Reducing preventable hospital readmissions is a national priority for payers, providers, and policymakers seeking to improve health care and lower costs. The rate of readmission is being used as a benchmark to determine the quality of healthcare provided by the hospitals. In thisproject, we have used machine learning techniques like Logistic Regression, Random Forest and Support Vector Machines to analyze the health claims data and identify demographic and medical factors that play a crucial role in predicting all-cause readmissions. As the health claims data is high dimensional, we have used Principal Component Analysis as a dimension reduction technique and used the results for building regression models. We compared and evaluated these models based on the Area Under Curve (AUC) metric. Random Forest model gave the highest performance followed by Logistic Regression and Support Vector Machine models. These models can be used to identify the crucial factors causing readmissions and help identify patients to focus on to reduce the chances of readmission, ultimately bringing down the cost and increasing the quality of healthcare provided to the patients.

Accurate prediction of medical conditions with straight past clinical evidence is a long-sought topic in the medical management and health insurance field. Although great progress has been made with machine learning algorithms, the medical community is still skeptical about the model accuracy and interpretability. This paper presents an innovative hierarchical attention deep learning model to achieve better prediction and clear interpretability that can be easily understood by medical professionals. This paper developed an Interpretable Hierarchical Attention Network (IHAN). IHAN uses a hierarchical attention structure that matches naturally with the medical history data structure and reflects patients encounter (date of service) sequence. The model attention structure consists of 3 levels: (1) attention on the medical code types (diagnosis codes, procedure codes, lab test results, and prescription drugs), (2) attention on the sequential medical encounters within a type, (3) attention on the individual medical codes within an encounter and type. This model is applied to predict the occurrence of stage 3 chronic kidney disease (CKD), using three years medical history of Medicare Advantage (MA) members from an American nationwide health insurance company. The model takes members medical events, both claims and Electronic Medical Records (EMR) data, as input, makes a prediction of stage 3 CKD and calculates contribution from individual events to the predicted outcome.

Objective: To improve prediction of Chronic Kidney Disease (CKD) progression to End Stage Renal Disease (ESRD) using machine learning (ML) and deep learning (DL) models applied to an integrated clinical and claims dataset of varying observation windows, supported by explainable AI (XAI) to enhance interpretability and reduce bias. Materials and Methods: We utilized data about 10,326 CKD patients, combining their clinical and claims information from 2009 to 2018. Following data preprocessing, cohort identification, and feature engineering, we evaluated multiple statistical, ML and DL models using data extracted from five distinct observation windows. Feature importance and Shapley value analysis were employed to understand key predictors. Models were tested for robustness, clinical relevance, misclassification errors and bias issues. Results: Integrated data models outperformed those using single data sources, with the Long Short-Term Memory (LSTM) model achieving the highest AUC (0.93) and F1 score (0.65). A 24-month observation window was identified as optimal for balancing early detection and prediction accuracy. The 2021 eGFR equation improved prediction accuracy and reduced racial bias, notably for African American patients. Discussion: Improved ESRD prediction accuracy, results interpretability and bias mitigation strategies presented in this study have the potential to significantly enhance CKD and ESRD management, support targeted early interventions and reduce healthcare disparities. Conclusion: This study presents a robust framework for predicting ESRD outcomes in CKD patients, improving clinical decision-making and patient care through multi-sourced, integrated data and AI/ML methods. Future research will expand data integration and explore the application of this framework to other chronic diseases.

This study explores the potential of utilizing administrative claims data, combined with advanced machine learning and deep learning techniques, to predict the progression of Chronic Kidney Disease (CKD) to End-Stage Renal Disease (ESRD). We analyze a comprehensive, 10-year dataset provided by a major health insurance organization to develop prediction models for multiple observation windows using traditional machine learning methods such as Random Forest and XGBoost as well as deep learning approaches such as Long Short-Term Memory (LSTM) networks. Our findings demonstrate that the LSTM model, particularly with a 24-month observation window, exhibits superior performance in predicting ESRD progression, outperforming existing models in the literature. We further apply SHapley Additive exPlanations (SHAP) analysis to enhance interpretability, providing insights into the impact of individual features on predictions at the individual patient level. This study underscores the value of leveraging administrative claims data for CKD management and predicting ESRD progression.

The property and casualty (P&C) insurance industry faces challenges in developing claim predictive models due to the highly right-skewed distribution of positive claims with excess zeros. To address this, actuarial science researchers have employed "zero-inflated" models that combine a traditional count model and a binary model. This paper investigates the use of boosting algorithms to process insurance claim data, including zero-inflated telematics data, to construct claim frequency models. Three popular gradient boosting libraries - XGBoost, LightGBM, and CatBoost - are evaluated and compared to determine the most suitable library for training insurance claim data and fitting actuarial frequency models. Through a comprehensive analysis of two distinct datasets, it is determined that CatBoost is the best for developing auto claim frequency models based on predictive performance. Furthermore, we propose a new zero-inflated Poisson boosted tree model, with variation in the assumption about the relationship between inflation probability $p$ and distribution mean $\mu$, and find that it outperforms others depending on data characteristics. This model enables us to take advantage of particular CatBoost tools, which makes it easier and more convenient to investigate the effects and interactions of various risk features on the frequency model when using telematics data.

