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Research Article

Identification of high-risk patients for early death or unplanned readmission using the LACE index in an older Portuguese population

[version 1; peer review: 1 approved, 1 approved with reservations]
PUBLISHED 03 Oct 2017
Author details Author details
OPEN PEER REVIEW
REVIEWER STATUS

Abstract

Background: Unplanned readmissions are frequent, associated with high costs and potentially preventable. Pre-discharge risk screening is a crucial step to prevent hospital readmissions. This study evaluates the LACE index as a tool capable of identifying patients with high risk of early readmission or death in an older Portuguese population.
Methods: We performed a retrospective study in a tertiary care hospital in Portugal. All acute patients, aged ≥ 65 years, discharged from the Internal Medicine Service between 1 January and 30 June 2014 were included. Data was collected from hospital records. The LACE index was calculated for each patient. A comparative analysis was performed based on a cutoff of 10 (≥10 indicates a high-risk population) for the LACE score.
Results: 1407 patients were evaluated, with a mean age of 81.7±7.6 years; 41.2% were male, 52.2% were dependent for ≥1 activities of daily living, the average Charlson comorbidity index was 3.54±2.8. There were 236 (16.8%) readmissions, 132 (9.4%) deaths and 307 (21.8%) patients were dead and/or readmitted within 30 days of discharge. At 90 days, 523 (37.2%) patients were dead and/or readmitted. The LACE score was higher in patients who died or were readmitted within 30 days compared with those who were not (13.2±2.7 versus 11.5±3.0, p <0.0001). Patients with LACE score ≥10 had significantly higher mortality and readmission rates compared to those with LACE score <10: at 30 days, 25.5% versus 9.3% (OR 3.34, 95% CI 2.24-4.98, p <0.0001); at 90 days, 43.4% versus 16.2% (OR 3.98, 95% CI 2.89-5.49, p <0.0001). However, the discriminative capacity of LACE index assessed by C-statistic was relatively poor: 0.663 (95% CI 0.630-0.696) and 0.676 (95% CI 0.648-0.704), respectively.
Conclusions: This study shows that the LACE index should be used with reservations for predicting 30 and 90-day readmission or death in complex elderly patients.

Keywords

hospital readmissions, elderly, LACE index

Introduction

Unplanned hospital readmissions are frequent1,2, particularly in elderly patients with comorbidities3,4. These are associated with high costs and a poor global prognosis13. Portugal is no different from other Western countries, in which there is a rapid ageing of the population. As a consequence, the number of complex elderly patients with multiple diseases requiring hospitalisation has increased in the last two decades, similarly to the readmission rate5.

The problem of hospital readmissions has gained great interest from the medical community and the governments of most developed countries1,2. Several studies suggest that rehospitalizations are potentially preventable6,7, and the ratio of readmissions is now seen as a quality benchmark for health care systems811. There have been a large number of publications in recent years on this subject, and some countries have made efforts to cultivate programs to reduce the impact of this major problem2,12,13.

A pre-discharge risk screening is the first crucial step in any model that attempts to prevent unplanned hospital readmissions. Several readmission screening tools have been created14,15, such as the LACE index16, PARR-3017, 8Ps18, and HOSPITAL score19. However, none prove to be completely adequate14,15.

The LACE index was first presented in 2010, by Van Walraven et al. This is a simple, quick and inexpensive tool that includes length of stay, acuity of the admission (emergency), comorbidities (measured with the Charlson comorbidity index [CCI]) and previous emergency department visits before readmission. It was designed to predict early death or unplanned readmission after discharge from hospital to the home setting16 (Table 1). However, subsequent studies have failed to obtain consistent results2024.

Table 1. The LACE index (adapted from van Walraven C et al. 201016, reproduced with permission).

VariableValuePoints
Length of stay
(days)
<10
11
22
33
4–64
7–135
≥147
Acute admission
(emergency)
Yes3
No0
Charlson comorbidity
index score
00
11
22
33
≥45
Emergency department
visits during previous
6 months
00
11
22
33
≥44

Note: The LACE score is calculated by summing the points attributed to the 4 variables.

The original LACE index was based on a middle-aged population living in Canada, with good functional status and few comorbidities16. This population is not representative of the kind of patient usually observed in acute care facilities in Portugal. Further research is essential to clarify whether the LACE index is a useful tool in predicting the risk of readmission in elderly patients with multiple diseases.

