A risk stratification tool for hospitalisation in Australia using primary care data.

Predictive risk models using general practice (GP) data to predict the risk of hospitalisation have the potential to identify patients for targeted care. Effective use can help deliver significant reductions in the incidence of hospitalisation, particularly for patients with chronic conditions, the highest consumers of hospital resources. There are currently no published validated risk models for the Australian context using GP data to predict hospitalisation. In addition, published models for other contexts typically rely on a patient's history of prior hospitalisations, a field not commonly available in GP information systems, as a predictor. We present a predictive risk model developed for use by GPs to assist in targeting coordinated healthcare to patients most in need. The algorithm was developed and validated using a retrospective primary care cohort, linked to records of hospitalisation in Victoria, Australia, to predict the risk of hospitalisation within one year. Predictors employed include demographics, prescription history, pathology results and disease diagnoses. Prior hospitalisation information was not employed as a predictor. Our model shows good performance and has been implemented within primary care practices participating in Health Care Homes, an Australian Government initiative being trialled for providing ongoing comprehensive care for patients with chronic and complex conditions.