• Surain B Roberts, Michael Colacci, Fahad Razak, and Amol A Verma.
• Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada. surain.roberts@unityhealth.to.
• J Gen Intern Med. 2023 Nov 1; 38 (15): 330333123303-3312.

BackgroundMethods to accurately predict the risk of in-hospital mortality are important for applications including quality assessment of healthcare institutions and research.ObjectiveTo update and validate the Kaiser Permanente inpatient risk adjustment methodology (KP method) to predict in-hospital mortality, using open-source tools to measure comorbidity and diagnosis groups, and removing troponin which is difficult to standardize across modern clinical assays.DesignRetrospective cohort study using electronic health record data from GEMINI. GEMINI is a research collaborative that collects administrative and clinical data from hospital information systems.ParticipantsAdult general medicine inpatients at 28 hospitals in Ontario, Canada, between April 2010 and December 2022.Main MeasuresThe outcome was in-hospital mortality, modeled by diagnosis group using 56 logistic regressions. We compared models with and without troponin as an input to the laboratory-based acute physiology score. We fit and validated the updated method using internal-external cross-validation at 28 hospitals from April 2015 to December 2022.Key ResultsIn 938,103 hospitalizations with 7.2% in-hospital mortality, the updated KP method accurately predicted the risk of mortality. The c-statistic at the median hospital was 0.866 (see Fig. 3) (25th-75th 0.848-0.876, range 0.816-0.927) and calibration was strong for nearly all patients at all hospitals. The 95th percentile absolute difference between predicted and observed probabilities was 0.038 at the median hospital (25th-75th 0.024-0.057, range 0.006-0.118). Model performance was very similar with and without troponin in a subset of 7 hospitals, and performance was similar with and without troponin for patients hospitalized for heart failure and acute myocardial infarction.ConclusionsAn update to the KP method accurately predicted in-hospital mortality for general medicine inpatients in 28 hospitals in Ontario, Canada. This updated method can be implemented in a wider range of settings using common open-source tools.© 2023. The Author(s), under exclusive licence to Society of General Internal Medicine.

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