The aim of this study was to assess the ability of the LACE index to predict the risk of readmission or death within 30 and 90 days after discharge in elderly patients at a Portuguese tertiary hospital.

Methods

Study population

We performed a retrospective study in Coimbra Hospital and Universitary Centre, a tertiary care hospital in Portugal. The study included all acute patients aged ≥ 65 years, who were discharged from the Internal Medicine Service between 1 January and 30 June 2014 (n=1619). The first hospitalisation during the study period was established as the index admission, and we counted no more than one readmission for each patient. Exclusion criteria were planned admission, discharge to rehabilitation or continuing care facility, transfer to another acute care hospital, leaving the hospital against medical advice, or death. A total of 1407 patients were eligible for analysis (Figure 1).

120a67d7-e197-449d-b09a-7b8db748c7aa_figure1.gif

Figure 1. Flow chart of patient inclusion, with reasons for exclusion, and total study population.

Data collection

Medical and demographic data were collected from hospital records, including age, gender, residence, functional status, comorbidities (CCI), reason for admission, medications, length of stay and healthcare utilisation in the previous 6 months (emergency department visits and number of hospital admissions). Readmissions and mortality at 30 and 90 days since the indexed admission were also obtained.

Instrument

The LACE index was calculated for each patient. The LACE score ranges from 0 to 19 - higher scores are related to increased risk of readmission or death after discharge16. Previous investigations have failed to reach an optimal cut-off for defining high-risk populations. Therefore, we decided to establish 10 as the cutoff, considering that it has already been used in some publications2022. For a more accurate interpretation of the data obtained, we also found it useful to divide patients into three risk groups: low (0–7), moderate (8–13), and high (≥14) risk.

Statistical analysis

We compared the characteristics of patients with or without 30-day readmission or death using Chi-square for categorical variables and Student’s t-test for continuous variables. The area under the receiver operating characteristic (ROC) curve C-statistic (ROC area) was estimated to assess the discriminating ability of the LACE index to predict: (1) readmission, (2) death, and (3) readmission or death within 30 and 90 days. Statistical significance was set at p <0.05. Descriptive and statistical analysis were performed in SPSS v.23.0 (IBM Corp., Armonk, NY, USA). Data are presented as the mean ± standard deviation.

Results

A total of 1407 patients were evaluated. Their demographic and clinical baseline characteristics are shown in Table 2, as well as the comparison between patients with and without readmission or death after 30 days of discharge. The age of patients ranged from 65 to 104 years (mean 81.7±7.6); 41.2% were male, 52.2% were dependent on one or more activities of daily living (ADL), the average CCI score was 3.54±2.8, and 23.2% of patients had a hospital admission in the previous 6 months. Admissions were predominantly emergencies (99.6%), and the most common reasons included pneumonia, urinary tract infection, chronic obstructive pulmonary disease, and heart failure. The patients were hospitalised for 9.5±8.9 days, discharged with 7.53±3.4 different medications, and the average LACE index score was 11.8±3.0. The median time to complete the LACE index was 44 seconds for each patient.

Table 2. Patient characteristics, and comparison of groups with and without readmission or death within 30 days.

Patient variableOverall cohort
(n=1407)
Death or unplanned readmission within
30 days
No
n=1100 (78.2)
Yes
n=307 (21.8)
p value
Age (years), mean (SD)81.7 (7.6)81.6 (7.4)82.1 (7.7)0.3073
Gender (male), n (%)579 (41.2)435 (39.5)144 (46.9)0.0243
Residence, n (%)
Assisted-living facility
Home

210 (14.9)
1197 (85.1)

158 (14.4)
942 (85.6)

52 (16.9)
255 (83.1)

0.2635
Dependent for one or more ADL,
n (%)
734 (52.2)517 (47.0)217 (70.7) <0.0001
Charlson comorbidity index
score, mean (SD)
3.54 (2.8)3.24 (2.7)4.62 (3.2)<0.0001
Hospital admission in previous
6 months, n (%)
326 (23.2)227 (20.6)99 (32.2)<0.0001
Length of stay in days, mean (SD)9.5 (8.9)8.87 (7.7)11.51 (12.2)<0.0001
Number of medications at
discharge, mean (SD)
7.53 (3.4)7.38 (3.4)8.1 (3.5)0.0026
LACE score, mean (SD)11.8 (3.0)11.5 (3.0) 13.2 (2.7)<0.0001

In the overall cohort, there were 236 (16.8%) readmissions, 132 (9.4%) deaths and 307 (21.8%) patients were dead and/or readmitted within 30 days of discharge. At 90 days there were 404 (28.7%) readmissions, 255 (18.1%) deaths, and 523 (37.2%) patients were dead and/or readmitted (Table 3).

