Mortality Predictions on Admission as a Context for Organizing Care Activities

Mark E. Cowen, MD, SM; Robert L. Strawderman, ScD; Jennifer L. Czerwinski, BA; , Mary Jo Smith, RN, MS; Lakshmi K. Halasyamani, MD

Disclosures

Journal of Hospital Medicine. 2013;8(5):229-235. 

In This Article

Abstract and Introduction

Abstract

Background Favorable health outcomes are more likely to occur when the clinical team recognizes patients at risk and intervenes in consort. Prediction rules can identify high-risk subsets, but the availability of multiple rules for various conditions present implementation and assimilation challenges.

Methods A prediction rule for 30-day mortality at the beginning of the hospitalization was derived in a retrospective cohort of adult inpatients from a community hospital in the Midwestern United States from 2008 to 2009, using clinical laboratory values, past medical history, and diagnoses present on admission. It was validated using 2010 data from the same and from a different hospital. The calculated mortality risk was then used to predict unplanned transfers to intensive care units, resuscitation attempts for cardiopulmonary arrests, a condition not present on admission (complications), intensive care unit utilization, palliative care status, in-hospital death, rehospitalizations within 30 days, and 180-day mortality.

Results The predictions of 30-day mortality for the derivation and validation datasets had areas under the receiver operating characteristic curve of 0.88. The 30-day mortality risk was in turn a strong predictor for in-hospital death, palliative care status, 180-day mortality; a modest predictor for unplanned transfers and cardiopulmonary arrests; and a weaker predictor for the other events of interest.

Conclusions The probability of 30-day mortality provides health systems with an array of prognostic information that may provide a common reference point for organizing the clinical activities of the many health professionals involved in the care of the patient.

Introduction

Favorable health outcomes are more likely to occur when the healthcare team quickly identifies and responds to patients at risk.[1–3] However, the treatment process can break down during handoffs if the clinical condition and active issues are not well communicated.[4] Patients whose decline cannot be reversed also challenge the health team. Many are referred to hospice late,[5] and some do not receive the type of end-of-life care matching their preferences.[6]

Progress toward the elusive goal of more effective and efficient care might be made via an industrial engineering approach, mass customization, in which "bundles" of services are delivered based on the anticipated needs of subsets of patients.[7,8] An underlying rationale is the frequent finding that a small proportion of individuals experiences the majority of the events of interest, commonly referenced as the Pareto principle.[7]Clinical prediction rules can help identify these high-risk subsets.[9] However, as more condition-specific rules become available, the clinical team faces logistical challenges when attempting to incorporate these into practice. For example, which team member will be responsible for generating the prediction and communicating the level of risk? What actions should follow for a given level of risk? What should be done for patients with conditions not addressed by an existing rule?

In this study, we present our rationale for health systems to implement a process for generating mortality predictions at the time of admission on most, if not all, adult patients as a context for the activities of the various clinical team members. Recent studies demonstrate that in-hospital or 30-day mortality can be predicted with substantial accuracy using information available at the time of admission.[10–19]Relationships are beginning to be explored among the risk factors for mortality and other outcomes such as length of stay, unplanned transfers to intensive care units, 30-day readmissions, and extended care facility placement.[10,20–22] We extend this work by examining how a number of adverse events can be understood through their relationship with the risk of dying. We begin by deriving and validating a new mortality prediction rule using information feasible for our institution to use in its implementation.

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