Common Risk Stratification of Hospital and Ambulatory Patients

Area of Science:

• Healthcare Management
• Public Health
• Clinical Informatics

Background:

• Patient care, especially for those with multiple chronic conditions or near end-of-life, is often hindered by healthcare team miscommunication.
• Standardized risk stratification across hospital and ambulatory settings could potentially improve care coordination and patient outcomes.

Purpose of the Study:

• To develop, validate, and implement an all-payer ambulatory risk stratification model.
• To predict patients' probability of dying within 30 days to identify high-risk individuals in an ambulatory setting.

Main Methods:

• Development of an all-payer ambulatory risk stratification model based on predicted 30-day mortality.
• Validation of the model against existing hospital risk strata.
• Implementation within a large multispecialty practice.

Main Results:

• The developed ambulatory risk strata demonstrated comparable 30-day mortality rates to established hospital strata.
• High-risk ambulatory strata, comprising less than 20% of the population, identified a significant proportion of patients with multiple comorbidities (85%) and those with high mortality risk (over 80% within 30 or 180 days).
• This stratification also identified two-thirds of patients experiencing nonsurgical hospitalizations within 30 days.

Conclusions:

• An all-payer ambulatory risk stratification model effectively identifies high-risk patients, improving care for those with multiple chronic conditions and end-of-life needs.
• The common risk framework facilitates improved clinical care models and communication between practices and hospitals.
• This approach enhances the ability to manage complex patient populations and reduce adverse healthcare events.