External Validation of the Diabetes Early Re-Admission Risk Indicator (Derri™)

doi:10.4158/EP-2018-0035

Endocrine Practice

Volume 24, Issue 6, June 2018, Pages 527-541

https://doi.org/10.4158/EP-2018-0035 Get rights and content

ABSTRACT

Objective: The Diabetes Early Re-admission Risk Indicator (DERRI™) was previously developed and internally validated as a tool to predict the risk of all-cause re-admission within 30 days of discharge (30-day re-admission) of hospitalized patients with diabetes. In this study, the predictive performance of the DERRI™ with and without additional predictors was assessed in an external sample.

Methods: We conducted a retrospective cohort study of adult patients with diabetes discharged from two academic medical centers between January 1, 2000 and December 31, 2014. We applied the previously developed DERRI™, which includes admission laboratory results, sociodemographics, a diagnosis of certain comorbidities, and recent discharge information, and evaluated the effect of adding metabolic indicators on predictive performance using multivariable logistic regression. Total cholesterol and hemoglobin A1c (A1c) were selected based on clinical relevance and univariate association with 30-day re-admission.

Results: Among 105,974 discharges, 19,032 (18.0%) were followed by 30-day re-admission for any cause. The DERRI™ had a C-statistic of 0.634 for 30-day re-admission. Total cholesterol was the lipid parameter most strongly associated with 30-day re-admission. The DERRI™ predictors A1c and total cholesterol were significantly associated with 30-day re-admission; however, their addition to the DERRI™ did not significantly change model performance (C-statistic, 0.643 [95% confidence interval, 0.638 to 0.647]; P = .92).

Conclusion: Performance of the DERRI™ in this external cohort was modest but comparable to other re-admission prediction models. Addition of A1c and total cholesterol to the DERRI™ did not significantly improve performance. Although the DERRI™ may be useful to direct resources toward diabetes patients at higher risk, better prediction is needed.

Abbreviations: A1c = hemoglobin A1c; CI = confidence interval; DERRI™ = Diabetes Early Re-admission Risk Indicator; GEE = generalized estimating equation; HDL-C = high-density-lipoprotein cholesterol; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; LDL-C = low-density-lipoprotein cholesterol

Section snippets

INTRODUCTION

Hospital re-admission within 30 days of discharge (30-day re-admission) is a high-priority healthcare quality measure and target for cost reduction (1–3). More than a quarter of hospital expenditures in the United States are incurred by patients with diabetes (4). In this population, up to 20% of hospitalizations are followed by a 30-day re-admission (5–10), corresponding to nearly 2 million discharges annually (11).

Interventions aimed at reducing the risk of 30-day re-admission of various

Study Sample

The methods used to select the cohort (external validation sample), define variables, and analyze the data were similar to those used to develop the DERRI™ (10). A total of 105,960 hospital discharges were retrospectively selected from the electronic medical records of 42,800 patients hospitalized at two urban academic medical centers in Boston, Massachusetts (Massachusetts General Hospital and Brigham and Women's Hospital) between January 1, 2000, and December 31, 2014, the time period for

RESULTS

There were 105,960 discharges in this external validation sample, of which 19,032 (18.0%) were associated with 30-day re-admission for any cause. Characteristics of the cohort are presented in Table 1. With the exception of gender, English fluency, and insurance status, most of the variables were associated with 30-day re-admission in univariate analysis. The most common reasons for re-admission were cardiovascular disease, infection, and diabetes (Table 2).

The C-statistic of the DERRI™ was

DISCUSSION

In this retrospective study of 105,960 discharges of patients with diabetes, we examined the external validity of the DERRI™, a previously developed and internally validated tool comprised of 10 parameters that predicts the 30-day re-admission risk of individual patients. In this sample, the DERRI™ had modest predictive performance based on a C-statistic of 0.634. Additionally, total cholesterol, HDL-C, LDL-C, triglycerides, and A1c levels were evaluated for association with re-admission.

CONCLUSION

In summary, performance of the DERRI™ in this external cohort to predict early re-admission risk of patients with diabetes was modest. Although lower A1c and total cholesterol levels were found to be associated with higher re-admission risk, these parameters do not add significant predictive power to the DERRI™. Additional research is needed to identify better predictors of re-admission among patients with diabetes.

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Cited by (17)

