Maanasi Samant, MD

Rapid response systems (RRSs) have been developed to identify and treat deteriorating patients on general hospital units.[1] The most commonly proposed approach to the problem of identifying and stabilizing deteriorating hospitalized patients includes some combination of an early warning system to detect the deterioration and an RRS to deal with it. We previously demonstrated that a relatively simple hospital‐specific prediction model employing routine laboratory values and vital sign data is capable of predicting clinical deterioration, the need for intensive care unit (ICU) transfer, and hospital mortality in patients admitted to general medicine units.[2, 3, 4, 5, 6]

Hospital readmissions within 30 days of hospital discharge occur often and are difficult to predict. Starting in 2013, readmission penalties have been applied to specific conditions in the United States (acute myocardial infarction, heart failure, and pneumonia), with the expectation that additional conditions will be added to this group in years to come.[7, 8] Unfortunately, interventions developed to date have not been universally successful in preventing hospital readmissions for various medical conditions and patient types.[9] One potential explanation for this is the inability to reliably predict which patients are at risk for readmission to better target preventative interventions. Predictors of hospital readmission can be disease specific, such as the presence of multivessel disease in patients hospitalized with myocardial infarction,[10] or more general, such as lack of available medical follow‐up postdischarge.[11] Therefore, we performed a study to determine whether the occurrence of automated clinical deterioration alerts (CDAs) predicted 30‐day hospital readmission.

METHODS

RESULTS

The final cohort had 3015 patients with a mean age of 57.5 17.5 years and 47.8% males. The most common reasons for hospital admission were infection or sepsis syndrome including pneumonia and urinary tract infections (23.6%), congestive heart failure or other cardiac conditions (18.4%), respiratory distress including chronic obstructive pulmonary disease (16.2%), acute or chronic renal failure (9.7%), gastrointestinal disorders (8.4%), and diabetes mellitus management (7.4%). Overall, there were 567 (18.8%) patients who were readmitted within 30 days of their hospital discharge date.

Table 2 shows the characteristics of patients readmitted within 30 days and of patients not requiring hospital readmission within 30 days. Patients requiring hospital readmission within 30 days were younger and had significantly more comorbidities as manifested by significantly greater Charlson scores and individual comorbidities including coronary artery disease, congestive heart disease, peripheral vascular disease, connective tissue disease, cirrhosis, diabetes mellitus with end‐organ complications, renal failure, and metastatic cancer. Patients with a 30‐day readmission had significantly longer duration of hospitalization, more emergency department visits in the 6 months prior to the index hospitalization, lower minimum hemoglobin measurements, higher minimum serum creatinine values, and were more likely to have Medicare or Medicaid insurance compared to patients without a 30‐day readmission.

There were 1141 (34.4%) patients that triggered a CDA. Patients triggering a CDA were significantly more likely to have a 30‐day readmission compared to those who did not trigger a CDA (23.6% vs 15.9%; P < 0.001). Patients triggering a CDA were also significantly more likely to be readmitted within 60 days (31.7% vs 22.1%; P < 0.001) and 90 days (35.8% vs 26.2%; P < 0.001) compared to patients who did not trigger a CDA. Multiple logistic regression identified the triggering of a CDA to be independently associated with 30‐day readmission (OR: 1.40; 95% CI: 1.26‐1.55; P = 0.001) (Table 3). Other independent predictors of 30‐day readmission were: an emergency department visit in the previous 6 months, increasing age in 1‐year increments, presence of connective tissue disease, diabetes mellitus with end‐organ complications, chronic renal disease, cirrhosis, and metastatic cancer (Hosmer‐Lemeshow goodness of fit test, 0.363). Figure 1 reveals the ROC curves for the logistic regression model (Table 3) with and without the CDA variable. As the ROC curves document, the 2 models had similar sensitivity for the entire range of specificities. Reflecting this, the area under the ROC curve for the model inclusive of the CDA variable equaled 0.675 (95% CI: 0.649‐0.700), whereas the area under the ROC curve for the model excluding the CDA variable equaled 0.658 (95% CI: 0.632‐0.684).

