Assessing the impact of social determinants of health on predictive models for potentially avoidable 30-day readmission or death

Abstract

Objectives: Early hospital readmissions or deaths are key healthcare quality measures in pay-for-performance programs. Predictive models could identify patients at higher risk of readmission or death and target interventions. However, existing models usually do not incorporate social determinants of health (SDH) information, although this information is of great importance to address health disparities related to social risk factors. The objective of this study is to examine the impact of social determinants of health on predictive models for potentially avoidable 30-day readmission.

Methods: We extracted electronic health record data for 19,941 hospital admissions between January 2015 and November 2017 at an academic medical center in New York City. We applied the Simplified HOSPITAL score model to predict potentially avoidable 30-day readmission or death and examined if incorporating individual- and community-level SDH could improve the prediction using cross-validation. We calculated the C-statistic for discrimination, Brier score for accuracy, and Hosmer-Lemeshow test for calibration for each model using logistic regression. Analysis was conducted for all patients and three subgroups that may be disproportionately affected by social risk factors, namely Medicaid patients, patients who are 65 or older, and obese patients.

Results: The Simplified HOSPITAL score model achieved similar performance in our sample compared to previous studies. Adding SDH did not improve the prediction among all patients. However, adding individual- and community-level SDH at the US census tract level significantly improved the prediction for all three subgroups. Specifically, C-statistics improved from 0.70 to 0.73 for Medicaid patients, from 0.66 to 0.68 for patients 65 or older, and from 0.70 to 0.73 for obese patients.

Conclusions: Patients from certain subgroups may be more likely to be affected by social risk factors. Incorporating SDH into predictive models may be helpful to identify these patients and reduce health disparities associated with vulnerable social conditions.