The quality of healthcare provided by hospitals is subject to considerable variability. Consequently, accurate measurements of hospital performance are essential for various decision-makers, including patients, hospital managers and health insurers. Hospital performance is assessed via the health outcomes of their patients. However, as the risk profiles of patients between hospitals vary, measuring hospital performance requires adjustment for patient risk. This task is formalized in the state-of-the-art procedure through a hierarchical generalized linear model, that isolates hospital fixed-effects from the effect of patient risk on health outcomes. Due to the linear nature of this approach, any non-linear relations or interaction terms between risk variables are neglected.
In this work, we propose a novel method for measuring hospital performance adjusted for patient risk. This method captures non-linear relationships as well as interactions among patient risk variables, specifically the effect of co-occurring health conditions on health outcomes. For this purpose, we develop a tailored neural network architecture that is partially interpretable: a non-linear part is used to encode risk factors, while a linear structure models hospital fixed-effects, such that the risk-adjusted hospital performance can be estimated. We base our evaluation on more than 13 million patient admissions across almost 1,900 US hospitals as provided by the Nationwide Readmissions Database. Our model improves the ROC-AUC over the state-of-the-art by 4.1 percent. These findings demonstrate that a large portion of the variance in health outcomes can be attributed to non-linear relationships between patient risk variables and implicate that the current approach of measuring hospital performance should be expanded.
Over- and undertreatment harm patients and society and confound other healthcare quality measures. Despite a growing body of research covering specific conditions, we lack tools to systematically detect and measure over- and undertreatment in hospitals. We demonstrate a test used to monitor over- and undertreatment in Dutch hospitals, and illustrate its results applied to the aggregated administrative treatment data of 1,836,349 patients at 89 hospitals in 2013. We employ a random effects model to create risk-adjusted funnel plots that account for natural variation among hospitals, allowing us…
To assess the efficiency and the resource consumption level in healthcare scope, many economic and social factors have to be considered. An index which has recently been studied by the researchers, is length of hospital stay (LOS) defined as how long each patient is hospitalized. Detecting and controlling the factors affecting this index can help to reduce healthcare costs and also to improve healthcare service efficiency. The effects of three major factors, say, the season during which the patient is hospitalized, the patients age and his/her gender on LOS pertaining to 82718 patients receivi…
Researchers are often faced with evaluating the effect of a policy or program that was simultaneously initiated across an entire population of units at a single point in time, and its effects over the targeted population can manifest at any time period afterwards. In the presence of data measured over time, Bayesian time series models have been used to impute what would have happened after the policy was initiated, had the policy not taken place, in order to estimate causal effects. However, the considerations regarding the definition of the target estimands, the underlying assumptions, the pl…
The difference in restricted mean survival times between two groups is a clinically relevant summary measure. With observational data, there may be imbalances in confounding variables between the two groups. One approach to account for such imbalances is to estimate a covariate-adjusted restricted mean difference by modeling the covariate-adjusted survival distribution and then marginalizing over the covariate distribution. We demonstrate that the mean-squared error of the restricted mean difference is bounded by the mean-squared error of the covariate-adjusted survival distribution estimators…
Comparing outcomes across hospitals, often to identify underperforming hospitals, is a critical task in health services research. However, naive comparisons of average outcomes, such as surgery complication rates, can be misleading because hospital case mixes differ -- a hospital's overall complication rate may be lower due to more effective treatments or simply because the hospital serves a healthier population overall. In this paper, we develop a method of ``direct standardization'' where we re-weight each hospital patient population to be representative of the overall population and then co…
Over the past decades, both critical care and cancer care have improved substantially. Due to increased cancer-specific survival, we hypothesized that both the number of cancer patients admitted to the ICU and overall survival have increased since the millennium change. MIMIC-III, a freely accessible critical care database of Beth Israel Deaconess Medical Center, Boston, USA was used to retrospectively study trends and outcomes of cancer patients admitted to the ICU between 2002 and 2011. Multiple logistic regression analysis was performed to adjust for confounders of 28-day and 1-year mortali…
Objective: To evaluate the relationship between coronavirus disease 2019 (COVID-19) diagnosis with SARS-CoV-2 variant B.1.1.7 (also known as Variant of Concern 202012/01) and the risk of hospitalisation compared to diagnosis with wildtype SARS-CoV-2 variants. Design: Retrospective cohort, analysed using stratified Cox regression. Setting: Community-based SARS-CoV-2 testing in England, individually linked with hospitalisation data. Participants: 839,278 laboratory-confirmed COVID-19 patients, of whom 36,233 had been hospitalised within 14 days, tested between 23rd November 2020 and 31st January…