Figure 1

DISCUSSION

We demonstrated that the occurrence of an automated CDA is associated with increased risk for 30‐day hospital readmission. However, the addition of the CDA variable to the other variables identified to be independently associated with 30‐day readmission (Table 3) did not significantly add to the overall predictive accuracy of the derived logistic regression model. Other investigators have previously attempted to develop automated predictors of hospital readmission. Amarasingham et al. developed a real‐time electronic predictive model that identifies hospitalized heart failure patients at high risk for readmission or death from clinical and nonclinical risk factors present on admission.[13] Their electronic model demonstrated good discrimination for 30‐day mortality and readmission and performed as well, or better than, models developed by the Center for Medicaid and Medicare Services and the Acute Decompensated Heart Failure Registry. Similarly, Baillie et al. developed an automated prediction model that was effectively integrated into an existing EMR and identified patients on admission who were at risk for readmission within 30 days of discharge.[14] Our automated CDA differs from these previous risk predictors by surveying patients throughout their hospital stay as opposed to identifying risk for readmission at a single time point.

Several limitations of our study should be recognized. First, this was a noninterventional study aimed at examining the ability of CDAs to predict hospital readmission. Future studies are needed to assess whether the use of enhanced readmission prediction algorithms can be utilized to avert hospital readmissions. Second, the data derive from a single center, and this necessarily limits the generalizability of our findings. As such, our results may not reflect what one might see at other institutions. For example, Barnes‐Jewish Hospital has a regional referral pattern that includes community hospitals, regional long‐term acute care hospitals, nursing homes, and chronic wound, dialysis, and infusion clinics. This may explain, in part, the relatively high rate of hospital readmission observed in our cohort. Third, there is the possibility that CDAs were associated with readmission by chance given the number of potential predictor variables examined. The importance of CDAs as a determinant of rehospitalization requires confirmation in other independent populations. Fourth, it is likely that we did not capture all hospital readmissions, primarily those occurring outside of our hospital system. Therefore, we may have underestimated the actual rates of readmission for this cohort. Finally, we cannot be certain that all important predictors of hospital readmission were captured in this study.

The development of an accurate real‐time early warning system has the potential to identify patients at risk for various adverse outcomes including clinical deterioration, hospital death, and postdischarge readmission. By identifying patients at greatest risk for readmission, valuable healthcare resources can be better targeted to such populations. Our findings suggest that existing readmission predictors may suboptimally risk‐stratify patients, and it may be important to include additional clinical variables if pay for performance and other across‐institution comparisons are to be fair to institutions that care for more seriously ill patients. The variables identified as predictors of 30‐day hospital readmission in our study, with the exception of a CDA, are all readily identifiable clinical characteristics. The modest incremental value of a CDA to these clinical characteristics suggests that they would suffice for the identification of patients at high risk for hospital readmission. This is especially important for safety‐net institutions not routinely employing automated CDAs. These safety‐net hospitals provide a disproportionate level of care for patients who otherwise would have difficulty obtaining inpatient medical care and disproportionately carry the greatest burden of hospital readmissions.[15]

Rapid response systems (RRSs) have been developed to identify and treat deteriorating patients on general hospital units.[1] The most commonly proposed approach to the problem of identifying and stabilizing deteriorating hospitalized patients includes some combination of an early warning system to detect the deterioration and an RRS to deal with it. We previously demonstrated that a relatively simple hospital‐specific prediction model employing routine laboratory values and vital sign data is capable of predicting clinical deterioration, the need for intensive care unit (ICU) transfer, and hospital mortality in patients admitted to general medicine units.[2, 3, 4, 5, 6]

Hospital readmissions within 30 days of hospital discharge occur often and are difficult to predict. Starting in 2013, readmission penalties have been applied to specific conditions in the United States (acute myocardial infarction, heart failure, and pneumonia), with the expectation that additional conditions will be added to this group in years to come.[7, 8] Unfortunately, interventions developed to date have not been universally successful in preventing hospital readmissions for various medical conditions and patient types.[9] One potential explanation for this is the inability to reliably predict which patients are at risk for readmission to better target preventative interventions. Predictors of hospital readmission can be disease specific, such as the presence of multivessel disease in patients hospitalized with myocardial infarction,[10] or more general, such as lack of available medical follow‐up postdischarge.[11] Therefore, we performed a study to determine whether the occurrence of automated clinical deterioration alerts (CDAs) predicted 30‐day hospital readmission.

