Predicting Outcome for Hospitalized Cardiac Patients Using a Combined Neural Network and Rough Set Approach

M.B. Zaremba) and A. Wielgos8

I)

Dipartement dinformatique, Universitt du Qutbec Hull, Quebec J8Y 3G5,Canada E-mail: zarembaauqah. uquebec.ca 2, The Ottawa General Hospital 501 Smyth Road, Ottawa, Ontario KIH 8L6, Canada E-mail: wielgosz@uottawa.ca
statistical approaches as well as physician-based estimations. [1,2] However, adoption has been slow in part because of methodological and practical limitations and in part because of the need to accommodate the complex reasoning of nonparametric regression. [3] The problem of missing data in many patient records - a situation often encountered in real world applications, but one of important potential implications in this application - forced us to look into an adaptive architecture of the neural system. Also, given the large number (over one hundred) of variables in the data, direct application of neural technology alone was considered potentially inadequate. Manual selection of the type of attributes most pertinent to the classification and prediction problem at hand would not guarantee an optimal solution. This problem called for an automated method to define the type of input information provided to the network. Our objective w a s to develop a neural network system that would predict outcomes from hospitalization of patients treated for an acute myocardial infarction (AMI), by integrating a rough set approach. The basic architecture retained as a result of this work comprised a number of neural networks controlled by an input data processing, rule-based module. Most of the resulting rules served during the system design phase - to reduce the number of neural network input variables. Other rules were used - in the system operation phase - to dynamically select the networks that best fit the type of information describing the current patient.

Abstract
This paper describes a hospitalization prediction system based on neural network technology. It focuses on predicting the following output variables identified as crucialfor the purposes o f the project: the length o f stay in f stay in the Intensive Care Unit, and hospital, the length o f hospitalization defined as a transferred, the outcome o discharged or deceased patient. The general approach f first applying adoptedfor solving the problem consists o inductive learning based on the techniques of rough sets to f input data and a small set o f generate a reduced set o rules specific to the output variable. The results serve to define and structure the architecture o f the neural system f the number o f neural networks and their input in terms o variables, as well as to dynamically select the networks that best fit the type o f information describing the current patient. A database o f over 1,000 cardiac patients, f admitted to the Ottawa General Hospital over a period o 4 years was used.

I. INTRODUCTION
The ability to predict accurately hospital length of stay and patient disposition is an imperative of efficient care management. Past experience is the best resource for the development of a predictive model. Given the large number of potential predictor variables in an experiential patient database and the freedom to define new relationships, neural network technology provides an attractive approach for the development of predictive models. Artificial neural network technology has been applied in a variety of medical settings [l] including cardiovascular, with results that are comparable to other

II. HOSPITALIZATION DATA

The data were collected systematically on all consecutive patients discharged between January 1994 and December

O-7803-5529-6/99/$10.00 01999 IEEEl

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1997 with a diagnosis of AMI in one hospital, as part of a point of care surveillance system. The variables contained in the data set were considered important for the identification of disease severity as well as for auditing the timeliness of thrombolytic treatment and the development of any related complications. The input data were derived from 102 variables including the demographic history of the patient, the medical history, the clinical presentation, the concomitant medications taken within 24 hours of the diagnosis of AMI,and selected procedures performed in the hospital prior to discharge, including an ECG.

where the elements of the discernibility matrix MB contain the attribute that can be used to discern between objects xi and xj:

MB(i,j) = { a E B I discerns(u, a(xi),(x~))}

The attribute subsets that do not contain any dispensable attributes, i.e., the minimal subsets, are called reducts. In other words, reducts that relate to a given object represent the minimum amount of information required to discern that object from other discernible objects.

III.

COMBINED NEURAL NETWORK

AND ROUGH SET ARCHITECTURE

A. Decision Tables Based on the prognostic requirements, that define the choice of the output variables, and a general analysis of the medical treatment administered to the patient upon arrival in hospital, twenty decision tables were obtained. They were later used throughout the system design process as a reference for defining the architecture as well as evaluating the performance of neural network classifiers. The number of tables resulted from a combination of four types of medical treatment: - thrombolytic treatment with a diagnostic ECG - thrombolytic treatment without a diagnostic ECG - no thrombolytic treatment with a diagnostic ECG - no thrombolytic treatment without a diagnostic ECG and five outcomes: patient transferred, patient discharged, patient deceased, length of stay in intensive care, and length of stay in this hospital.

In order to incorporate the decision (in general, labelling) associated with each object of an information system, in our case the outcome of the hospitalization associated with each patient, we can define a decision system Z = (U, A U { d)), where d E A is the decision attribute. The elements of A are then called condition attributes.
Using the notions introduced above, we can represent our problem in terms of four information systems: ZI = (U,, AI U (4) - for patients treated with a thrombolytic and with a diagnostic ECG ZZ = (U, Az U (4) - for patients treated with a thrombolytic and without a diagnostic ECG 1 3 = ( U , A3 U {d)) - for patients not treated with a thrombolytic and with a diagnostic ECG 1 4 = ( U , A4 U (4) - for patients not treated with a thrombolytic and without a diagnostic ECG The set {d)of decision attributes comprises three binary attributes for dl (patient transferred), dz (patient discharged), d3 (patient deceased), and two integer attributes for d4 (length of stay at intensive care) and d5 (length of stay at this hospital).

