An Update to the Kaiser Permanente Inpatient Risk Adjustment Methodology Accurately Predicts In-Hospital Mortality: a Retrospective Cohort Study

BACKGROUND

Methods to accurately predict the risk of in-hospital mortality are important for applications including quality assessment of healthcare institutions and research.

OBJECTIVE

To update and validate the Kaiser Permanente inpatient risk adjustment methodology (KP method) to predict in-hospital mortality, using open-source tools to measure comorbidity and diagnosis groups, and removing troponin which is difficult to standardize across modern clinical assays.

DESIGN

Retrospective cohort study using electronic health record data from GEMINI. GEMINI is a research collaborative that collects administrative and clinical data from hospital information systems.

PARTICIPANTS

Adult general medicine inpatients at 28 hospitals in Ontario, Canada, between April 2010 and December 2022.

MAIN MEASURES

The outcome was in-hospital mortality, modeled by diagnosis group using 56 logistic regressions. We compared models with and without troponin as an input to the laboratory-based acute physiology score. We fit and validated the updated method using internal-external cross-validation at 28 hospitals from April 2015 to December 2022.

KEY RESULTS

In 938,103 hospitalizations with 7.2% in-hospital mortality, the updated KP method accurately predicted the risk of mortality. The c-statistic at the median hospital was 0.866 (see Fig. 3) (25th-75th 0.848-0.876, range 0.816-0.927) and calibration was strong for nearly all patients at all hospitals. The 95th percentile absolute difference between predicted and observed probabilities was 0.038 at the median hospital (25th-75th 0.024-0.057, range 0.006-0.118). Model performance was very similar with and without troponin in a subset of 7 hospitals, and performance was similar with and without troponin for patients hospitalized for heart failure and acute myocardial infarction.

CONCLUSIONS

An update to the KP method accurately predicted in-hospital mortality for general medicine inpatients in 28 hospitals in Ontario, Canada. This updated method can be implemented in a wider range of settings using common open-source tools.

Diagnostic consistency between admission and discharge of pediatric cases in a tertiary teaching hospital in China

BACKGROUND

Patient-centered, high-quality health care relies on accurate and timely diagnosis. Diagnosis is a complex, error-prone process. Prevention of errors involves understanding the cause of errors. This study investigated diagnostic discordance between admission and discharge in pediatric cases.

METHODS

We retrospectively reviewed the electronic medical records of 5381 pediatric inpatients during 2017-2018 in a tertiary teaching hospital. We analyzed diagnostic consistency by comparing the first 4 digits of admission and discharge ICD-10 codes of the cases and classified them as concordant for "complete and partial match" or discordant for "no match".

RESULTS

Diagnostic discordance was observed in 49.2% with the highest prevalence in infections of the nervous and respiratory systems (Ps < 0.001). Multiple (multivariable) logistic regression analysis predicted a lower risk of diagnostic discordance with older children (aOR, 95%CI: 0.94, 0.93-0.96) and a higher risk with infectious diseases (aOR, 95%CI: 1.49, 1.33-1.66) and admission by resident and attending pediatricians (aOR, 95%CI: 1.41, 1.30-1.54). Discordant cases had a higher rate of antibiotic prescription (OR, 95%CI: 2.09, 1.87-2.33), a longer duration of antibiotic use (P = 0.02), a longer length of hospital stay (P < 0.001), and higher medical expenses (P < 0.001).

CONCLUSIONS

This study denotes a considerably high rate of discordance between admission and discharge diagnoses with an associated higher and longer prescription of antibiotics, a longer length of stay, and higher medical expenses among Chinese pediatric inpatient cases. Infectious diseases were identified as high-risk clinical conditions for discordance. Considering potential diagnostic and coding errors, departmental investigation of preventable diagnostic discordance is suggested for quality health care and preventing potential medicolegal consequences.

MONitoring Knockbacks in EmergencY (MONKEY) – An Audit of Disposition Outcomes in Emergency Patients with Rejected Admission Requests

Background

Emergency Department (ED) clinicians commonly experience difficulties in referring patients to inpatient teams for hospital admission. There is limited literature reporting on patient outcomes following these complicated referrals, where ED requests for inpatient admission are rejected – which study investigators termed a “knockback”.

Purpose

To identify disposition outcomes and referral accuracy in ED patients whose admission referral was initially rejected. Secondary objectives were to identify additional patient, clinician and systemic factors associated with knockbacks.

Selection and Methodology

Emergency clinicians prospectively nominated a convenience sample of patients identified as having knockbacks over two time periods (Jan–Feb 2020 and Aug 2020 to Jan 2021) at a tertiary Australian ED. Data were analyzed with a mixed-methods approach and subsequent descriptive and thematic analyses were performed.

Results

A total of 109 patients were identified as knockbacks. The referrals were warranted, with 89.0% of cases (n = 97) ultimately requiring a hospital admission. In 60.6% (n = 66) of the admissions, patients were admitted under the inpatient team initially referred to by the ED, suggesting referrals were generally accurate. The number of in-hospital units involved in the admission process and ED length of stay were positively correlated (0.409, p < 0.001). Patient factors associated with knockbacks include pre-existing chronic medical conditions and presenting acutely unwell. Analysis of clinicians’ perspectives yielded recurring themes of disagreements over admission destination and diagnostic uncertainty.

