Improving Medicare's Hospital Compare Mortality Model.

OBJECTIVE: To improve the predictions provided by Medicare's Hospital Compare (HC) to facilitate better informed decisions regarding hospital choice by the public. DATA SOURCES/SETTING: Medicare claims on all patients admitted for Acute Myocardial Infarction between 2009 through 2011. STUDY DESIGN: Cohort analysis using a Bayesian approach, comparing the present assumptions of HC (using a constant mean and constant variance for all hospital random effects), versus an expanded model that allows for the inclusion of hospital characteristics to permit the data to determine whether they vary with attributes of hospitals, such as volume, capabilities, and staffing. Hospital predictions are then created using directly standardized estimates to facilitate comparisons between hospitals. DATA COLLECTION/EXTRACTION METHODS: Medicare fee-for-service claims. PRINCIPAL FINDINGS: Our model that included hospital characteristics produces very different predictions from the current HC model, with higher predicted mortality rates at hospitals with lower volume and worse characteristics. Using Chicago as an example, the expanded model would advise patients against seeking treatment at the smallest hospitals with worse technology and staffing. CONCLUSION: To aid patients when selecting between hospitals, the Centers for Medicare and Medicaid Services (CMS) should improve the HC model by permitting its predictions to vary systematically with hospital attributes such as volume, capabilities, and staffing.

Ensemble of trees approaches to risk adjustment for evaluating a hospital's performance.

A commonly used method for evaluating a hospital's performance on an outcome is to compare the hospital's observed outcome rate to the hospital's expected outcome rate given its patient (case) mix and service. The process of calculating the hospital's expected outcome rate given its patient mix and service is called risk adjustment (Iezzoni 1997). Risk adjustment is critical for accurately evaluating and comparing hospitals' performances since we would not want to unfairly penalize a hospital just because it treats sicker patients. The key to risk adjustment is accurately estimating the probability of an Outcome given patient characteristics. For cases with binary outcomes, the method that is commonly used in risk adjustment is logistic regression. In this paper, we consider ensemble of trees methods as alternatives for risk adjustment, including random forests and Bayesian additive regression trees (BART). Both random forests and BART are modern machine learning methods that have been shown recently to have excellent performance for prediction of outcomes in many settings. We apply these methods to carry out risk adjustment for the performance of neonatal intensive care units (NICU). We show that these ensemble of trees methods outperform logistic regression in predicting mortality among babies treated in NICU, and provide a superior method of risk adjustment compared to logistic regression.

Negotiating Multicollinearity with Spike-and-Slab Priors.

In multiple regression under the normal linear model, the presence of multicollinearity is well known to lead to unreliable and unstable maximum likelihood estimates. This can be particularly troublesome for the problem of variable selection where it becomes more difficult to distinguish between subset models. Here we show how adding a spike-and-slab prior mitigates this difficulty by filtering the likelihood surface into a posterior distribution that allocates the relevant likelihood information to each of the subset model modes. For identification of promising high posterior models in this setting, we consider three EM algorithms, the fast closed form EMVS version of Rockova and George (2014) and two new versions designed for variants of the spike-and-slab formulation. For a multimodal posterior under multicollinearity, we compare the regions of convergence of these three algorithms. Deterministic annealing versions of the EMVS algorithm are seen to substantially mitigate this multimodality. A single simple running example is used for illustration throughout.

Exploratory Bayesian model selection for serial genetics data.

Characterizing the process by which molecular and cellular level changes occur over time will have broad implications for clinical decision making and help further our knowledge of disease etiology across many complex diseases. However, this presents an analytic challenge due to the large number of potentially relevant biomarkers and the complex, uncharacterized relationships among them. We propose an exploratory Bayesian model selection procedure that searches for model simplicity through independence testing of multiple discrete biomarkers measured over time. Bayes factor calculations are used to identify and compare models that are best supported by the data. For large model spaces, i.e., a large number of multi-leveled biomarkers, we propose a Markov chain Monte Carlo (MCMC) stochastic search algorithm for finding promising models. We apply our procedure to explore the extent to which HIV-1 genetic changes occur independently over time.