Demand for Personal Protective Equipment (PPE) such as surgical masks, gloves, and gowns has increased significantly since the onset of the COVID-19 pandemic. In hospital settings, both medical staff and patients are required to wear PPE. As these facilities resume regular operations, staff will be required to wear PPE at all times while additional PPE will be mandated during medical procedures. This will put increased pressure on hospitals which have had problems predicting PPE usage and sourcing its supply. To meet this challenge, we propose an approach to predict demand for PPE. Specificall…
Days Alive at Home vs Out of Hospital: Why the Difference Matters for Trial Endpoints
MRC Biostatistics Unit, University of Cambridge（剑桥大学医学研究委员会生物统计单元）；Papworth Trials Unit Collaboration, Royal Papworth Hospital（皇家帕普沃斯医院帕沃斯试验单位合作组织）；University of Cambridge（剑桥大学）；Department of Anaesthesia, Royal Papworth Hospital（皇家帕普沃斯医院麻醉科）
Randomized control trials (RCTs) are the gold standard for estimating causal effects, but often use samples that are non-representative of the actual population of interest. We propose a reweighting method for estimating population average treatment effects in settings with noncompliance. Simulations show the proposed compliance-adjusted population estimator outperforms its unadjusted counterpart when compliance is relatively low and can be predicted by observed covariates. We apply the method to evaluate the effect of Medicaid coverage on health care use for a target population of adults who …
In the field of quality of health care measurement, one approach to assessing patient sickness at admission involves a logistic regression of mortality within 30 days of admission on a fairly large number of sickness indicators (on the order of 100) to construct a sickness scale, employing classical variable selection methods to find an ``optimal'' subset of 10--20 indicators. Such ``benefit-only'' methods ignore the considerable differences among the sickness indicators in cost of data collection, an issue that is crucial when admission sickness is used to drive programs (now implemented or u…
In clinical trials, a covariate-adjusted response-adaptive (CARA) design allows a subject newly entering a trial a better chance of being allocated to a superior treatment regimen based on cumulative information from previous subjects, and adjusts the allocation according to individual covariate information. Since this design allocates subjects sequentially, it is natural to apply a sequential method for estimating the treatment effect in order to make the data analysis more efficient. In this paper, we study the sequential estimation of treatment effect for a general CARA design. A stopping c…
Indirect comparisons of treatment-specific outcomes across separate studies often inform decision-making in the absence of head-to-head randomized comparisons. Differences in baseline characteristics between study populations may introduce confounding bias in such comparisons. Matching-adjusted indirect comparison (MAIC) (Signorovitch et al., 2010) has been used to adjust for differences in observed baseline covariates when the individual patient-level data (IPD) are available for only one study and aggregate data (AGD) are available for the other study. The approach weights outcomes from the …
From Observational Data to Clinical Recommendations: A Causal Framework for Estimating Patient-level Treatment Effects and Learning Policies
Faculty of Data and Decision Sciences, Technion（数据与决策科学学院，技术ion）；Blavatnik School of Computer Science, Tel-Aviv University（Blavatnik计算机科学学院，特拉维夫大学）；Department of Cardiology, Rambam Health Care Campus（心内科部，拉马姆医疗中心）；The Bruce Rappaport Faculty of Medicine, Technion（布鲁斯·拉帕波特医学院，技术ion）；Department of Statistics and Operations Research, School of Mathematical Sciences, Tel Aviv University（统计与运筹学部，数学科学学院，特拉维夫大学）
Introduction: The goal of this paper is to study inequities in breast cancer (BC) health care outcomes for Chilean women, including case fatality (FR) and survival rates (SR), stratified by type of health care provider and geographical area. A secondary goal is to estimate BC incidence (IR) and mortality (MR) rates by health care providers and region. Methods: We used two public anonymized databases provided by the Ministry of Health: the national death and hospital discharges datasets. For survival analysis, we used the Kaplan Meier product-limit estimator (KM) with a 95% ci and the Cox propo…
Estimating Treatment Effects for Depression in Longitudinal Therapy Switching Settings
University of Houston（休斯顿大学）；Adler Graduate Professional School（阿德勒研究生专业学校）；Lakehead University（湖首大学）；Northern Ontario School of Medicine（北安大略医学院）；Virginia Tech（弗吉尼亚理工大学）
Evaluating air quality interventions is confronted with the challenge of interference since interventions at a particular pollution source likely impact air quality and health at distant locations and air quality and health at any given location are likely impacted by interventions at many sources. The structure of interference in this context is dictated by complex atmospheric processes governing how pollution emitted from a particular source is transformed and transported across space, and can be cast with a bipartite structure reflecting the two distinct types of units: 1) interventional un…
Multivariate meta-analysis (MMA) is a powerful tool for jointly estimating multiple outcomes' treatment effects. However, the validity of results from MMA is potentially compromised by outcome reporting bias (ORB), or the tendency for studies to selectively report outcomes. Until recently, ORB has been understudied. Since ORB can lead to biased conclusions, it is crucial to correct the estimates of effect sizes and quantify their uncertainty in the presence of ORB. With this goal, we develop a Bayesian selection model to adjust for ORB in MMA. We further propose a measure for quantifying the i…
Stepped wedge cluster randomized trials (SW-CRTs) with binary outcomes are increasingly used in prevention and implementation studies. Marginal models represent a flexible tool for analyzing SW-CRTs with population-averaged interpretations, but the joint estimation of the mean and intraclass correlation coefficients (ICCs) can be computationally intensive due to large cluster-period sizes. Motivated by the need for marginal inference in SW-CRTs, we propose a simple and efficient estimating equations approach to analyze cluster-period means. We show that the quasi-score for the marginal mean de…