Conclusion

In this patient sample, emergency referrals for admission were mostly warranted and accurate. Knockbacks increase ED length of stay and may adversely affect patient care. Further focused discussion and clearer referral guidelines between ED clinicians and their inpatient colleagues are required.

The discrepancy between admission and discharge diagnoses: Underlying factors and potential clinical outcomes in a low socioeconomic country

Objective

The discrepancy between admission and discharge diagnosis can lead to possible adverse patient outcomes. There are gaps in integrated studies, and less is understood about its characteristics and effects. Therefore, this study was conducted to determine the frequency, characteristics, and outcomes of diagnostic discrepancies at admission and discharge.

Design and data sources

This retrospective study reviewed the admitting and discharge diagnoses of adult patients admitted at Aga Khan University Hospital (AKUH), Internal Medicine Department between October 2018 and February 2019. The frequency and outcomes of discrepancies in patient diagnoses were noted among Emergency Department (ED) physician versus admitting physician, admitting physician versus discharge physician, and ED physician versus discharge physician for the full match, partial match, and mismatch diagnoses. The studied outcomes included interdepartmental transfer, Intensive Care Unit (ICU) transfer, in-hospital mortality, readmission within 30 days, and the length of stay. For simplicity, we only analyzed the factors for the discrepancy among ED physicians and discharge physicians.

Results

Out of 537 admissions, there were 25.3–27.2% admissions with full match diagnoses while 18.6–19.4% and 45.3–47.9% had mismatch and partial match diagnoses respectively. The discrepancy resulted in an increased number of interdepartmental transfers (5–5.8%), ICU transfers (5.6–8.7%), in-hospital mortality (8–11%), and readmissions within 30 days in ED (14.4%-16.7%). A statistically significant difference was observed for the ward’s length of stay with the most prolonged stay in partially matched diagnoses (6.3 ± 5.4 days). Among all the factors that were evaluated for the diagnostic discrepancy, older age, multi-morbidities, level of trainee clerking the patient, review by ED faculty, incomplete history, and delay in investigations at ED were associated with significant discrepant diagnoses.

Conclusions

Diagnostic discrepancies are a relevant and significant healthcare problem. Fixed patient or physician characteristics do not readily predict diagnostic discrepancies. To reduce the diagnostic discrepancy, emphasis should be given to good history taking and thorough physical examination. Patients with older age and multi-morbidity should receive significant consideration.

Study protocol for a prospective, double-blinded, observational study investigating the diagnostic accuracy of an app-based diagnostic health care application in an emergency room setting: the eRadaR trial

INTRODUCTION

Occurrence of inaccurate or delayed diagnoses is a significant concern in patient care, particularly in emergency medicine, where decision making is often constrained by high throughput and inaccurate admission diagnoses. Artificial intelligence-based diagnostic decision support system have been developed to enhance clinical performance by suggesting differential diagnoses to a given case, based on an integrated medical knowledge base and machine learning techniques. The purpose of the study is to evaluate the diagnostic accuracy of Ada, an app-based diagnostic tool and the impact on patient outcome.

METHODS AND ANALYSIS

The eRadaR trial is a prospective, double-blinded study with patients presenting to the emergency room (ER) with abdominal pain. At initial contact in the ER, a structured interview will be performed using the Ada-App and both, patients and attending physicians, will be blinded to the proposed diagnosis lists until trial completion. Throughout the study, clinical data relating to diagnostic findings and types of therapy will be obtained and the follow-up until day 90 will comprise occurrence of complications and overall survival of patients. The primary efficacy of the trial is defined by the percentage of correct diagnoses suggested by Ada compared with the final discharge diagnosis. Further, accuracy and timing of diagnosis will be compared with decision making of classical doctor-patient interaction. Secondary objectives are complications, length of hospital stay and overall survival.

ETHICS AND DISSEMINATION

Ethical approval was received by the independent ethics committee (IEC) of the Goethe-University Frankfurt on 9 April 2020 including the patient information material and informed consent form. All protocol amendments must be reported to and adapted by the IEC. The results from this study will be submitted to peer-reviewed journals and reported at suitable national and international meetings.

TRIAL REGISTRATION NUMBER

DRKS00019098.

Factors Affecting Mortality in Patients Admitted to the Hospital by Emergency Physicians despite Disagreement with Other Specialties

Background

Emergency physicians (EPs) face critical admission decisions, and their judgments are questioned in some developing systems. This study aims to define the factors affecting mortality in patients admitted to the hospital by EPs against in-service departments' decision and evaluate EPs' admission diagnosis with final discharge diagnosis.

Methods

This is a retrospective analysis of prospectively collected data of ten consecutive years (2008–2017) of an emergency department of a university medical center. Adult patients (≥18 years-old) who were admitted to the hospital by EPs against in-service departments' decision were enrolled in the study. Significant factors affecting mortality were defined by the backward logistic regression model.

