Choosing a model to predict hospital admission: An observational study of new variants of predictive models for case finding

Objectives: To test the performance of new variants of models to identify people at risk of an emergency hospital admission. We compared (1) the impact of using alternative data sources (hospital inpatient, A&E, outpatient and general practitioner (GP) electronic medical records) (2) the effects of local calibration on the performance of the models and (3) the choice of population denominators. Design: Multivariate logistic regressions using person-level data adding each data set sequentially to test value of additional variables and denominators. Setting: 5 Primary Care Trusts within England. Participants: 1 836 099 people aged 18-95 registered with GPs on 31 July 2009. Main outcome measures: Models to predict hospital admission and readmission were compared in terms of the positive predictive value and sensitivity for various risk strata and with the receiver operating curve C statistic. Results: The addition of each data set showed moderate improvement in the number of patients identified with little or no loss of positive predictive value. However, even with inclusion of GP electronic medical record information, the algorithms identified only a small number of patients with no emergency hospital admissions in the previous 2 years. The model pooled across all sites performed almost as well as the models calibrated to local data from just one site. Using population denominators from GP registers led to better case finding. Conclusions: These models provide a basis for wider application in the National Health Service. Each of the models examined produces reasonably robust performance and offers some predictive value. The addition of more complex data adds some value, but we were unable to conclude that pooled models performed less well than those in individual sites. Choices about model should be linked to the intervention design. Characteristics of patients identified by the algorithms provide useful information in the design/costing of intervention strategies to improve care coordination/outcomes for these patients.