8%, p = 0.002); similar costs ($21.8K [$13.3K to $34.9K] vs $21.9K [$13.1K to $36.3K]); and lower value of care (0.8 [0.5 to 1.3] vs 1.2 [0.7 to 2.0], p < 0.001).
Conclusions: Overtriage was associated with low value of care; undertriage was associated with both low value of care and increased mortality and morbidity. The proposed framework for generating automated postoperative triage classifications is reproducible.
(Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)
Study Design: This longitudinal cohort study included adults undergoing inpatient surgery at two university hospitals. Triage classifications were generated by an explainable deep learning model using preoperative and intraoperative electronic health record features. Nearest neighbor algorithms identified risk-matched controls. Primary outcomes were mortality, morbidity, and value of care (inverted risk-adjusted mortality/total direct costs).
Results: Among 4,669 ICU admissions, 237 (5.1%) were overtriaged. Compared with 1,021 control ward admissions, overtriaged admissions had similar outcomes but higher costs ($15.9K [interquartile range $9.8K to $22.3K] vs $10.7K [$7.0K to $17.6K], p < 0.001) and lower value of care (0.2 [0.1 to 0.3] vs 1.5 [0.9 to 2.2], p < 0.001). Among 8,594 ward admissions, 1,029 (12.0%) were undertriaged. Compared with 2,498 control ICU admissions, undertriaged admissions had longer hospital length-of-stays (6.4 [3.4 to 12.4] vs 5.4 [2.6 to 10.4] days, p < 0.001); greater incidence of hospital mortality (1.7% vs 0.7%, p = 0.03), cardiac arrest (1.4% vs 0.5%, p = 0.04), and persistent acute kidney injury without renal recovery (5.2% vs 2.8%, p = 0.002); similar costs ($21.8K [$13.3K to $34.9K] vs $21.9K [$13.1K to $36.3K]); and lower value of care (0.8 [0.5 to 1.3] vs 1.2 [0.7 to 2.0], p < 0.001).
Conclusions: Overtriage was associated with low value of care; undertriage was associated with both low value of care and increased mortality and morbidity. The proposed framework for generating automated postoperative triage classifications is reproducible.
(Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)