Validation of the multivariable In-hospital Mortality for PulmonAry embolism using Claims daTa (IMPACT) prediction rule within an all-payer inpatient administrative claims database

Abstract

Objective: To validate the In-hospital Mortality for PulmonAry embolism using Claims daTa (IMPACT) prediction rule, in a database consisting only of inpatient claims.

Design: Retrospective claims database analysis.

Setting: The 2012 Healthcare Cost and Utilization Project National Inpatient Sample.

Participants: Pulmonary embolism (PE) admissions were identified by an International Classification of Diseases, ninth edition (ICD-9) code either in the primary position or secondary position when accompanied by a primary code for a PE complication. The multivariable IMPACT rule, which includes age and 11 comorbidities, was used to estimate patients' probability of in-hospital mortality and classify them as low or higher risk (≤1.5% deemed low risk).

Primary and secondary outcome measures: The rule's sensitivity, specificity, positive and negative predictive values (PPV and NPV) and area under the receiver operating characteristic curve statistic for predicting in-hospital mortality with accompanying 95% CIs.

Results: A total of 34,108 admissions for PE were included, with a 3.4% in-hospital case-fatality rate. IMPACT classified 11, 025 (32.3%) patients as low risk, and low risk patients had lower in-hospital mortality (OR, 0.17, 95% CI 0.13 to 0.21), shorter length of stay (-1.2 days, p<0.001) and lower total treatment costs (-$3074, p<0.001) than patients classified as higher risk. IMPACT had a sensitivity of 92.4%, 95% CI 90.7 to 93.8 and specificity of 33.2%, 95% CI 32.7 to 33.7 for classifying mortality risk. It had a high NPV (>99%), low PPV (4.6%) and an AUC of 0.74, 95% CI 0.73 to 0.76.

Conclusions: The IMPACT rule appeared valid when used in this all payer, inpatient only administrative claims database. Its high sensitivity and NPV suggest the probability of in-hospital death in those classified as low risk by IMPACT was minimal.

Keywords: GENERAL MEDICINE (see Internal Medicine); INTERNAL MEDICINE; THORACIC MEDICINE; VASCULAR MEDICINE.