Concomitant Procedures, Black Race, Male Sex, and General Anesthesia Show Fair Predictive Value for Prolonged Rotator Cuff Repair Operative Time: Analysis of the NSQIP Database Using Machine Learning.

Abstract

Purpose: The purpose of this study is to develop machine learning models using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database to predict prolonged operative time (POT) for rotator cuff repair (RCR). Furthermore, this study aims to use the trained machine learning (ML) models, cross-referenced with traditional multivariate logistic regression (MLR), to determine the key perioperative variables that may predict POT for RCR.

Methods: Data were obtained from a large, national database (NSQIP) from 2021. Patients with unilateral RCR procedures were included. Demographic, preoperative, and operative variables were analyzed. A multivariable logistic regression (MLR) model and various other machine learning techniques, including random forest (RF) and artificial neural network (ANN), were compared using area under the curve (AUC), calibration, Brier score, and decision curve analysis. Feature importance was identified from the overall best-performing model.

Results: A total of 6,690 patients met inclusion criteria. The random forest (RF) ML model had the highest AUC upon internal validation (0.706) and the lowest Brier score (0.15), outperforming the other models. The RF model also demonstrated strong performance upon assessment of the calibration curves (Slope = 0.86, Intercept = 0.08) and decision curve analysis. The model identified concomitant procedure, specifically labral repair and biceps tenodesis, as the most important variable for determining POT, followed by age <30 years, Black or African American race, male sex, and general anesthesia.

Conclusions: Despite the advanced machine learning models used in this study, the NSQIP dataset was only able to fairly predict POT following RCR. The RF model identified concomitant procedures, specifically labral repair and biceps tenodesis, as the most important variables for determining POT. Additionally, demographic factors such as age <30 years, Black race, and general anesthesia were significant predictors. While male sex was identified as important in the RF model, the MLR model indicated that its predictive value is primarily in conjunction with specific procedures like biceps tenodesis and subacromial decompression.