B. Rough Set-Based Reahrction

Given an information system Z = (U, A), where U is a finite set of objects and A is a finite set of attributes, and suppose that a subset X E U cannot be defined in a crisp manner using attributes B E A, a rough set [4] is any subset X E U defined through its lower and upper approximations:

C. Neural Network Based Prediction System

The neural network architectures discussed in this paper consist of three layers of neurons, with the number of input neurons dependent on the type of decision table (information system) involved, and with a single output neuron (binary or linear). The input variables for the networks relating to system Z l :

The lower approximation can be expressed as those objects that certainly belong to subset X, and the upper approximation as those objects that possibly belong to X.

An important relation defined with respect to the objects of an information system is an indiscernibility relation R B E U x U.It is defined as

Demographic/medicalhistory: 1 ) Sex 2 ) Age 3 ) Ansina 4) Hypertension 5 ) PreViousMI 6) Current Smoker

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7) Diabetes 8) Hypercholesterolemia 9) Pulse 10) Systolicblood pressure 11) Diastolic blood pressure

Design phase
Training data (Decision tables)

Operationphase

Clinical Presentation: 12) No congestive heart failure 13) Pulmonary edema 14) Rales 15) Number of affected leads 16) Thrombolytic drug type 17) Total delay time to IV lytic 18) Hospital arrival to IV lytic delay time 19) W a s patient transferred to this hospital? a s patient already in hospital? 20) W 21) Peak CPK 22) Delay before arrival in hospital Concomitantmedications within 24 hours of the diagnosis of AM: 23) ASA 24) Oral Beta Blocker 25) IVHeparin 26) IVNTG 27) Ace Inhibitor 28) IV Beta Blocker 29) SQHeparin Otherproceduresperformed at this hospitalprior to discharge: 30) Coronary Angiography
31) Stress Test

Selector

I
I

I-----------

Rediction results Fig. 1. System architecture.

I V . RESULTS
The computation of the reducts was performed using an exhaustive reducer algorithm, which performed better for binary output networks than other algorithms, such as the Holte reducer. [SI The time of the brute force computation of all reducts done by the exhaustive reducer algorithm was acceptable for the size of the dataset under consideration. Table 1 presents the results of the prediction of the outcome of the "patient transferred'' decision variable. Table 1 Results of prediction for Patient Transfer Decision system 4(d1) . . IZ(dI) I3(dI) IAdd Training Testing

32) Pacemaker implantation

For the networks relating to system I2, input 15 was eliminated. Inputs 16, 17, and 18 did not intervene in the networks relating to system 13.Neural networks associated with system I4 did not use inputs 15, 16, 17, and 18.

D. System Integration
The general approach adopted for solving the problem consists of first applying inductive learning based on the techniques of rough sets to generate a small set of rules o s t of the resulting rules specific to the output variable. M serve - during the system design phase - to define and structure the architecture of the neural system in terms of the number of neural networks and their input variables. Other rules are used in the system operation phase to dynamically select the networks that best fit the type of information describing the current patient. The pertinent input data are then fed to the selected neural system. The diagram in Fig.1 outlines the flow of information in the prediction system.

NN
100% 100% 100% 100%
90.5%

Rough set
94.1% 90.0% 93.9% 94.0%

83.3% 83.3% 92.5%

Similar results were obtained for decision variables d 2 and d3. The difference between the purely neural network and rough set enhanced processing was larger for d3 (patient deceased). The best prediction results were obtained for the decision systems pertaining to the patients not administered with medication, and with ECG (Ij(d3) =

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1OO%), and to the patients administered with medication, and with ECG.

Z. Pawlak, Rough Sets: Theoreticul Aspects of Reasoning about Data. Kluver Academic Publishers, Dordrecht, The

Netherlands, 1991.
5

The comparison between the two prediction schemes, with and without rough set-based processing, was less conclusive in the case of length of stay prediction. Whereas the application of the rough set methodology offered better results for d4 (length of stay in ICU), albeit at a lower success rate (40 - 50%), it performed better only for the patients not treated with the medication in the case of d5 (length of stay in this hospital). For the patients treated with medication, and without a diagnostic ECG, the neural network successful prediction rate was 100%.

RC. Holte, Very simple classification rules perform well on most commonly used datasets. Muchine Learning, vol.11, no.1, pp. 63-91, 1993.

V. CONCLUSIONS
The performance of a set of neural networks performing different classification and prediction tasks was generally enhanced by integrating the neural system with a rough set based classification scheme, both in the design and the operation phase. The most significant enhancement of the results with respect to purely neural processing was obtained for the prediction of a transfer and the deceased status of a patient.
Our work is novel in the development of a dynamic neural architecture controlled by a rule based and data reduction system generated automatically by using a rough set methodology.

ACKNOWLEDGMENTS
We wish to acknowledge R. Porquet, P. Hotte, R. Jalbert and I. Qaozandry for their programming and testing. Computations were performed on a parallel computer system available through the UQAH - 3156362 Canada Inc. Research and Development Project.

REFERENCES
Ravidin PM, Clark GM. A practical application of neural network analysis for predicting outcome of individual breast cancer patients. Breast Cancer Res and Treat 22:285-293, 1992.

Baxt WG.U s e of an artifical neural network for the diagnosis of myocardial infarction.Ann Int Med 115:843848,1991. Itchhaporia D., Snow PB, Almassy RJ et al. Artificial Neural Networks: Current Status in Cardiovascular Medicine. JACC 28515-521, 1996.

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