Development and validation of a dynamic inpatient risk prediction model for clinically significant hypokalemia using electronic health record data.

Abstract

The purpose of this study was to develop a dynamic risk prediction model for inpatient hypokalemia and evaluate its predictive performance. A retrospective cohort included all admissions aged 18 years and above from 2 large tertiary hospitals in Florida over a 22-month period. Hypokalemia was defined as a potassium value of less than 3 mmol/L, and subsequent initiation of potassium supplements. Twenty-five risk factors (RF) identified from literature were operationalized using discrete electronic health record (EHR) data elements. For each of the first 5 hospital days, we modeled the probability of developing hypokalemia at the subsequent hospital day using logistic regression. Predictive performance of our model was validated with 100 bootstrap datasets and evaluated by the C statistic and Hosmer-Lemeshow goodness-of-fit test. A total of 4511 hypokalemia events occurred over 263 436 hospital days (1.71%). Validated C statistics of the prediction model ranged from 0.83 (Day 1 model) to 0.86 (Day 3), while p-values for the Hosmer-Lemeshow test spanned from 0.005 (Day 1) to 0.27 (Day 4 and 5). For the Day 3 prediction, 9.9% of patients with risk scores in the 90th percentile developed hypokalemia and accounted for 60.4% of all hypokalemia events. After controlling for baseline potassium values, strong predictors included diabetic ketoacidosis, increased mineralocorticoid activity, polyuria, use of kaliuretics, use of potassium supplements and watery stool. This is the first risk prediction model for hypokalemia. Our model achieved excellent discrimination and adequate calibration ability. Once externally validated, this risk assessment tool could use real-time EHR information to identify individuals at the highest risk for hypokalemia and support proactive interventions by pharmacists.