Accepted for/Published in: Journal of Medical Internet Research
Date Submitted: Mar 11, 2025
Open Peer Review Period: Mar 11, 2025 - May 6, 2025
Date Accepted: Apr 17, 2025
(closed for review but you can still tweet)
Pragmatic risk stratification method to identify emergency department presentations for alternative care service pathways: a registry-based retrospective study over 5 years
ABSTRACT
Background:
Redirecting avoidable presentations to alternative care service pathways (ACSPs) may lead to better allocation of resources for pre-hospital emergency care. Stratifying emergency department (ED) presentations by admission risk using diagnosis codes might be useful to identify patients suitable for ACSPs.
Objective:
To cluster ICD-10 diagnosis codes based on hospital admission risk and identify ED presentation characteristics associated with these clusters, to develop an exploratory classification to identify groups potentially suitable for ACSPs
Methods:
Retrospective observational data from a database of all visits to the ED of a tertiary care institution over five years (2016-2020) were analysed. K-means clustering grouped diagnosis codes according to admission outcomes. Multivariable logistic regression was performed to determine the association of characteristics with cluster membership. ICD-10 codes were grouped into blocks, and analysed for cumulative coverage to identify dominant groups associated with lower hospital admission risk.
Results:
A total of 215,477 ambulatory attendances classified as Priority Levels 3 (Ambulatory) and 4 (Non-emergency) under the Patient Acuity Category Scale were selected, with a 17.3 (0.4)% overall admission rate. The mean presentation age was 46.2 (19.4) years. Four clusters with varying hospital admission risks (Cluster 1: 4.7%; Cluster 2: 19.5%; Cluster 3: 47.8%; Cluster 4: 78.0%) were identified. Moderate (OR = 2.40 [2.28, 2.51]) and severe (OR = 3.29 [3.13, 3.45]) Charlson Comorbidity Index scores increased odds of admission. Among 132 ICD-10 blocks, low-risk categories included musculoskeletal/connective tissue disorders and head/lower limbs injuries. Higher-risk categories included respiratory infections such as influenza and pneumonia, and infections of the skin and subcutaneous tissue.
Conclusions:
Most ambulatory presentations at the ED were categorised into low-risk clusters with a minimal likelihood of hospital admission. Stratifying ICD-10 diagnosis codes by admission outcomes and ranking them based on frequency provides a structured approach to potentially stratify admission risk. Clinical Trial: NUS-IRB-2025-60
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