Comparison of Severity of Illness Scores and Artificial Intelligence Models That Are Predictive of Intensive Care Unit Mortality: Meta-analysis and Review of the Literature

BACKGROUND: Severity of illness scores-Acute Physiology and Chronic Health Evaluation, Simplified Acute Physiology Score, and Sequential Organ Failure Assessment-are current risk stratification and mortality prediction tools used in intensive care units (ICUs) worldwide. Developers of artificial intelligence or machine learning (ML) models predictive of ICU mortality use the severity of illness scores as a reference point when reporting the performance of these computational constructs. OBJECTIVE: This study aimed to perform a literature review and meta-analysis of articles that compared binary classification ML models with the severity of illness scores that predict ICU mortality and determine which models have superior performance. This review intends to provide actionable guidance to clinicians on the performance and validity of ML models in supporting clinical decision-making compared with the severity of illness score models. METHODS: Between December 15 and 18, 2020, we conducted a systematic search of PubMed, Scopus, Embase, and IEEE databases and reviewed studies published between 2000 and 2020 that compared the performance of binary ML models predictive of ICU mortality with the performance of severity of illness score models on the same data sets. We assessed the studies' characteristics, synthesized the results, meta-analyzed the discriminative performance of the ML and severity of illness score models, and performed tests of heterogeneity within and among studies. RESULTS: We screened 461 abstracts, of which we assessed the full text of 66 (14.3%) articles. We included in the review 20 (4.3%) studies that developed 47 ML models based on 7 types of algorithms and compared them with 3 types of the severity of illness score models. Of the 20 studies, 4 (20%) were found to have a low risk of bias and applicability in model development, 7 (35%) performed external validation, 9 (45%) reported on calibration, 12 (60%) reported on classification measures, and 4 (20%) addressed explainability. The discriminative performance of the ML-based models, which was reported as AUROC, ranged between 0.728 and 0.99 and between 0.58 and 0.86 for the severity of illness score-based models. We noted substantial heterogeneity among the reported models and considerable variation among the AUROC estimates for both ML and severity of illness score model types. CONCLUSIONS: ML-based models can accurately predict ICU mortality as an alternative to traditional scoring models. Although the range of performance of the ML models is superior to that of the severity of illness score models, the results cannot be generalized due to the high degree of heterogeneity. When presented with the option of choosing between severity of illness score or ML models for decision support, clinicians should select models that have been externally validated, tested in the practice environment, and updated to the patient population and practice environment. TRIAL REGISTRATION: PROSPERO CRD42021203871; https://tinyurl.com/28v2nch8.

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