Causal determinants of postoperative length of stay in cardiac surgery using causal graphical learning. J Thorac Cardiovasc Surg 2023 Nov;166(5):e446-e462
Date
09/27/2022Pubmed ID
36154975Pubmed Central ID
PMC9968823DOI
10.1016/j.jtcvs.2022.08.012Scopus ID
2-s2.0-85138837041 (requires institutional sign-in at Scopus site) 3 CitationsAbstract
OBJECTIVE: We aimed to learn the causal determinants of postoperative length of stay in cardiac surgery patients undergoing isolated coronary artery bypass grafting or aortic valve replacement surgery.
METHODS: For patients undergoing isolated coronary artery bypass grafting or isolated aortic valve replacement surgeries between 2011 and 2016, we used causal graphical modeling on electronic health record data. The Fast Causal Inference (FCI) algorithm from the Tetrad software was used on data to estimate a Partial Ancestral Graph (PAG) depicting direct and indirect causes of postoperative length of stay, given background clinical knowledge. Then, we used the latent variable intervention-calculus when the directed acyclic graph is absent (LV-IDA) algorithm to estimate strengths of causal effects of interest. Finally, we ran a linear regression for postoperative length of stay to contrast statistical associations with what was learned by our causal analysis.
RESULTS: In our cohort of 2610 patients, the mean postoperative length of stay was 219 hours compared with the Society of Thoracic Surgeons 2016 national mean postoperative length of stay of approximately 168 hours. Most variables that clinicians believe to be predictors of postoperative length of stay were found to be causes, but some were direct (eg, age, diabetes, hematocrit, total operating time, and postoperative complications), and others were indirect (including gender, race, and operating surgeon). The strongest average causal effects on postoperative length of stay were exhibited by preoperative dialysis (209 hours); neuro-, pulmonary-, and infection-related postoperative complications (315 hours, 89 hours, and 131 hours, respectively); reintubation (61 hours); extubation in operating room (-47 hours); and total operating room duration (48 hours). Linear regression coefficients diverged from causal effects in magnitude (eg, dialysis) and direction (eg, crossclamp time).
CONCLUSIONS: By using retrospective electronic health record data and background clinical knowledge, causal graphical modeling retrieved direct and indirect causes of postoperative length of stay and their relative strengths. These insights will be useful in designing clinical protocols and targeting improvements in patient management.
Author List
Lee JJR, Srinivasan R, Ong CS, Alejo D, Schena S, Shpitser I, Sussman M, Whitman GJR, Malinsky DAuthor
Stefano Schena MD, PhD Associate Professor in the Surgery department at Medical College of WisconsinMESH terms used to index this publication - Major topics in bold
Cardiac Surgical ProceduresHumans
Length of Stay
Postoperative Complications
Renal Dialysis
Retrospective Studies
