Objective: To assess both the feasibility and potential impact of predicting preventable hospital readmissions using causal machine learning applied to data from the implementation of a readmissions prevention intervention (the Transitions Program).
Data sources: Electronic health records maintained by Kaiser Permanente Northern California (KPNC).
Study design: Retrospective causal forest analysis of postdischarge outcomes among KPNC inpatients. Using data from both before and after implementation, we apply causal forests to estimate individual-level treatment effects of the Transitions Program intervention on 30-day readmission. These estimates are used to characterize treatment effect heterogeneity and to assess the notional impacts of alternative targeting strategies in terms of the number of readmissions prevented.
Data collection: 1 539 285 index hospitalizations meeting the inclusion criteria and occurring between June 2010 and December 2018 at 21 KPNC hospitals.
Principal findings: There appears to be substantial heterogeneity in patients' responses to the intervention (omnibus test for heterogeneity p = 2.23 × 10-7 ), particularly across levels of predicted risk. Notably, predicted treatment effects become more positive as predicted risk increases; patients at somewhat lower risk appear to have the largest predicted effects. Moreover, these estimates appear to be well calibrated, yielding the same estimate of annual readmissions prevented in the actual treatment subgroup (1246, 95% confidence interval [CI] 1110-1381) as did a formal evaluation of the Transitions Program (1210, 95% CI 990-1430). Estimates of the impacts of alternative targeting strategies suggest that as many as 4458 (95% CI 3925-4990) readmissions could be prevented annually, while decreasing the number needed to treat from 33 to 23, by targeting patients with the largest predicted effects rather than those at highest risk.
Conclusions: Causal machine learning can be used to identify preventable hospital readmissions, if the requisite interventional data are available. Moreover, our results suggest a mismatch between risk and treatment effects.
Keywords: clinical decision rules; machine learning; patient readmission; risk assessment.
© Health Research and Educational Trust.