Table 3. The role of the LACE index in predicting events after hospital discharge.

Total,
n (%)
DiscriminationLACE <10,
n (%)
LACE ≥10,
n (%)
Odds ratio
Outcomen=1407C statistic (95% CI)n=322 (22.9)n=1085 (77.1)(95% CI)p value
30-day readmission only236 (16.8)0.652 (0.615-0.689)21 (6.5)215 (19.8)3.54 (2.22-5.65)<0.0001
30-day death only132 (9.4)0.672 (0.625-0.718)12 (3.7)120 (11.1)3.21 (1.75-5.89)<0.0001
30-day death and/or
readmission
307 (21.8)0.663 (0.630-0.696)30 (9.3)277 (25.5)3.34 (2.24-4.98)<0.0001
90-day readmission only404 (28.7)0.649 (0.619-0.680)38 (11.8)366 (33.7)3.80 (2.65-5.46)<0.0001
90-day death only255 (18.1)0.678 (0.644-0.713)22 (6.8)233 (21.5)3.73 (2.36-5.89)<0.0001
90-day death and/or
readmission
523 (37.2)0.676 (0.648-0.704)52 (16.2)471 (43.4)3.98 (2.89-5.49)<0.0001

The group of patients with 30-day events (death or readmission) were slightly older and had a higher percentage of men compared to non-event patients (Table 2). In the comparison of these two groups, dependence for one or more ADL, CCI, hospital admission in the previous 6 months, length of initial hospital stay, and number of medications at discharge showed statistically significant differences (Table 2). The LACE score was also significantly higher in patients with death or readmission within 30 days compared with non-event patients (13.2±2.7 versus 11.5±3.0, p <0.0001).

LACE scores ranged between 4 and 19. There were no patients with a LACE score of ≤3. As seen in Figure 2 and Figure 3, those with a higher LACE score presented with an increased risk of readmission or death. The 30-day death or readmission ranged from 0.0% for a LACE score of 4–5 to 30.0–44.4% for a LACE score of 18–19. The same pattern was found at 90 days, with the risk of death or readmission ranging between 0.0% for a LACE score of 4, and 60.0–67.7% for a LACE score of 17–19.

120a67d7-e197-449d-b09a-7b8db748c7aa_figure2.gif

Figure 2. LACE score and the risk of death or readmission within 30 days.

120a67d7-e197-449d-b09a-7b8db748c7aa_figure3.gif

Figure 3. LACE score and the risk of death or readmission within 90 days.

Patients with a LACE score ≥10 represented 77.1% (1085) of the sample. In this group, we observed significantly higher mortality and readmission rates compared to patients with LACE score <10 (Table 3): 30-day readmission, 19.8% versus 6.5% (OR 3.54, 95% CI 2.22-5.65, p <0.0001); 30-day death, 11.1% versus 3.7% (OR 3.21, 95% CI 1.75-5.89, p <0.0001); 30-day death or readmission, 25.5% versus 9.3% (OR 3.34, 95% CI 2.24-4.98, p <0.0001); 90-day readmission, 33.7% versus 11.8% (OR 3.80, 95% CI 2.65-5.46, p <0.0001); 90-day death, 21.5% versus 6.8% (OR 3.73, 95% CI 2.36-5.89, p <0.0001); 90-day death or readmission, 43.4% versus 16.2% (OR 3.98, 95% CI 2.89-5.49, p <0.0001).

The ROC curves of the LACE index as a predictor of readmission, death, and readmission or death within 30-days are displayed in Figure 4. The C-statistics associated with the LACE index were 0.652 (95% CI 0.615-0.689), 0.672 (95% CI 0.625-0.718), and 0.663 (95% CI 0.630-0.696), respectively (Table 3). However, the highest C-statistic achieved was relative to mortality at 90 days (0.678, 95% CI 0.644-0.713). The discriminative capacity of the LACE index as assessed by C-statistic was relatively poor in all outcomes evaluated, and tended to be a better predictor for evaluating death than for readmissions. These results are consistent with those found in other works21,22.

