title: Using decision trees to manage hospital readmission risk for acute myocardial infarction, heart failure, and pneumonia.
abstract: To improve healthcare quality and reduce costs, the Affordable Care Act places hospitals at financial risk for excessive readmissions associated with acute myocardial infarction (AMI), heart failure (HF), and pneumonia (PN). Although predictive analytics is increasingly looked to as a means for measuring, comparing, and managing this risk, many modeling tools require data inputs that are not readily available and/or additional resources to yield actionable information. This article demonstrates how hospitals and clinicians can use their own structured discharge data to create decision trees that produce highly transparent, clinically relevant decision rules for better managing readmission risk associated with AMI, HF, and PN. For illustrative purposes, basic decision trees are trained and tested using publically available data from the California State Inpatient Databases and an open-source statistical package. As expected, these simple models perform less well than other more sophisticated tools, with areas under the receiver operating characteristic (ROC) curve (or AUC) of 0.612, 0.583, and 0.650, respectively, but achieve a lift of at least 1.5 or greater for higher-risk patients with any of the three conditions. More importantly, they are shown to offer substantial advantages in terms of transparency and interpretability, comprehensiveness, and adaptability. By enabling hospitals and clinicians to identify important factors associated with readmissions, target subgroups of patients at both high and low risk, and design and implement interventions that are appropriate to the risk levels observed, decision trees serve as an ideal application for addressing the challenge of reducing hospital readmissions.
authors.affiliation: Department of Health Economics, UPMC Health Plan, U.S. Steel Tower, 9th Floor, 600 Grant Street, Pittsburgh, PA, 15219, USA.
authors.forename: John P
authors.initials: JP
authors.lastname: Hilbert
authors.forename: Scott
authors.initials: S
authors.lastname: Zasadil
authors.forename: Donna J
authors.initials: DJ
authors.lastname: Keyser
authors.forename: Pamela B
authors.initials: PB
authors.lastname: Peele
mesh_terms: D017677:Age Distribution; D000368:Aged; D019540:Area Under Curve; D002140:California; D015897:Comorbidity; D016208:Databases, Factual; D003663:Decision Trees; D004469:Economics, Hospital / Q000331:legislation & jurisprudence*; D005260:Female; D006333:Heart Failure; D006801:Humans; D007297:Inpatients / Q000706:statistics & numerical data; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction; D010351:Patient Discharge / Q000191:economics / Q000592:standards* / Q000706:statistics & numerical data; D058991:Patient Protection and Affordable Care Act / Q000191:economics* / Q000592:standards; D010359:Patient Readmission / Q000191:economics / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data*; D011014:Pneumonia; D011787:Quality of Health Care / Q000191:economics / Q000331:legislation & jurisprudence* / Q000706:statistics & numerical data; D012372:ROC Curve; D018570:Risk Assessment / Q000379:methods; D012308:Risk Management / Q000379:methods; D017678:Sex Distribution; D014481:United States