Developing a clinical decision support framework for integrating predictive models into routine nursing practices in home health care for patients with heart failure

Abstract

Background: The healthcare industry increasingly values high-quality and personalized care. Patients with heart failure (HF) receiving home health care (HHC) often experience hospitalizations due to worsening symptoms and comorbidities. Therefore, close symptom monitoring and timely intervention based on risk prediction could help HHC clinicians prevent emergency department (ED) visits and hospitalizations. This study aims to (1) describe important variables associated with a higher risk of ED visits and hospitalizations in HF patients receiving HHC; (2) map data requirements of a clinical decision support (CDS) tool to the exchangeable data standard for integrating a CDS tool into the care of patients with HF; (3) outline a pipeline for developing a real-time artificial intelligence (AI)-based CDS tool.

Methods: We used patient data from a large HHC organization in the Northeastern US to determine the factors that can predict ED visits and hospitalizations among patients with HF in HHC (9362 patients in 12,223 care episodes). We examined vital signs, HHC visit details (e.g., the purpose of the visit), and clinical note-derived variables. The study identified critical factors that can predict ED visits and hospitalizations and used these findings to suggest a practical CDS tool for nurses. The tool's proposed design includes a system that can analyze data quickly to offer timely advice to healthcare clinicians.

Results: Our research showed that the length of time since a patient was admitted to HHC and how recently they have shown symptoms of HF were significant factors predicting an adverse event. Additionally, we found this information from the last few HHC visits before the occurrence of an ED visit or hospitalization were particularly important in the prediction. One hundred percent of clinical demographic profiles from the Outcome and Assessment Information Set variables were mapped to the exchangeable data standard, while natural language processing-driven variables couldn't be mapped due to their nature, as they are generated from unstructured data. The suggested CDS tool alerts nurses about newly emerging or rising risks, helping them make informed decisions.

Conclusions: This study discusses the creation of a time-series risk prediction model and its potential CDS applications within HHC, aiming to enhance patient outcomes, streamline resource utilization, and improve the quality of care for individuals with HF.

Clinical relevance: This study provides a detailed plan for a CDS tool that uses the latest AI technology designed to aid nurses in their day-to-day HHC service. Our proposed CDS tool includes an alert system that serves as a guard rail to prevent ED visits and hospitalizations. This tool can potentially improve how nurses make decisions and improve patient outcomes by providing early warnings about ED visits and hospitalizations.

Keywords: artificial intelligence; clinical decision support; electronic health records; heart failure; home care services; nursing informatics.

FIGURE 1

(a) Top 20 features associated with risk for ED visits and hospitalizations in HHC. The x‐axis displays the SHAP values of the features, while the y‐axis lists the top 20 features in descending order of importance, with the most important factors at the top. (b) Features associated with risk for ED visit and hospitalization presented over time. Rank number indicates the order of importance for each feature. Features that are not time‐variant: Deep learning‐based features (Ranks 7, 9,11, 15, 16, 17); Topic models: Instruction on self‐management (Ranks 12); TF‐IDF features: “ER” / “no further” / “generic” (Ranks 14, 18, 19). These were not included in this figure.

FIGURE 2

High‐level architecture of time‐series risk model in patients with HF receiving HHC.