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Original Investigation |

International Validity of the HOSPITAL Score to Predict 30-Day Potentially Avoidable Hospital Readmissions

Jacques D. Donzé, MD, MSc1,2,3; Mark V. Williams, MD4; Edmondo J. Robinson, MD, MBA, MSHP5; Eyal Zimlichman, MD, MSc6; Drahomir Aujesky, MD, MSc1; Eduard E. Vasilevskis, MD, MPH7,8,9; Sunil Kripalani, MD, MSc7,8; Joshua P. Metlay, MD, PhD10; Tamara Wallington, MD11; Grant S. Fletcher, MD, MPH12; Andrew D. Auerbach, MD, MPH13; Jeffrey L. Schnipper, MD, MPH2,3
[+] Author Affiliations
1Division of General Internal Medicine, Bern University Hospital, Bern, Switzerland
2Division of General Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
3Harvard Medical School, Boston, Massachusetts
4Center for Health Services Research, University of Kentucky, Lexington
5Value Institute, Christiana Care Health System, Wilmington, Delaware
6Sheba Medical Centre, Tel Hashomer, Israel
7Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
8Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee
9Veterans Affairs Tennessee Valley – Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee
10Division of General Internal Medicine, Massachusetts General Hospital, Boston
11William Osler Health System, Ontario, Canada
12Department of Medicine, Harborview Medical Center, University of Washington, Seattle
13Division of Hospital Medicine, University of California-San Francisco, San Francisco
JAMA Intern Med. 2016;176(4):496-502. doi:10.1001/jamainternmed.2015.8462.
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Importance  Identification of patients at a high risk of potentially avoidable readmission allows hospitals to efficiently direct additional care transitions services to the patients most likely to benefit.

Objective  To externally validate the HOSPITAL score in an international multicenter study to assess its generalizability.

Design, Setting, and Participants  International retrospective cohort study of 117 065 adult patients consecutively discharged alive from the medical department of 9 large hospitals across 4 different countries between January 2011 and December 2011. Patients transferred to another acute care facility were excluded.

Exposures  The HOSPITAL score includes the following predictors at discharge: hemoglobin, discharge from an oncology service, sodium level, procedure during the index admission, index type of admission (urgent), number of admissions during the last 12 months, and length of stay.

Main Outcomes and Measures  30-day potentially avoidable readmission to the index hospital using the SQLape algorithm.

Results  Overall, 117 065 adults consecutively discharged alive from a medical department between January 2011 and December 2011 were studied. Of all medical discharges, 16 992 of 117 065 (14.5%) were followed by a 30-day readmission, and 11 307 (9.7%) were followed by a 30-day potentially avoidable readmission. The discriminatory power of the HOSPITAL score to predict potentially avoidable readmission was good, with a C statistic of 0.72 (95% CI, 0.72-0.72). As in the derivation study, patients were classified into 3 risk categories: low (n = 73 031 [62.4%]), intermediate (n = 27 612 [23.6%]), and high risk (n = 16 422 [14.0%]). The estimated proportions of potentially avoidable readmission for each risk category matched the observed proportion, resulting in an excellent calibration (Pearson χ2 test P = .89).

Conclusions and Relevance  The HOSPITAL score identified patients at high risk of 30-day potentially avoidable readmission with moderately high discrimination and excellent calibration when applied to a large international multicenter cohort of medical patients. This score has the potential to easily identify patients in need of more intensive transitional care interventions to prevent avoidable hospital readmissions.

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Figure 1.
Study Flow Diagram

During the study period, a total of 121 136 adults were discharged alive from the medical department of the 9 participating centers, and 117 065 (96.6%) discharges were included in the analysis.

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Figure 2.
Receiving Operating Characteristic Curve of the HOSPITAL Score

The HOSPITAL score had a C statistic of 0.72 (95% CI, 0.72-0.72), showing good discrimination.

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