Alzheimer's disease and related dementias (ADRD) ranks as the sixth leading cause of death in the US, underlining the importance of accurate ADRD risk prediction. While recent advancement in ADRD risk prediction have primarily relied on imaging analysis, yet not all patients undergo medical imaging before an ADRD diagnosis. Merging machine learning with claims data can reveal additional risk factors and uncover interconnections among diverse medical codes. Our goal is to utilize Graph Neural Networks (GNNs) with claims data for ADRD risk prediction. Addressing the lack of human-interpretable reasons behind these predictions, we introduce an innovative method to evaluate relationship importance and its influence on ADRD risk prediction, ensuring comprehensive interpretation. We employed Variationally Regularized Encoder-decoder Graph Neural Network (VGNN) for estimating ADRD likelihood. We created three scenarios to assess the model's efficiency, using Random Forest and Light Gradient Boost Machine as baselines. We further used our relation importance method to clarify the key relationships for ADRD risk prediction. VGNN surpassed other baseline models by 10% in the area under the receiver operating characteristic. The integration of the GNN model and relation importance interpretation could potentially play an essential role in providing valuable insight into factors that may contribute to or delay ADRD progression. Employing a GNN approach with claims data enhances ADRD risk prediction and provides insights into the impact of interconnected medical code relationships. This methodology not only enables ADRD risk modeling but also shows potential for other image analysis predictions using claims data.

This study compares the safety of autonomous- and human drivers. It finds that the Waymo One autonomous service is significantly safer towards other road users than human drivers are, as measured via collision causation. The result is determined by comparing Waymo's third party liability insurance claims data with mileage- and zip-code-calibrated Swiss Re (human driver) private passenger vehicle baselines. A liability claim is a request for compensation when someone is responsible for damage to property or injury to another person, typically following a collision. Liability claims reporting and their development is designed using insurance industry best practices to assess crash causation contribution and predict future crash contributions. In over 3.8 million miles driven without a human being behind the steering wheel in rider-only (RO) mode, the Waymo Driver incurred zero bodily injury claims in comparison with the human driver baseline of 1.11 claims per million miles (cpmm). The Waymo Driver also significantly reduced property damage claims to 0.78 cpmm in comparison with the human driver baseline of 3.26 cpmm. Similarly, in a more statistically robust dataset of over 35 million miles during autonomous testing operations (TO), the Waymo Driver, together with a human autonomous specialist behind the steering wheel monitoring the automation, also significantly reduced both bodily injury and property damage cpmm compared to the human driver baselines.

Importance: The prevalence of severe mental illnesses (SMIs) in the United States is approximately 3% of the whole population. The ability to conduct risk screening of SMIs at large scale could inform early prevention and treatment. Objective: A scalable machine learning based tool was developed to conduct population-level risk screening for SMIs, including schizophrenia, schizoaffective disorders, psychosis, and bipolar disorders,using 1) healthcare insurance claims and 2) electronic health records (EHRs). Design, setting and participants: Data from beneficiaries from a nationwide commercial healthcare insurer with 77.4 million members and data from patients from EHRs from eight academic hospitals based in the U.S. were used. First, the predictive models were constructed and tested using data in case-control cohorts from insurance claims or EHR data. Second, performance of the predictive models across data sources were analyzed. Third, as an illustrative application, the models were further trained to predict risks of SMIs among 18-year old young adults and individuals with substance associated conditions. Main outcomes and measures: Machine learning-based predictive models for SMIs in the general population were built based on insurance claims and EHR.

While the emergence of large administrative claims data provides opportunities for research, their use remains limited by the lack of clinical annotations relevant to disease outcomes, such as recurrence in breast cancer (BC). Several challenges arise from the annotation of such endpoints in administrative claims, including the need to infer both the occurrence and the date of the recurrence, the right-censoring of data, or the importance of time intervals between medical visits. Deep learning approaches have been successfully used to label temporal medical sequences, but no method is currently able to handle simultaneously right-censoring and visit temporality to detect survival events in medical sequences. We propose EDEN (Event DEtection Network), a time-aware Long-Short-Term-Memory network for survival analyses, and its custom loss function. Our method outperforms several state-of-the-art approaches on real-world BC datasets. EDEN constitutes a powerful tool to annotate disease recurrence from administrative claims, thus paving the way for the massive use of such data in BC research.

Autism, also referred to as autism spectrum disorder (ASD), is a neurological and developmental disorder that impacts behavior, social interaction, speech, nonverbal communication, self-regulation, and relationships. Symptoms of ASD appear within the first three years of life. Early diagnosis and intervention of ASD may make a significant difference later in life. A new study published in BMJ Health & Care Informatics demonstrates how artificial intelligence (AI) machine learning and real-world health claims data can predict autism spectrum disorder (ASD) in children under 30 months. "Our prediction model for ASD diagnosis could lead to a significant impact on the screening strategies for ASD in young children," wrote the study authors affiliated with The Pennsylvania State University College of Medicine and The Pennsylvania State University.