Background:
Readmissions after hospitalization for acute myocardial infarction (AMI) are common, but the few available risk prediction models have poor predictive ability. Including more data from hospitalization may improve risk prediction.
Objectives:
To assess if an AMI-specific electronic health record (EHR) readmission risk prediction model derived and validated from data through the entire hospital course (‘full stay’ model) outperforms a model using data available only from the first day of hospitalization (‘first day’ model).
Methods:
EHR data from AMI hospitalizations from 6 diverse hospitals in north Texas from 2009-2010 were used to derive a model predicting all-cause non-elective 30-day readmissions which was then validated using five-fold cross-validation.
Results:
Of 826 consecutive index AMI admissions, 13% were followed by a 30-day readmission. History of diabetes (AOR 2.41, 95% CI 1.37-4.24), SBP <100 mmHg on admission (AOR 2.18, 95% CI 1.68-2.82), elevated Cr (≥2 mg/dL) on admission (AOR 2.56, 95% CI 2.52-6.08), elevated BNP on admission (AOR 6.36, 95% CI 1.65-24.47) and lack of PCI within 24 hours of admission (AOR 1.31, 95% CI 1.02-1.69) were significant predictors of readmission. Our ‘first-day’ AMI readmissions model based on these predictors had good discrimination (
Table
). Adding three other variables from the hospital course - use of IV diuretics (AOR 1.58, 95% CI 1.07-2.31), anemia (hematocrit ≤ 33%) on discharge (AOR 2.04, 95% CI 1.20-3.46), and discharge to post-acute care (AOR 1.50, 95% CI 0.90-2.50) - improved discrimination of the ‘full stay’ AMI model but only modestly improved net reclassification and calibration.
Conclusions:
A ‘full-stay’ AMI-specific EHR readmission model modestly outperformed a ‘first-day’ EHR model, a multi-condition EHR model, and the CMS AMI model. Surprisingly, incorporating more hospitalization data improved discrimination of the full-stay AMI model but did
not
meaningfully improve reclassification compared to the first-day model. Readmissions in AMI may be accurately predicted on the first day of hospitalization; waiting until later in hospitalization does not markedly improve risk prediction.
Rationale, design, and implementation protocol of an electronic health record integrated clinical prediction rule (iCPR) randomized trial in primary care
