Machine learning for initial insulin estimation in hospitalized patients

Objective: The study sought to determine whether machine learning can predict initial inpatient total daily dose (TDD) of insulin from electronic health records more accurately than existing guideline-based dosing recommendations. Materials and Methods: Using electronic health records from a tertiary academic center between 2008 and 2020 of 16,848 inpatients receiving subcutaneous insulin who achieved target blood glucose control of 100-180 mg/dL on a calendar day, we trained an ensemble machine learning algorithm consisting of regularized regression, random forest, and gradient boosted tree models for 2-stage TDD prediction. We evaluated the ability to predict patients requiring more than 6 units TDD and their point-value TDDs to achieve target glucose control. Results: The method achieves an area under the receiver-operating characteristic curve of 0.85 (95% confidence interval [CI], 0.84-0.87) and area under the precision-recall curve of 0.65 (95% CI, 0.64-0.67) for classifying patients who require more than 6 units TDD. For patients requiring more than 6 units TDD, the mean absolute percent error in dose prediction based on standard clinical calculators using patient weight is in the range of 136%-329%, while the regression model based on weight improves to 60% (95% CI, 57%-63%), and the full ensemble model further improves to 51% (95% CI, 48%-54%). Discussion: Owingto the narrow therapeutic window and wide individual variability, insulin dosing requires adaptive and predictive approaches that can be supported through data-driven analytic tools. Conclusions: Machine learning approaches based on readily available electronic medical records can discriminate which inpatients will require more than 6 units TDD and estimate individual doses more accurately than standard guidelines and practices.