Predicting in-hospital length of stay: a two-stage modeling approach to account for highly skewed data

Abstract

Background: In the early stages of the COVID-19 pandemic our institution was interested in forecasting how long surgical patients receiving elective procedures would spend in the hospital. Initial examination of our models indicated that, due to the skewed nature of the length of stay, accurate prediction was challenging and we instead opted for a simpler classification model. In this work we perform a deeper examination of predicting in-hospital length of stay. Methods: We used electronic health record data on length of stay from 42,209 elective surgeries. We compare different loss-functions (mean squared error, mean absolute error, mean relative error), algorithms (LASSO, Random Forests, multilayer perceptron) and data transformations (log and truncation). We also assess the performance of two stage hybrid classification-regression approach. Results: Our results show that while it is possible to accurately predict short length of stays, predicting longer length of stay is extremely challenging. As such, we opt for a two-stage model that first classifies patients into long versus short length of stays and then a second stage that fits a regresssor among those predicted to have a short length of stay. Discussion: The results indicate both the challenges and considerations necessary to applying machine-learning methods to skewed outcomes. Conclusions: Two-stage models allow those developing clinical decision support tools to explicitly acknowledge where they can and cannot make accurate predictions.