Trajectory-guided discharge stratification for heart failure using short-context electronic health record sequence modeling

Purpose: Heart failure (HF) discharge planning depends on identifying patients at risk of deterioration or death, yet accurate prediction from routinely collected electronic health records (EHRs) remains challenging. Methods: We develop trajectory-guided discharge stratification for heart failure (TGDS-HF), a methodology that reads the patient in-hospital trajectory of diagnoses, vital signs, laboratories, medications, and procedures end-to-end with a compact short-context autoregressive Transformer, and uses it to stratify one-year risks of clinical instability (a rehospitalization phenotype) or mortality for discharge care. We instantiate TGDS-HF on a Swedish HF cohort (N = 42,820) to predict one-year clinical instability or mortality at the initial HF diagnosis in-hospital. TGDS-HF has three components: category-level tokenization, recency-weighted temporal representation, and sequence model configuration. We run ablations on these components to show the effectiveness of TGDS-HF. Results: Against traditional eXtreme gradient boosting machine (XGBoost) and bidirectional encoder representations from Transformers (BERT)-based EHR sequence-modeling baselines, TGDS-HF (Llama backbone) achieved area under the precision-recall curves (AUPRCs) with 95% confidence intervals of 0.555 (0.535-0.575) and 0.574 (0.550-0.599) across the two tasks at the method default, with robust calibration. A task-specific refinement using daily aggregation of repeated continuous events improves the mortality task to 0.582 (0.558-0.608). Further, TGDS-HF maintains strong performance under reduced clinical concept availability and limited training data. Conclusion: Combined predictions of instability and mortality from TGDS-HF may support personalized discharge planning, ranging from follow-up in primary care to specialist-led management and, when appropriate, palliative care.