120a67d7-e197-449d-b09a-7b8db748c7aa_figure4.gif

Figure 4. ROC curves for the LACE index within 30 days.

Note: ROC curves for the LACE index as a predictor of readmission (left), death (middle) and readmission or death (right) within 30 days.

We performed an additional descriptive analysis, dividing patients into three risk groups: 122 patients (8.7%) were at low risk (LACE 0-7); 873 (62.0%) were at moderate risk (LACE 8-13), and 412 (29.3%) were at high risk (LACE ≥14). As we see in Figure 5, in the high-risk group, a third (33.7%) of patients were readmitted or died 30 days after discharge, and more than a half (54%) had an event at 90 days. In contrast, individuals defined as low and moderate risk had a much lower event rate (5.7% and 18.4% at 30 days, 13.1% and 32.8% at 90 days, respectively).

120a67d7-e197-449d-b09a-7b8db748c7aa_figure5.gif

Figure 5. Readmission, death and readmission or death according to risk group, as defined by LACE index score.

Gender: 0=female 1=male;Age:years;"Residence: Home=0; Assisted-living facility=1";Medications discharged with: number;"Dependent for one or more ADL: No=0; Yes=1";Charlson Comorbidity Index (CCI);Lenght of stay: days;"Hospital admission in previous 6 months: 0=no; yes=1";LACE Score;"Risk group categorisation: 0=Low (0-7); 1=Intermediate (8-13); 2= High (14-19)";"30- day death: 0=no; yes=1";"90- day death: 0=no; yes=1";"30-day readmission: no=0; yes=1";"90-day readmission: no=0; yes=1";"30-day death or readmission: no=0; yes=1";"90-day death or readmission: no=0; yes=1
1;[95;104]";0;4;1;6;6;0;10;1;0;0;1;1;1;1
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This is a portion of the data; to view all the data, please download the file.
Dataset 1.Demographic and clinical data for all 1407 patients.
The data file contains the main medical and demographic variables collected for all 1407 patients, including: age, gender, residence, functional status, number of medications at discharge, length of stay, CCI score, hospital admission in the previous 6 months, LACE index score, readmissions and mortality at 30/90 days, and risk group categorization.

Discussion

It is now clear that unplanned readmissions are associated with high costs and avoidable health risks for patients1,2. This major problem is even greater in countries such as Portugal, where most of patients are elderly with complex and multiple comorbidities. Available data confirm that this is an increasing problem in Portuguese hospitals5, but the annual cost of readmissions is unknown.

In the US, about 17% (US$17.4 billion) of total hospital payments by Medicare in 2004 were related to readmissions1. Previous studies have shown that a significant portion of early readmissions can be prevented6,7. The implementation of the Affordable Care Act's Hospital Readmission and Reduction Program reinforced this idea. This program, which economically penalises US hospitals with high readmission rates, is associated with a significant decline in the number of rehospitalizations13.

The development of readmission prevention programs should be a priority for hospital and health system leaders. Unplanned hospital readmissions and early death after discharge can be taken as markers of health care quality810. However, considering these events as a direct consequence of inadequate care or premature discharge is simplistic and reductive11,12. Hospital readmissions are still difficult to predict, resulting from the complex relationship between multiple factors.

Prevention strategies and the implementation of a post-discharge plan requires the identification of individuals at a high risk of readmission, which depends on prediction tools12. There are not predictors of hospital readmission validated for the Portuguese population. For this study, the LACE index was chosen as it is a simple, quick and easy instrument created to predict the risk of readmission and early death at 30 days16. The predictive capability of LACE has shown tremendous inconsistency in different populations2024. However, attempts to improve the LACE index through the incorporation of other variables have resulted in more complex and time-consuming models without showing any significant advantage2427.

This single-center retrospective study was based on a population of elderly people with significant comorbidity, polypharmacy, and usually compromised functional status. These baseline characteristics are representative of the general reality of the Portuguese Internal Medicine wards. This is in contrast to the much younger, independent and “relatively healthy” Canadian population used to derive the original LACE index16.

As expected, the hospital readmission rate and mortality were elevated, with 21.8% of patients experiencing readmission or death at 30 days, and 37.2% at 90 days after discharge. Most patients had a high LACE score (77.1% had LACE score ≥10), due to high CCI, prolonged hospitalisations, and almost all admissions were emergencies.

