title: Predicting the cumulative risk of death during hospitalization by modeling weekend, weekday and diurnal mortality risks.
abstract: BACKGROUND
  Current prognostic models factor in patient and disease specific variables but do not consider cumulative risks of hospitalization over time. We developed risk models of the likelihood of death associated with cumulative exposure to hospitalization, based on time-varying risks of hospitalization over any given day, as well as day of the week. Model performance was evaluated alone, and in combination with simple disease-specific models.
  
  
  METHODS
  Patients admitted between 2000 and 2006 from 501 public and private hospitals in NSW, Australia were used for training and 2007 data for evaluation. The impact of hospital care delivered over different days of the week and or times of the day was modeled by separating hospitalization risk into 21 separate time periods (morning, day, night across the days of the week). Three models were developed to predict death up to 7-days post-discharge: 1/a simple background risk model using age, gender; 2/a time-varying risk model for exposure to hospitalization (admission time, days in hospital); 3/disease specific models (Charlson co-morbidity index, DRG). Combining these three generated a full model. Models were evaluated by accuracy, AUC, Akaike and Bayesian information criteria.
  
  
  RESULTS
  There was a clear diurnal rhythm to hospital mortality in the data set, peaking in the evening, as well as the well-known 'weekend-effect' where mortality peaks with weekend admissions. Individual models had modest performance on the test data set (AUC 0.71, 0.79 and 0.79 respectively). The combined model which included time-varying risk however yielded an average AUC of 0.92. This model performed best for stays up to 7-days (93% of admissions), peaking at days 3 to 5 (AUC 0.94).
  
  
  CONCLUSIONS
  Risks of hospitalization vary not just with the day of the week but also time of the day, and can be used to make predictions about the cumulative risk of death associated with an individual's hospitalization. Combining disease specific models with such time varying- estimates appears to result in robust predictive performance. Such risk exposure models should find utility both in enhancing standard prognostic models as well as estimating the risk of continuation of hospitalization.
authors.affiliation: Centre for Health Informatics, Australian Institute for Health Innovation, University of New South Wales, Sydney 2052, Australia. e.coiera@unsw.edu.au.
authors.forename: Enrico
authors.initials: E
authors.lastname: Coiera
authors.forename: Ying
authors.initials: Y
authors.lastname: Wang
authors.forename: Farah
authors.initials: F
authors.lastname: Magrabi
authors.forename: Oscar Perez
authors.initials: OP
authors.lastname: Concha
authors.forename: Blanca
authors.initials: B
authors.lastname: Gallego
authors.forename: William
authors.initials: W
authors.lastname: Runciman
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D002940:Circadian Rhythm; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D009517:New South Wales / Q000453:epidemiology; D012306:Risk; D018570:Risk Assessment / Q000379:methods; D013997:Time Factors; D055815:Young Adult