Prospective stratification of patients at risk for emergency department revisit: resource utilization and population management strategy implications.

Bo Jin,Yue Wang,Chunqing Zhu,Karl G Sylvester,Frank Stearns,Jun Ji,Shiying Hao,Eric Widen,Yifan Zhao,Yong Wang,Xuefeng B Ling,Zhongkai Hu,Todd Rogow,Changlin Fu,Yue Zhao ,Dingwei Dai ,Shaun T Alfreds ,Andrew Shin ,Yuming Jiang ,Devore S Culver

doi:10.1186/s12873-016-0074-5

Abstract

BackgroundEstimating patient risk of future emergency department (ED) revisits can guide the allocation of resources, e.g. local primary care and/or specialty, to better manage ED high utilization patient populations and thereby improve patient life qualities.MethodsWe set to develop and validate a method to estimate patient ED revisit risk in the subsequent 6 months from an ED discharge date. An ensemble decision-tree-based model with Electronic Medical Record (EMR) encounter data from HealthInfoNet (HIN), Maine’s Health Information Exchange (HIE), was developed and validated, assessing patient risk for a subsequent 6 month return ED visit based on the ED encounter-associated demographic and EMR clinical history data. A retrospective cohort of 293,461 ED encounters that occurred between January 1, 2012 and December 31, 2012, was assembled with the associated patients’ 1-year clinical histories before the ED discharge date, for model training and calibration purposes. To validate, a prospective cohort of 193,886 ED encounters that occurred between January 1, 2013 and June 30, 2013 was constructed.ResultsStatistical learning that was utilized to construct the prediction model identified 152 variables that included the following data domains: demographics groups (12), different encounter history (104), care facilities (12), primary and secondary diagnoses (10), primary and secondary procedures (2), chronic disease condition (1), laboratory test results (2), and outpatient prescription medications (9). The c-statistics for the retrospective and prospective cohorts were 0.742 and 0.730 respectively. Total medical expense and ED utilization by risk score 6 months after the discharge were analyzed. Cluster analysis identified discrete subpopulations of high-risk patients with distinctive resource utilization patterns, suggesting the need for diversified care management strategies.ConclusionsIntegration of our method into the HIN secure statewide data system in real time prospectively validated its performance. It promises to provide increased opportunity for high ED utilization identification, and optimized resource and population management.Electronic supplementary materialThe online version of this article (doi:10.1186/s12873-016-0074-5) contains supplementary material, which is available to authorized users.

Highlights

Estimating patient risk of future emergency department (ED) revisits can guide the allocation of resources, e.g. local primary care and/or specialty, to better manage ED high utilization patient populations and thereby improve patient life qualities
Characteristics of study subjects In addition to clinical and field care-giver judgments, we reviewed a “time to event” curve of ED revisits of the retrospective cohort, to determine whether 6-month post discharge ED revisit assessment is clinically reasonable in that a large proportion of patients had ED returns with 6 months that accounts for considerable resource demands
The ED revisit “time-to-event curve” showed a pattern of rapid accrual with a stable and consistent ED revisit rate thereafter

Summary

Introduction

Estimating patient risk of future emergency department (ED) revisits can guide the allocation of resources, e.g. local primary care and/or specialty, to better manage ED high utilization patient populations and thereby improve patient life qualities. Background and importance The utilization of emergency department (ED) services in the United States (U.S.) is growing at an alarming rate [1]. When patients return to the ED after discharge, it is generally believed that revisits are attributable to the nature of the disease, medical errors, and inadequacy of initial evaluation or treatment [3]. ED revisits can involve patients who are in a high-risk population of specific demographics [4]. Some ED-discharged patients return for non-emergency problems [3], while others could be underserved due to the lack of local primary care and/or specialty availability, which significantly increases overall emergency use [5]. Recent evidence from U.S Oregon’s health insurance experiment found that a limited expansion of a Medicaid program for uninsured, low-income adults increased ED use [6]

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