Comparing state-wide and single-center data to predict high-frequency emergency department utilization among patients with asthma exacerbation

Abstract

Background

Previous studies examining high-frequency ED utilization have primarily used single-center data, potentially leading to ascertainment bias if patients visit multiple centers. The goals of this study were (1) to create a predictive model to prospectively identify patients at risk of high-frequency ED utilization for asthma, and (2) to examine how that model differed using state-wide versus single-center data.

Methods

To track ED visits within a state, we analyzed 2011-2013 data from the New York State Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases (SEDD). The first year of data (2011) was used to determine prior utilization; 2012 was used to identify index ED visits for asthma and for demographics; and 2013 was used for outcome ascertainment. High-frequency utilization was defined as 4+ ED visits for asthma within one year after the index visit. We performed analyses separately for children (age <21 years) and adults, and constructed two models: one included all state-wide (multi-center) visits, and the other was restricted to index hospital (single-center) visits. Multivariable logistic regression models were developed from potential predictors selected a priori. The final model was chosen by evaluating model performance using AIC scores, 10-fold cross validation, and ROC curves.

Results

Among children, high-frequency ED utilization for asthma was observed in 2,417/94,258 (2.56%) using all state-wide visits, compared to 1,853/94,258 (1.97%) for index hospital visits only. Among adults, the corresponding results were 7,779/159,874 (4.87%) and 5,053/159,874 (3.16%), respectively. In the multi-center visit model, the area under the curve (AUC) from 10-fold cross validation for children was 0.70 (95% CI: 0.69-0.72), compared to 0.71 (95% CI: 0.69-0.72) in the single-center visit model. The corresponding AUC results for adults were 0.76 (95% CI: 0.76-0.77) and 0.76 (0.75-0.77), respectively.

Conclusion

Data available at the index ED visit can predict subsequent high-frequency utilization for asthma with AUC ranging from 0.70-0.76. Model accuracy was similar regardless of whether outcome ascertainment included all state-wide visits (multi-center) or was limited to the index hospital (single-center).

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