Jejo D Koola1,2,3, Sam B Ho4,5,6, Aize Cao7,8, Guanhua Chen9, Amy M Perkins10, Sharon E Davis8, Michael E Matheny7,8,10,11. 1. Tennessee Valley Healthcare System (TVHS) VA Medical Center, Veterans Health Administration, Nashville, TN, USA. jkoola@ucsd.edu. 2. Division of Hospital Medicine, Department of Medicine, University of California, San Diego, CA, USA. jkoola@ucsd.edu. 3. Health System Department of Biomedical Informatics, University of California, San Diego, CA, USA. jkoola@ucsd.edu. 4. VA San Diego Healthcare System, San Diego, CA, USA. 5. Division of Gastroenterology, Department of Medicine, University of California, San Diego, CA, USA. 6. Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai, UAE. 7. Tennessee Valley Healthcare System (TVHS) VA Medical Center, Veterans Health Administration, Nashville, TN, USA. 8. Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA. 9. Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI, USA. 10. Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA. 11. Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
Abstract
BACKGROUND: Early hospital readmission for patients with cirrhosis continues to challenge the healthcare system. Risk stratification may help tailor resources, but existing models were designed using small, single-institution cohorts or had modest performance. AIMS: We leveraged a large clinical database from the Department of Veterans Affairs (VA) to design a readmission risk model for patients hospitalized with cirrhosis. Additionally, we analyzed potentially modifiable or unexplored readmission risk factors. METHODS: A national VA retrospective cohort of patients with a history of cirrhosis hospitalized for any reason from January 1, 2006, to November 30, 2013, was developed from 123 centers. Using 174 candidate variables within demographics, laboratory results, vital signs, medications, diagnoses and procedures, and healthcare utilization, we built a 47-variable penalized logistic regression model with the outcome of all-cause 30-day readmission. We excluded patients who left against medical advice, transferred to a non-VA facility, or if the hospital length of stay was greater than 30 days. We evaluated calibration and discrimination across variable volume and compared the performance to recalibrated preexisting risk models for readmission. RESULTS: We analyzed 67,749 patients and 179,298 index hospitalizations. The 30-day readmission rate was 23%. Ascites was the most common cirrhosis-related cause of index hospitalization and readmission. The AUC of the model was 0.670 compared to existing models (0.649, 0.566, 0.577). The Brier score of 0.165 showed good calibration. CONCLUSION: Our model achieved better discrimination and calibration compared to existing models, even after local recalibration. Assessment of calibration by variable parsimony revealed performance improvements for increasing variable inclusion well beyond those detectable for discrimination.
BACKGROUND: Early hospital readmission for patients with cirrhosis continues to challenge the healthcare system. Risk stratification may help tailor resources, but existing models were designed using small, single-institution cohorts or had modest performance. AIMS: We leveraged a large clinical database from the Department of Veterans Affairs (VA) to design a readmission risk model for patients hospitalized with cirrhosis. Additionally, we analyzed potentially modifiable or unexplored readmission risk factors. METHODS: A national VA retrospective cohort of patients with a history of cirrhosis hospitalized for any reason from January 1, 2006, to November 30, 2013, was developed from 123 centers. Using 174 candidate variables within demographics, laboratory results, vital signs, medications, diagnoses and procedures, and healthcare utilization, we built a 47-variable penalized logistic regression model with the outcome of all-cause 30-day readmission. We excluded patients who left against medical advice, transferred to a non-VA facility, or if the hospital length of stay was greater than 30 days. We evaluated calibration and discrimination across variable volume and compared the performance to recalibrated preexisting risk models for readmission. RESULTS: We analyzed 67,749 patients and 179,298 index hospitalizations. The 30-day readmission rate was 23%. Ascites was the most common cirrhosis-related cause of index hospitalization and readmission. The AUC of the model was 0.670 compared to existing models (0.649, 0.566, 0.577). The Brier score of 0.165 showed good calibration. CONCLUSION: Our model achieved better discrimination and calibration compared to existing models, even after local recalibration. Assessment of calibration by variable parsimony revealed performance improvements for increasing variable inclusion well beyond those detectable for discrimination.
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Authors: Jejo David Koola; Samuel Ho; Guanhua Chen; Amy M Perkins; Aize Cao; Sharon E Davis; Michael E Matheny Journal: BMJ Open Gastroenterol Date: 2019-11-26