METHODS

RESULTS

The final cohort had 3015 patients with a mean age of 57.5 17.5 years and 47.8% males. The most common reasons for hospital admission were infection or sepsis syndrome including pneumonia and urinary tract infections (23.6%), congestive heart failure or other cardiac conditions (18.4%), respiratory distress including chronic obstructive pulmonary disease (16.2%), acute or chronic renal failure (9.7%), gastrointestinal disorders (8.4%), and diabetes mellitus management (7.4%). Overall, there were 567 (18.8%) patients who were readmitted within 30 days of their hospital discharge date.

Table 2 shows the characteristics of patients readmitted within 30 days and of patients not requiring hospital readmission within 30 days. Patients requiring hospital readmission within 30 days were younger and had significantly more comorbidities as manifested by significantly greater Charlson scores and individual comorbidities including coronary artery disease, congestive heart disease, peripheral vascular disease, connective tissue disease, cirrhosis, diabetes mellitus with end‐organ complications, renal failure, and metastatic cancer. Patients with a 30‐day readmission had significantly longer duration of hospitalization, more emergency department visits in the 6 months prior to the index hospitalization, lower minimum hemoglobin measurements, higher minimum serum creatinine values, and were more likely to have Medicare or Medicaid insurance compared to patients without a 30‐day readmission.

There were 1141 (34.4%) patients that triggered a CDA. Patients triggering a CDA were significantly more likely to have a 30‐day readmission compared to those who did not trigger a CDA (23.6% vs 15.9%; P < 0.001). Patients triggering a CDA were also significantly more likely to be readmitted within 60 days (31.7% vs 22.1%; P < 0.001) and 90 days (35.8% vs 26.2%; P < 0.001) compared to patients who did not trigger a CDA. Multiple logistic regression identified the triggering of a CDA to be independently associated with 30‐day readmission (OR: 1.40; 95% CI: 1.26‐1.55; P = 0.001) (Table 3). Other independent predictors of 30‐day readmission were: an emergency department visit in the previous 6 months, increasing age in 1‐year increments, presence of connective tissue disease, diabetes mellitus with end‐organ complications, chronic renal disease, cirrhosis, and metastatic cancer (Hosmer‐Lemeshow goodness of fit test, 0.363). Figure 1 reveals the ROC curves for the logistic regression model (Table 3) with and without the CDA variable. As the ROC curves document, the 2 models had similar sensitivity for the entire range of specificities. Reflecting this, the area under the ROC curve for the model inclusive of the CDA variable equaled 0.675 (95% CI: 0.649‐0.700), whereas the area under the ROC curve for the model excluding the CDA variable equaled 0.658 (95% CI: 0.632‐0.684).

Figure 1

DISCUSSION

We demonstrated that the occurrence of an automated CDA is associated with increased risk for 30‐day hospital readmission. However, the addition of the CDA variable to the other variables identified to be independently associated with 30‐day readmission (Table 3) did not significantly add to the overall predictive accuracy of the derived logistic regression model. Other investigators have previously attempted to develop automated predictors of hospital readmission. Amarasingham et al. developed a real‐time electronic predictive model that identifies hospitalized heart failure patients at high risk for readmission or death from clinical and nonclinical risk factors present on admission.[13] Their electronic model demonstrated good discrimination for 30‐day mortality and readmission and performed as well, or better than, models developed by the Center for Medicaid and Medicare Services and the Acute Decompensated Heart Failure Registry. Similarly, Baillie et al. developed an automated prediction model that was effectively integrated into an existing EMR and identified patients on admission who were at risk for readmission within 30 days of discharge.[14] Our automated CDA differs from these previous risk predictors by surveying patients throughout their hospital stay as opposed to identifying risk for readmission at a single time point.

Several limitations of our study should be recognized. First, this was a noninterventional study aimed at examining the ability of CDAs to predict hospital readmission. Future studies are needed to assess whether the use of enhanced readmission prediction algorithms can be utilized to avert hospital readmissions. Second, the data derive from a single center, and this necessarily limits the generalizability of our findings. As such, our results may not reflect what one might see at other institutions. For example, Barnes‐Jewish Hospital has a regional referral pattern that includes community hospitals, regional long‐term acute care hospitals, nursing homes, and chronic wound, dialysis, and infusion clinics. This may explain, in part, the relatively high rate of hospital readmission observed in our cohort. Third, there is the possibility that CDAs were associated with readmission by chance given the number of potential predictor variables examined. The importance of CDAs as a determinant of rehospitalization requires confirmation in other independent populations. Fourth, it is likely that we did not capture all hospital readmissions, primarily those occurring outside of our hospital system. Therefore, we may have underestimated the actual rates of readmission for this cohort. Finally, we cannot be certain that all important predictors of hospital readmission were captured in this study.

