NLP-based assessment of prescription appropriateness from Italian referrals

Objective: This study proposes a Natural Language Processing pipeline to evaluate prescription appropriateness in Italian referrals, where reasons for prescriptions are recorded only as free text, complicating automated comparisons with guidelines. The pipeline aims to derive, for the first time, a comprehensive summary of the reasons behind these referrals and a quantification of their appropriateness. While demonstrated in a specific case study, the approach is designed to generalize to other types of examinations. Methods: Leveraging embeddings from a transformer-based model, the proposed approach clusters referral texts, maps clusters to labels, and aligns these labels with existing guidelines. We present a case study on a dataset of 496,971 referrals, consisting of all referrals for venous echocolordopplers of the lower limbs between 2019 and 2021 in the Lombardy Region. A sample of 1,000 referrals was manually annotated to validate the results. Results: The pipeline exhibited high performance for referrals' reasons (Prec=92.43%, Rec=83.28%) and excellent results for referrals' appropriateness (Prec=93.58%, Rec=91.52%) on the annotated subset. Analysis of the entire dataset identified clusters matching guideline-defined reasons - both appropriate and inappropriate - as well as clusters not addressed in the guidelines. Overall, 34.32% of referrals were marked as appropriate, 34.07% inappropriate, 14.37% likely inappropriate, and 17.24% could not be mapped to guidelines. Conclusions: The proposed pipeline effectively assessed prescription appropriateness across a large dataset, serving as a valuable tool for health authorities. Findings have informed the Lombardy Region's efforts to strengthen recommendations and reduce the burden of inappropriate referrals.