In the study population, those with a LACE score ≥10 had a 3-fold increased risk of being readmitted or dead at 30 days, and this risk was even higher at 90 days - almost 4 times compared to the group of patients with a LACE score <10. However, the LACE index had a relative poor discriminative ability in predicting 30-day readmissions alone (c-statistic 0.652), and only a slightly better performance in 30-day mortality prediction (c-statistic 0.672). A similar pattern was obtained at 90 days. This performance was poorer than the findings in the original study by Van Walraven et al.16, but very consistent with other studies conducted in similar populations (UK21 and Singapore22).

Despite these results, we found it interesting to classify patients into three risk groups. With this approach, we obtained interesting results. In the high-risk group (LACE score 14–19), more than half of the patients were readmitted or died at 90 days; therefore, making this a hypothetical perfect target to integrate a structured post-discharge preventive plan. This strategy may be more advantageous in clinical practice than defining low- and high-risk patients based on a single cutoff. Further research is required to determine if a specific post-discharge intervention in this group (LACE score 14–19) may decrease the number of early deaths and readmissions.

Limitations

Our study has some limitations. First, this single-center study was based on a relatively small sample of patients. Second, as a retrospective study, only the variables usually collected were evaluated. Characteristics such as economic status and frailty were not assessed. Third, the causes of unplanned readmission and death were not analysed. Fourth, patients readmitted in hospitals other than ours were not included. This may have led to an underestimated readmission rate in this study. Fifth, the outcomes related to 90 days after discharge were never validated and were mentioned in a very few studies, which limits the comparative analysis of our findings. The same is true for the risk stratification in three groups.

Conclusions

This study shows that the LACE index should be used with reservations for predicting 30 and 90-day readmission or death in complex elderly patients. Further research is needed to determine an effective way to stratify patients at risk of readmission according to the LACE index and to clarify the real impact of post-discharge intervention in these patients.

Data availability

Dataset 1: Demographic and clinical data for all 1407 patients. The data file contains the main medical and demographic variables collected for all 1407 patients, including: age, gender, residence, functional status, number of medications at discharge, length of stay, CCI score, hospital admission in the previous 6 months, LACE index score, readmissions and mortality at 30/90 days, and risk group categorization. doi, 10.5256/f1000research.11315.d17675528

Ethical approval

This study was conducted according to the principles expressed in the Declaration of Helsinki. The study was approved by the Ethics Committee of Coimbra Hospital and Universitary Centre. The need for written informed consent from the participants was waived by the committee due to the retrospective nature of the study based only on data from medical records.

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Fonseca J, Costa F, Mateus J et al. Identification of high-risk patients for early death or unplanned readmission using the LACE index in an older Portuguese population [version 1; peer review: 1 approved, 1 approved with reservations]. F1000Research 2017, 6:1798 (https://doi.org/10.12688/f1000research.11315.1)
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Open Peer Review

Current Reviewer Status: ?
Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
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PUBLISHED 03 Oct 2017
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Reviewer Report 05 Nov 2018
Robert Robinson, Department of Internal Medicine, SIU School of medicine, Springfield, IL, USA 
Approved with Reservations
VIEWS 6
This article is well written and explores the utility of the LACE index in a different setting than other published studies - A tertiary care center in Portugal.

The background is well written, citing relevant articles and ... Continue reading
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CITE
HOW TO CITE THIS REPORT
Robinson R. Reviewer Report For: Identification of high-risk patients for early death or unplanned readmission using the LACE index in an older Portuguese population [version 1; peer review: 1 approved, 1 approved with reservations]. F1000Research 2017, 6:1798 (https://doi.org/10.5256/f1000research.12211.r40074)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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16
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Reviewer Report 09 Oct 2017
Nan Liu, Health Services Research Centre,  Singapore Health Services, Singapore, Singapore 
Approved
VIEWS 16
Thanks for the opportunity to review. In this manuscript, the authors validated the LACE index on identifying high risk elderly patients in a selected Portuguese population. 1407 patients were retrospectively recruited to evaluate the performance of LACE on its associations ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Liu N. Reviewer Report For: Identification of high-risk patients for early death or unplanned readmission using the LACE index in an older Portuguese population [version 1; peer review: 1 approved, 1 approved with reservations]. F1000Research 2017, 6:1798 (https://doi.org/10.5256/f1000research.12211.r26621)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

Comments on this article Comments (0)

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VERSION 1 PUBLISHED 03 Oct 2017
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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