Patient Understanding of Discharge Instructions for Home Diabetes Self-Management and Risk for Hospital Readmission and Emergency Department Visits
2021, Endocrine Practice
Citation Excerpt :
Thirty day readmission rates of up to 38.6% have been reported among patients with diabetes with high levels of comorbidities.16 The DERRI has been identified as an effective tool for retrospectively identifying patients at high risk for hospital readmission at 30 days using a large patient database.6,30,32 In this smaller prospective study, the difference in DERRI scores among patients with and without 30 days readmission did not reach statistical significance, but the difference was significantly higher in those readmitted within 90 days.
The primary objective of this study was to examine the patient comprehension of diabetes self-management instructions provided at hospital discharge as an associated risk of readmission.
Noncritically ill patients with diabetes completed patient comprehension questionnaires (PCQ) within 48 hours of discharge. PCQ scores were compared among patients with and without readmission or emergency department (ED) visits at 30 and 90 days. Glycemic measures 48 hours preceding discharge were investigated. Diabetes Early Readmission Risk Indicators (DERRIs) were calculated for each patient.
Of 128 patients who completed the PCQ, scores were similar among those with 30-day (n = 31) and 90-day (n = 54) readmission compared with no readmission (n = 72) (79.9 ± 14.4 vs 80.4 ± 15.6 vs 82.3 ± 16.4, respectively) or ED visits. Clarification of discharge information was provided for 47 patients. PCQ scores of 100% were achieved in 14% of those with and 86% without readmission at 30 days (P = .108). Of predischarge glycemic measures, glycemic variability was negatively associated with PCQ scores (P = .035). DERRIs were significantly higher among patients readmitted at 90 days but not 30 days.
These results demonstrate similar PCQ scores between patients with and those without readmission or ED visits despite the need for corrective information in many patients. Measures of glycemic variability were associated with PCQ scores but not readmission risk. This study validates DERRI as a predictor for readmission at 90 days.
Risk factors for readmission of inpatients with diabetes: A systematic review
2019, Journal of Diabetes and its Complications
We have limited understanding of which risk factors contribute to increased readmission rates amongst people discharged from hospital with diabetes. We aim to complete the first review of its kind, to identify, in a systematic way, known risk factors for hospital readmission amongst people with diabetes, in order to better understand this costly complication.
The review was prospectively registered in the PROSPERO database. Risk factors were identified through systematic review of literature in PubMed, EMBASE & SCOPUS databases, performed independently by two authors prior to data extraction, with quality assessment and semi-quantitative synthesis according to PRISMA guidelines.
Eighty-three studies were selected for inclusion, predominantly from the United States, and utilising retrospective analysis of local or regional data sets. 76 distinct statistically significant risk factors were identified across 48 studies. The most commonly identified risk factors were; co-morbidity burden, age, race and insurance type. Few studies conducted power calculations; unstandardized effect sizes were calculated for the majority of statistically significant risk factors.
This review is important in assessing the current state of the literature and in supporting development of interventions to reduce readmission risk. Furthermore, it provides an important foundation for development of rigorous, pre-specified risk prediction models.
Validation and comparison of two 30-day re-admission prediction models in patients with diabetes
2019, Endocrine Practice
Citation Excerpt :
On the other hand, being able to use a general clinical re-admission prediction model, such as HOSPITAL score, has the advantage of simplifying implementation efforts. A limitation of our study is that we did not capture re-admissions that may have occurred in other hospitals (7,9,24,25). The possibility of re-admission to other hospitals exists in the non–re-admission group.
Objective: The objective was to evaluate the 30-day re-admission predictive performance of the HOSPITAL score and Diabetes Early Re-admission Risk Indicator (DERRI™) in hospitalized diabetes patients.
Methods: This was a case-control study in an academic, tertiary center in the United States. Adult hospitalized diabetes patients were randomly identified between January 1, 2014, and September 30, 2017. Patients were categorized into two groups: (1) re-admitted within 30 days, and (2) not re-admitted within 30 days. Predictive performance of the HOSPITAL and DERRI™ scores was evaluated by calculating receiver operating characteristics curves (c-statistic), Hosmer-Lemeshow goodness-of-fit tests, and Brier scores.
Results: A total of 200 patients were included (100 re-admitted, 100 non–re-admitted). The HOSPITAL score had a c-statistic of 0.731 (95% confidence interval [CI], 0.661 to 0.800), Hosmer-Lemeshow test P = .211, and Brier score 0.212. The DERRI™ score had a c-statistic of 0.796 (95% CI, 0.734 to 0.857), Hosmer-Lemeshow test P = .114, and Brier score 0.212. The difference in receiver operating characteristic curves was not statistically significant between the two scores but showed a higher c-statistic with the DERRI™ score (P = .055).
Conclusion: Both HOSPITAL and DERRI™ scores showed good predictive performance in 30-day re-admission of adult hospitalized diabetes patients. There was no significant difference in discrimination and calibration between the scores.
Abbreviations: CI = confidence interval; DERRI™ = Diabetes Early Re-admission Risk Indicator; IQR = interquartile range
SPUR: A Patient-Reported Medication Adherence Model as a Predictor of Admission and Early Readmission in Patients Living with Type 2 Diabetes
2023, Patient Preference and Adherence
16. Diabetes Care in the Hospital: Standards of Care in Diabetes—2023
2023, Diabetes Care
Predicting and Validating 30-day Hospital Readmission in Adults With Diabetes Whose Index Admission Is Diabetes-related
2022, Journal of Clinical Endocrinology and Metabolism

View all citing articles on Scopus

DISCLOSURE

The authors have no multiplicity of interest to disclose.

View full text

Original ArticlesExternal Validation of the Diabetes Early Re-Admission Risk Indicator (Derri™)

ABSTRACT

Section snippets

INTRODUCTION

Study Sample

RESULTS

DISCUSSION

CONCLUSION

Development and validation of a novel tool to predict hospital readmission risk among patients with diabetes

Predictive accuracy study: comparing a statistical model to clinicians' estimates of outcomes after coronary bypass surgery

A comparison of model-building strategies for lower respiratory tract infection in long-term care

Hospital readmission as an accountability measure

Medicare Hospital Readmissions: Issues, Policy Options and PPACA

Revisiting readmissions--changing the incentives for shared accountability

Economic costs of diabetes in the U.S. in 2012

Diagnosing diabetes and preventing rehospitalizations: the urban diabetes study

Lower rehospitalization rates among rural Medicare beneficiaries with diabetes

New bundled world: quality of care and readmission in diabetes patients

Predictors of 30 day hospital readmission in patients with type 2 diabetes: a retrospective, case–control, database study

Inpatient diabetes education is associated with less frequent hospital readmission among patients with poor glycemic control

HCUP Nationwide Inpatient Sample (NIS) 2013

Original Articles
External Validation of the Diabetes Early Re-Admission Risk Indicator (Derri™)