Machine Learning to Predict Mortality and Improve End-of-Life Outcomes among Minorities with Advanced Cancer

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PROJECT SUMMARY/ABSTRACT Multiple studies show that minority patients with advanced cancer have inadequate discussions about treatment, prognosis and goals of care which contributes to higher utilization of health care among minorities at the end-of-life. A primary contributor to the low rates of prognosis and goals of care discussions relates to oncologists inability to accurately predict mortality. Clinical decision support systems (CDSS) are designed to directly aid clinical decision making by utilizing individual patient characteristics to generate patient-specific assessments. Limited studies indicate CDSS can reduce disparities in process of care and care standardization. However, existing tools do not identify patients at highest risk of mortality, have not been linked to patient outcomes and have not been routinely evaluated in minority patients. Machine learning (ML) predictive models allow more accurate prognoses by modeling patient and disease- specific interactions and has the potential to obviate the racial bias that exists in the use of oncologist- specific prognostication. ML models utilizing electronic health record (EHR) data can accurately predict short-term mortality among oncology patients. However, little evidence exists that these models assist with clinical decision making or improve outcomes for minority patients with cancer. We will address systemic race/ethnicity-related barriers that contribute to disparities in end-of-life outcomes among minority cancer patients by: 1) Developing and validating a predictive model to identify patients with advanced solid cancers at high risk of death within 90-days; 2) Creating a CDSS system intervention that incorporates mortality predictive tool data to prompt goals of care conversations for solid cancer patients at high risk of mortality within 90 days; and 3) Conducting a stepped-wedge cluster randomized controlled trial to evaluate whether implementing a clinical decision support system for patients with advanced solid cancer at risk of death within 90 days increases goals of care discussions and decreases utilization of aggressive care at the end-of-life among minorities versus non-minorities. The predictive model will be created from cancer registry data linked to the EHR. We will then create a CDSS by conducting focus groups among an interdisciplinary team of oncology clinicians (physicians, advance practice providers, nurses and social workers). Additionally, we will conduct co-design workshops with the oncology clinicians to inform the implementation of the CDSS. Next, we will conduct a stepped-wedge cluster randomized controlled trial to evaluate whether utilization of the CDSS increases goals of care discussions, and decreases healthcare utilization at the end-of-life among minority versus non-minority patients with advanced solid cancer at risk of death within 90 days. Finally, we will perform exit interviews to refine the intervention and study procedures. Findings will inform a larger multi-center trial aimed at implementation of the CDSS among those predicted to have high mortality to improve the end-of-life outcomes of minority patients with cancer.