The development of an accurate real‐time early warning system has the potential to identify patients at risk for various adverse outcomes including clinical deterioration, hospital death, and postdischarge readmission. By identifying patients at greatest risk for readmission, valuable healthcare resources can be better targeted to such populations. Our findings suggest that existing readmission predictors may suboptimally risk‐stratify patients, and it may be important to include additional clinical variables if pay for performance and other across‐institution comparisons are to be fair to institutions that care for more seriously ill patients. The variables identified as predictors of 30‐day hospital readmission in our study, with the exception of a CDA, are all readily identifiable clinical characteristics. The modest incremental value of a CDA to these clinical characteristics suggests that they would suffice for the identification of patients at high risk for hospital readmission. This is especially important for safety‐net institutions not routinely employing automated CDAs. These safety‐net hospitals provide a disproportionate level of care for patients who otherwise would have difficulty obtaining inpatient medical care and disproportionately carry the greatest burden of hospital readmissions.[15]

Rapid response systems (RRSs) have been developed to identify and treat deteriorating patients on general hospital units.[1] The most commonly proposed approach to the problem of identifying and stabilizing deteriorating hospitalized patients includes some combination of an early warning system to detect the deterioration and an RRS to deal with it. We previously demonstrated that a relatively simple hospital‐specific prediction model employing routine laboratory values and vital sign data is capable of predicting clinical deterioration, the need for intensive care unit (ICU) transfer, and hospital mortality in patients admitted to general medicine units.[2, 3, 4, 5, 6]

Hospital readmissions within 30 days of hospital discharge occur often and are difficult to predict. Starting in 2013, readmission penalties have been applied to specific conditions in the United States (acute myocardial infarction, heart failure, and pneumonia), with the expectation that additional conditions will be added to this group in years to come.[7, 8] Unfortunately, interventions developed to date have not been universally successful in preventing hospital readmissions for various medical conditions and patient types.[9] One potential explanation for this is the inability to reliably predict which patients are at risk for readmission to better target preventative interventions. Predictors of hospital readmission can be disease specific, such as the presence of multivessel disease in patients hospitalized with myocardial infarction,[10] or more general, such as lack of available medical follow‐up postdischarge.[11] Therefore, we performed a study to determine whether the occurrence of automated clinical deterioration alerts (CDAs) predicted 30‐day hospital readmission.

METHODS

RESULTS

The final cohort had 3015 patients with a mean age of 57.5 17.5 years and 47.8% males. The most common reasons for hospital admission were infection or sepsis syndrome including pneumonia and urinary tract infections (23.6%), congestive heart failure or other cardiac conditions (18.4%), respiratory distress including chronic obstructive pulmonary disease (16.2%), acute or chronic renal failure (9.7%), gastrointestinal disorders (8.4%), and diabetes mellitus management (7.4%). Overall, there were 567 (18.8%) patients who were readmitted within 30 days of their hospital discharge date.

Table 2 shows the characteristics of patients readmitted within 30 days and of patients not requiring hospital readmission within 30 days. Patients requiring hospital readmission within 30 days were younger and had significantly more comorbidities as manifested by significantly greater Charlson scores and individual comorbidities including coronary artery disease, congestive heart disease, peripheral vascular disease, connective tissue disease, cirrhosis, diabetes mellitus with end‐organ complications, renal failure, and metastatic cancer. Patients with a 30‐day readmission had significantly longer duration of hospitalization, more emergency department visits in the 6 months prior to the index hospitalization, lower minimum hemoglobin measurements, higher minimum serum creatinine values, and were more likely to have Medicare or Medicaid insurance compared to patients without a 30‐day readmission.

