Background: Failure to achieve clinically significant outcome (CSO) improvement after total hip arthroplasty (THA) imposes a potential cost-to-risk imbalance in the context of bundle payment models. Patient perception of their health state is one component of such risk. The purpose of the current study is to develop machine learning algorithms to predict CSO for the patient-reported health state (PRHS) and build a clinical decision-making tool based on risk factors.
Methods: A retrospective review of primary THA patients between 2014 and 2017 was performed. Variables considered for prediction included demographics, medical history, preoperative PRHS, and modified Harris Hip Score. The minimal clinically important difference (MCID) for the PRHS was calculated using a distribution-based method. Five supervised machine learning algorithms were developed and assessed by discrimination, calibration, Brier score, and decision curve analysis.
Results: Of 616 patients, a total of 407 (69.2%) achieved the MCID for the PRHS. The random forest algorithm achieved the best performance in the independent testing set not used for algorithm development (c-statistic 0.97, calibration intercept -0.05, calibration slope 1.45, Brier score 0.054). The most important factors for achieving the MCID were preoperative PRHS, preoperative opioid use, age, and body mass index. Individual patient-level explanations were provided for the algorithm predictions and the algorithms were incorporated into an open access digital application available here: https://sorg-apps.shinyapps.io/THA_PRHS_mcid/.
Conclusion: The current study created a clinical decision-making tool based on partially modifiable risk factors for predicting CSO after THA. The tool demonstrates excellent discriminative capacity for identifying those at greatest risk for failing to achieve CSO in their current health state and may allow for preoperative health optimization.
Keywords: MCID; THA; clinical outcomes; clinically significant outcome; machine learning; total hip arthroplasty.
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