Causal determinants of postoperative length of stay in cardiac surgery using causal graphical learning.

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.

Identification and Estimation of Causal Effects Defined by Shift Interventions.

Causal inference quantifies cause effect relationships by means of counterfactual responses had some variable been artificially set to a constant. A more refined notion of manipulation, where a variable is artificially set to a fixed function of its natural value is also of interest in particular domains. Examples include increases in financial aid, changes in drug dosing, and modifying length of stay in a hospital. We define counterfactual responses to manipulations of this type, which we call shift interventions. We show that in the presence of multiple variables being manipulated, two types of shift interventions are possible. Shift interventions on the treated (SITs) are defined with respect to natural values, and are connected to effects of treatment on the treated. Shift interventions as policies (SIPs) are defined recursively with respect to values of responses to prior shift interventions, and are connected to dynamic treatment regimes. We give sound and complete identification algorithms for both types of shift interventions, and derive efficient semi-parametric estimators for the mean response to a shift intervention in a special case motivated by a healthcare problem. Finally, we demonstrate the utility of our method by using an electronic health record dataset to estimate the effect of extending the length of stay in the intensive care unit (ICU) in a hospital by an extra day on patient ICU readmission probability.