There were 1141 (34.4%) patients that triggered a CDA. Patients triggering a CDA were significantly more likely to have a 30‐day readmission compared to those who did not trigger a CDA (23.6% vs 15.9%; P < 0.001). Patients triggering a CDA were also significantly more likely to be readmitted within 60 days (31.7% vs 22.1%; P < 0.001) and 90 days (35.8% vs 26.2%; P < 0.001) compared to patients who did not trigger a CDA. Multiple logistic regression identified the triggering of a CDA to be independently associated with 30‐day readmission (OR: 1.40; 95% CI: 1.26‐1.55; P = 0.001) (Table 3). Other independent predictors of 30‐day readmission were: an emergency department visit in the previous 6 months, increasing age in 1‐year increments, presence of connective tissue disease, diabetes mellitus with end‐organ complications, chronic renal disease, cirrhosis, and metastatic cancer (Hosmer‐Lemeshow goodness of fit test, 0.363). Figure 1 reveals the ROC curves for the logistic regression model (Table 3) with and without the CDA variable. As the ROC curves document, the 2 models had similar sensitivity for the entire range of specificities. Reflecting this, the area under the ROC curve for the model inclusive of the CDA variable equaled 0.675 (95% CI: 0.649‐0.700), whereas the area under the ROC curve for the model excluding the CDA variable equaled 0.658 (95% CI: 0.632‐0.684).

Figure 1

DISCUSSION

We demonstrated that the occurrence of an automated CDA is associated with increased risk for 30‐day hospital readmission. However, the addition of the CDA variable to the other variables identified to be independently associated with 30‐day readmission (Table 3) did not significantly add to the overall predictive accuracy of the derived logistic regression model. Other investigators have previously attempted to develop automated predictors of hospital readmission. Amarasingham et al. developed a real‐time electronic predictive model that identifies hospitalized heart failure patients at high risk for readmission or death from clinical and nonclinical risk factors present on admission.[13] Their electronic model demonstrated good discrimination for 30‐day mortality and readmission and performed as well, or better than, models developed by the Center for Medicaid and Medicare Services and the Acute Decompensated Heart Failure Registry. Similarly, Baillie et al. developed an automated prediction model that was effectively integrated into an existing EMR and identified patients on admission who were at risk for readmission within 30 days of discharge.[14] Our automated CDA differs from these previous risk predictors by surveying patients throughout their hospital stay as opposed to identifying risk for readmission at a single time point.

Several limitations of our study should be recognized. First, this was a noninterventional study aimed at examining the ability of CDAs to predict hospital readmission. Future studies are needed to assess whether the use of enhanced readmission prediction algorithms can be utilized to avert hospital readmissions. Second, the data derive from a single center, and this necessarily limits the generalizability of our findings. As such, our results may not reflect what one might see at other institutions. For example, Barnes‐Jewish Hospital has a regional referral pattern that includes community hospitals, regional long‐term acute care hospitals, nursing homes, and chronic wound, dialysis, and infusion clinics. This may explain, in part, the relatively high rate of hospital readmission observed in our cohort. Third, there is the possibility that CDAs were associated with readmission by chance given the number of potential predictor variables examined. The importance of CDAs as a determinant of rehospitalization requires confirmation in other independent populations. Fourth, it is likely that we did not capture all hospital readmissions, primarily those occurring outside of our hospital system. Therefore, we may have underestimated the actual rates of readmission for this cohort. Finally, we cannot be certain that all important predictors of hospital readmission were captured in this study.

The development of an accurate real‐time early warning system has the potential to identify patients at risk for various adverse outcomes including clinical deterioration, hospital death, and postdischarge readmission. By identifying patients at greatest risk for readmission, valuable healthcare resources can be better targeted to such populations. Our findings suggest that existing readmission predictors may suboptimally risk‐stratify patients, and it may be important to include additional clinical variables if pay for performance and other across‐institution comparisons are to be fair to institutions that care for more seriously ill patients. The variables identified as predictors of 30‐day hospital readmission in our study, with the exception of a CDA, are all readily identifiable clinical characteristics. The modest incremental value of a CDA to these clinical characteristics suggests that they would suffice for the identification of patients at high risk for hospital readmission. This is especially important for safety‐net institutions not routinely employing automated CDAs. These safety‐net hospitals provide a disproportionate level of care for patients who otherwise would have difficulty obtaining inpatient medical care and disproportionately carry the greatest burden of hospital readmissions.[15]