Results

369 consecutive patients were studied, and 195 (52.8%) were males. The mean (SD) age was 65.5 (17.3) years. The logistic regression model showed that significant factors affecting mortality were intubation (p < 0.0001), low systolic blood pressure (p = 0.006), increased age (p = 0.013), and having a comorbidity (p = 0.024). There was no significant difference between EPs' primary admission diagnosis and patient's final primary diagnosis at the time of disposition from the admitted departments (McNemar–Bowker test, p = 0.45). 96% of the primary admission diagnoses of EPs were correct.

Conclusions

Intubation, low systolic blood pressure on presentation, increased age, and having a comorbidity increased the mortality. EPs admission diagnoses were highly correlated with the final diagnosis. EPs make difficult admission decisions with high accuracy, if needed.

The accuracy of a diagnosis of pneumonia in the emergency department

BACKGROUND

Achieving a high degree of diagnostic accuracy of infections in the emergency department (ED) is crucial since a delay in diagnosis can lead to increased mortality, whereas overdiagnosis can lead to antibiotic overprescription. Limited data are available as to ED diagnostic accuracy of infections. The aim of this study was to demonstrate the degree of discordance of an ED diagnosis of pneumonia in relation to an internal medicine ward's discharge diagnosis of hospitalized adults.

METHODS

We reviewed the records of all adults hospitalized in internal wards from November 2017-January 2018 diagnosed with an acute infection by an ED physician. The primary outcome was the discordance degree of an ED pneumonia diagnosis compared to the internal ward discharge diagnosis. The influence comorbidities and clinical characteristics on the diagnostic discordance were also evaluated.

RESULTS

The study included 875 adults; 434 were admitted with an ED diagnosis of a specific infection. Pneumonia was the most frequent ED diagnosis (n = 195, 45%), of them, 56 (29%) were discordant diagnosis in the internal ward.

CONCLUSION

Interpretation of chest X-rays with the assistance of a radiologist might help in reducing overdiagnosis and minimize antibiotic overprescription, thus improving the ED diagnostic accuracy of pneumonia.

Disagreement between emergency department admission diagnosis and hospital discharge diagnosis: mortality and morbidity

Previous studies have shown that changes in diagnoses from admission to discharge are associated with poorer outcomes. The aim of this study was to investigate how diagnostic discordance affects patient outcomes.

: The first three digits of ICD-9-CM codes at admission and discharge were compared for concordance. The study involved 6281 patients admitted to the Western Galilee Medical Center, Naharyia, Israel from the emergency department (ED) between 01 November 2012 and 21 January 2013. Concordant and discordant diagnoses were compared in terms of, length of stay, number of transfers, intensive care unit (ICU) admission, readmission, and mortality.

: Discordant diagnoses was associated with increases in patient mortality rate (5.1% vs. 1.5%; RR 3.35, 95% CI 2.43, 4.62; p<0.001), the number of ICU admissions (6.7% vs. 2.7%; RR 2.58, 95% CI 2.07, 3.32; p<0.001), hospital length of stay (3.8 vs. 2.5 days; difference 1.3 days, 95% CI 1.2, 1.4; p<0.001), ICU length of stay (5.2 vs. 3.8 days; difference 1.4 days, 95% CI 1.0, 1.9; p<0.001), and 30 days readmission (14.11% vs. 12.38%; RR 1.14, 95% CI 1.00, 1.30; p=0.0418). ED length of stay was also greater for the discordant group (3.0 vs. 2.9 h; difference 8.8 min; 95% CI 0.1, 0.2; p<0.001)

: These findings indicate discordant admission and discharge diagnoses are associated with increases in morbidity and mortality. Further research should identify modifiable causes of discordance.

Improving interunit transitions of care between emergency physicians and hospital medicine physicians: a conceptual approach

Patient care transitions across specialties involve more complexity than those within the same specialty, yet the unique social and technical features remain underexplored. Further, little consensus exists among researchers and practitioners about strategies to improve interspecialty communication. This concept article addresses these gaps by focusing on the hand-off process between emergency and hospital medicine physicians. Sensitivity to cultural and operational differences and a common set of expectations pertaining to hand-off content will more effectively prepare the next provider to act safely and efficiently when caring for the patient. Through a consensus decision-making process of experienced and published authorities in health care transitions, including physicians in both specialties as well as in communication studies, the authors propose content and style principles clinicians may use to improve transition communication. With representation from both community and academic settings, similarities and differences between emergency medicine and internal medicine are highlighted to heighten appreciation of the values, attitudes, and goals of each specialty, particularly pertaining to communication. The authors also examine different communication media, social and cultural behaviors, and tools that practitioners use to share patient care information. Quality measures are proposed within the structure, process, and outcome framework for institutions seeking to evaluate and monitor improvement strategies in hand-off performance. Validation studies to determine if these suggested improvements in transition communication will result in improved patient outcomes will be necessary. By exploring the dynamics of transition communication between specialties and suggesting best practices, the authors hope to strengthen hand-off skills and contribute to improved continuity of care.