Ank E Nijhawan1, Lisa R Metsch2, Song Zhang3, Daniel J Feaster4, Lauren Gooden2, Mamta K Jain1, Robrina Walker5, Shannon Huffaker6, Michael J Mugavero7, Petra Jacobs8, Wendy S Armstrong9, Eric S Daar10, Meg Sullivan11, Carlos Del Rio9,12, Ethan A Halm13. 1. Division of Infectious Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX. 2. Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY. 3. Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX. 4. Division of Biostatistics, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL. 5. Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX. 6. Kaiser Permanente, Oakland, CA. 7. Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL. 8. National Institute of Health, National Institute on Drug Abuse, North Bethesda, MD. 9. Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA. 10. Division of HIV Medicine, Department of Medicine, Los Angeles Biomedical Research Institute, Harbor-University of California Los Angeles Medical Center, Torrance, CA. 11. Division of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA. 12. Department of Global Health, Rollins School of Public Health, Atlanta, GA. 13. Division of General Internal Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX.
Abstract
BACKGROUND: Under the Affordable Care Act, hospitals receive reduced reimbursements for excessive 30-day readmissions. However, the Centers for Medicare and Medicaid Services does not consider social and behavioral variables in expected readmission rate calculations, which may unfairly penalize systems caring for socially disadvantaged patients, including patients with HIV. SETTING: Randomized controlled trial of patient navigation with or without financial incentives inHIV-positive substance users recruited from the inpatient setting at 11 US hospitals. METHODS: External validation of an existing 30-day readmission prediction model, using variables available in the electronic health record (EHR-only model), in a new multicenter cohort of HIV-positive substance users was assessed by C-statistic and Hosmer-Lemeshow testing. A second model evaluated sociobehavioral factors in improving the prediction model (EHR-plus model) using multivariable regression and C-statistic with cross-validation. RESULTS: The mean age of the cohort was 44.1 years, and participants were predominantly males (67.4%), non-white (88.0%), and poor (62.8%, <$20,000/year). Overall, 17.5% individuals had a hospital readmission within 30 days of initial hospital discharge. The EHR-only model resulted in a C-statistic of 0.65 (95% confidence interval: 0.60 to 0.70). Inclusion of additional sociobehavioral variables, food insecurity and readiness for substance use treatment, in the EHR-plus model resulted in a C-statistic of 0.74 (0.71 after cross-validation, 95% confidence interval: 0.64 to 0.77). CONCLUSIONS: Incorporation of detailed social and behavioral variables substantially improved the performance of a 30-day readmission prediction model for hospitalized HIV-positive substance users. Our findings highlight the importance of social determinants in readmission risk and the need to ask about, adjust for, and address them.
RCT Entities:
BACKGROUND: Under the Affordable Care Act, hospitals receive reduced reimbursements for excessive 30-day readmissions. However, the Centers for Medicare and Medicaid Services does not consider social and behavioral variables in expected readmission rate calculations, which may unfairly penalize systems caring for socially disadvantaged patients, including patients with HIV. SETTING: Randomized controlled trial of patient navigation with or without financial incentives in HIV-positive substance users recruited from the inpatient setting at 11 US hospitals. METHODS: External validation of an existing 30-day readmission prediction model, using variables available in the electronic health record (EHR-only model), in a new multicenter cohort of HIV-positive substance users was assessed by C-statistic and Hosmer-Lemeshow testing. A second model evaluated sociobehavioral factors in improving the prediction model (EHR-plus model) using multivariable regression and C-statistic with cross-validation. RESULTS: The mean age of the cohort was 44.1 years, and participants were predominantly males (67.4%), non-white (88.0%), and poor (62.8%, <$20,000/year). Overall, 17.5% individuals had a hospital readmission within 30 days of initial hospital discharge. The EHR-only model resulted in a C-statistic of 0.65 (95% confidence interval: 0.60 to 0.70). Inclusion of additional sociobehavioral variables, food insecurity and readiness for substance use treatment, in the EHR-plus model resulted in a C-statistic of 0.74 (0.71 after cross-validation, 95% confidence interval: 0.64 to 0.77). CONCLUSIONS: Incorporation of detailed social and behavioral variables substantially improved the performance of a 30-day readmission prediction model for hospitalized HIV-positive substance users. Our findings highlight the importance of social determinants in readmission risk and the need to ask about, adjust for, and address them.
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