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Evaluating the predictive strength of the LACE index in identifying patients at high risk of hospital readmission following an inpatient episode: a retrospective cohort study
  1. Sarah Damery1,
  2. Gill Combes2
  1. 1 Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
  2. 2 CLAHRC West Midlands Research Lead for Chronic Diseases Theme, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
  1. Correspondence to Dr Sarah Damery; s.l.damery{at}bham.ac.uk

Abstract

Objective To assess how well the LACE index and its constituent elements predict 30-day hospital readmission, and to determine whether other combinations of clinical or sociodemographic variables may enhance prognostic capability.

Design Retrospective cohort study with split sample design for model validation.

Setting One large hospital Trust in the West Midlands.

Participants All alive-discharge adult inpatient episodes between 1 January 2013 and 31 December 2014.

Data sources Anonymised data for each inpatient episode were obtained from the hospital information system. These included age at index admission, gender, ethnicity, admission/discharge date, length of stay, treatment specialty, admission type and source, discharge destination, comorbidities, number of accident and emergency (A&E) visits in the 6 months before the index admission and whether a patient was readmitted within 30 days of index discharge.

Outcome measures Clinical and patient characteristics of readmission versus non-readmission episodes, proportion of readmission episodes at each LACE score, regression modelling of variables associated with readmission to assess the effectiveness of LACE and other variable combinations to predict 30-day readmission.

Results The training cohort included data on 91 922 patient episodes. Increasing LACE score and each of its individual components were independent predictors of readmission (area under the receiver operating characteristic curve (AUC) 0.773; 95% CI 0.768 to 0.779 for LACE; AUC 0.806; 95% CI 0.801 to 0.812 for the four LACE components). A LACE score of 11 was most effective at distinguishing between higher and lower risk patients. However, only 25% of readmission episodes occurred in the higher scoring group. A model combining A&E visits and hospital episodes per patient in the previous year was more effective at predicting readmission (AUC 0.815; 95% CI 0.810 to 0.819).

Conclusions Although LACE shows good discriminatory power in statistical terms, it may have little added value over and above clinical judgement in predicting a patient’s risk of hospital readmission.

  • LACE
  • readmissions
  • case finding
  • risk stratification
  • hospital

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

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Footnotes

  • Contributors SD and GC designed the study. SD wrote the study protocol. SD undertook data analysis, with input from GC as needed. SD drafted and revised the paper and is the guarantor for the work. GC critically revised the paper for intellectual content. Both authors gave final approval of the manuscript and are accountable for all aspects of the accuracy and integrity of the work.

  • Funding This research was funded by the National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care West Midlands (CLAHRCWM).

  • Competing interests None declared.

  • Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.

  • Ethics approval Ethical approval was obtained from the University of Birmingham Research Ethics Committee (Ref: ERN_14-0914). Research governance approval was obtained from the R&D office of Sandwell and West Birmingham Hospitals NHS Trust (Ref: 14MISC40).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

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