title: An automated model using electronic medical record data identifies patients with cirrhosis at high risk for readmission.
abstract: OBJECTIVE
  Patients with cirrhosis have 1-month rates of readmission as high as 35%. Early identification of high-risk patients could permit interventions to reduce readmission. The aim of our study was to construct an automated 30-day readmission risk model for cirrhotic patients using electronic medical record (EMR) data available early during hospitalization.
  
  
  METHODS
  We identified patients with cirrhosis admitted to a large safety-net hospital from January 2008 through December 2009. A multiple logistic regression model for 30-day rehospitalization was developed using medical and socioeconomic factors available within 48 hours of admission and tested on a validation cohort. Discrimination was assessed using receiver operator characteristic curve analysis.
  
  
  RESULTS
  We identified 836 cirrhotic patients with 1291 unique admission encounters. Rehospitalization occurred within 30 days for 27% of patients. Significant predictors of 30-day readmission included the number of address changes in the prior year (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.05-1.21), number of admissions in the prior year (OR, 1.14; 95% CI, 1.05-1.24), Medicaid insurance (OR, 1.53; 95% CI, 1.10-2.13), thrombocytopenia (OR, 0.50; 95% CI, 0.35-0.72), low level of alanine aminotransferase (OR, 2.56; 95% CI, 1.09-6.00), anemia (OR, 1.63; 95% CI, 1.17-2.27), hyponatremia (OR, 1.78; 95% CI, 1.14-2.80), and Model for End-stage Liver Disease score (OR, 1.04; 95% CI, 1.01-1.06). The risk model predicted 30-day readmission, with c-statistics of 0.68 (95% CI, 0.64-0.72) and 0.66 (95% CI, 0.59-0.73) in the derivation and validation cohorts, respectively.
  
  
  CONCLUSIONS
  Clinical and social factors available early during admission and extractable from an EMR predicted 30-day readmission in cirrhotic patients with moderate accuracy. Decision support tools that use EMR-automated data are useful for risk stratification of patients with cirrhosis early during hospitalization.
authors.affiliation: Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas, Texas; Department of Internal Medicine, University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas, Texas; Department of Clinical Sciences, University of Texas Southwestern, Dallas, Texas. Electronic address: amit.singal@utsouthwestern.edu.
authors.forename: Amit G
authors.initials: AG
authors.lastname: Singal
authors.forename: Robert S
authors.initials: RS
authors.lastname: Rahimi
authors.forename: Christopher
authors.initials: C
authors.lastname: Clark
authors.forename: Ying
authors.initials: Y
authors.lastname: Ma
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Cuthbert
authors.forename: Don C
authors.initials: DC
authors.lastname: Rockey
authors.forename: Ruben
authors.initials: R
authors.lastname: Amarasingham
mesh_terms: D000328:Adult; D000368:Aged; D019411:Clinical Laboratory Techniques / Q000379:methods; D015510:Clinical Medicine / Q000379:methods; D015331:Cohort Studies; D003661:Decision Support Techniques; D057286:Electronic Health Records; D005260:Female; D006801:Humans; D008103:Liver Cirrhosis / Q000175:diagnosis*; D008297:Male; D008875:Middle Aged; D012372:ROC Curve; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods; D012680:Sensitivity and Specificity; D012923:Social Class
keywords: ALT; CI; EMR; Hepatic Informatics; ICD-9; IDI; INR; International Classification of Diseases, 9th revision; Liver Disease; MELD; Model for End-stage Liver Disease; OR; Quality of Care; Rehospitalization; Risk Model; alanine aminotransferase; confidence interval; electronic medical record; integrated discrimination improvement; international normalized ratio; odds ratio