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Usability and Applicability of the LACE Index as a Tool for Predicting Early Hospital Readmission and Mortality: A Scoping Review.

2- AUTHORS
Suelen Cristina Zandonadi Bernal
Orcid:0000-0002-1327-9261
UniversidadeEstadual de Maringá

Joshua Yamakami
Orcid: 0009-0002-2133-7924
UniversidadeEstadual de Maringá

Gabriel Mendes Plantier
Orcid: 0000-0002-2886-7760
UniversidadeEstadual de Maringá

Aline Zulin
Orcid: 0000-0001-6749-762x
UniversidadeEstadual de Maringá

Ivi Ribeiro Back
Orcid: 0000-0002-7867-8343
UniversidadeEstadual de Maringá

ThamiresFernandes Cardoso da Silva
Orcid: 0000-0001-7942-4989
UniversidadeEstadual de Maringá

Paulo Roberto Aranha Torres
Orcid: 0000-0001-7221-4153
UniversidadeEstadual de Maringá

CremideAparecidaTrindadeRadovanovic
Orcid: 0000-0001-9825-3062
UniversidadeEstadual de Maringá


 
3- ABSTRACT

Objective: to produce a systematic mapping of scientific production on the usability and applicability of the LACE Index as a tool for predicting early hospital readmission and mortality. Method:this scoping review, framed by JBI guidelines, covered eight databases and the grey literature.Results:of the twenty-eight publications reviewed, most addressed foreign populations and were published 2011 to 2023. Most were retrospective cohort studies with level of evidence 3by the criteria of the Oxford Center for Evidence-based Medicine. LACE scoring was used predominantly as a predictor of readmission and mortality, especially of medicalpatients. Conclusion:there is a significant gap in the literature due to the predominance of retrospective studies and the absence of prospective studies with a high level of evidence, in addition to isolated use of LACE as a tool to predict mortality.

4- KEYWORDS
Keywords:patient care continuity; nursing care; transitional care; patient readmission; mortality.

5- BODY OF ARTICLE IN FULL
INTRODUCTION
Hospitalreadmissionis defined as admission occurring within a pre-established interval of time subsequent to discharge from the original admission, also known as the index admission(1,2).In the context following hospital discharge, it is categorised as early when occurring within 30 days. Early readmissionis widely used as a measure of hospital performance and considered an indicator of the quality of care provided(3,4).
Studies indicate that the mean rate of hospital readmissionwithin 30 days varies from 15% to 20%(5,6).Note that these early readmissions have considerable financial impact on the health care system(7). In the United States, 19.6% of patients admitted are readmitted within 30 days, at an annual cost of approximately US$ 17.4 billion. In the United Kingdom, the financial impact of such readmissionsis estimated to be around £ 2.5 billionper year. In Canada, in the province of Ontario, readmissionsincur costs of CA$ 105 million annually(4,8,9).
A number of countries have directed research to understanding readmission rates, considering different analysis sets.In Singapore,the readmission ratewas 15.5% (10)and, among patients with acute myocardial infarction, rates were 12.6%in Canada (11) and 11.8% in Australia(12). Among older patients, the readmission ratewas 17.8%in the United Kingdom (13)and 18.9%in Denmark (14).
Given the financial impact, patient stress and increased risk of death associated with hospital readmissions, institutional studies are crucial to establishing post-discharge follow-up measures and proposing more intensive transitional care interventions with a view to reducing readmission-related expenses and mortality rates and improving the quality of care(15,16).
Reducing hospital readmission rateshas become an important concern in developed economies, but is still incipient in developing countries, including Brazil. Research in Brazilhas found readmission ratesof up to 31.7%, with readmission more prevalent among patients with prior stays of less than seven days, adults with pre-existing medical conditions and in hospitalswith fewer than 100 beds(7,17,18).
Considering the complexity of the problem, in which so many variables interact causally, it is important to use tools that can identify patients at greater risk of early readmissionand death, which may be useful in indicating care performance and directing improvement measures, so as to strengthen decision making, guarantee safer patient outcomes and lower hospital operating costs (16,17).
Developed by Carl van Walravenet al. in Canadain 2010, the LACE Indexconsiders four variables relating to hospital stay and identified bythe initial letters of each item: Length of stay, Acute admission, Charlson comorbidity index and Emergent admissions (number of acute admissions in the six months prior to the current admission)(19).
The LACE index has been validated in a number of countries, including England, Australiaand Brazilin 2020 and is a prime tool for assessing quality of care(1,18,19): the small number of variablesmakes it easily applicable in hospital staff routines. Also, as it requires no complex or external data (laboratory tests, complementary reports etc.), it can be used even in hospitalswith little information technology support(2,20,21). New studies are thus needed to evaluate the usability and applicability of the LACEIndex in samples of patients with different epidemiological profiles and in a diversity of contexts.
In that connection, the scoping review proposed here mapped scientific production on the usability and applicabilityof the LACE Indexas a tool for predicting early hospital readmissionand mortality.The proposed review offers a comprehensive analysis of use of the LACE Indexin predicting early hospital readmissionand mortality. By assessing the existing literature, it identified gaps in the researchand offered perceptions of the index’s applicabilityin different clinical contexts. With that as a basis, practical recommendations for health practitioners and managers are presented with a view to improving the quality of care and fostering evidence-based clinical practice.

METHOD
Study type
This scoping review was designed to explore essential concepts in one particular field of knowledge, using a diverse range of sources and covering the available literature extensively. Its purpose was to detect gaps in the existing research. Unlike other forms of review, which usually concentrate on specific issues, scoping reviews formulate broader researchquestions and can incorporate studies with a variety of methodological designs(22).
Methodological procedure
The methodological procedure followed in this study, between October 2023 and February 2024, implemented a series of stepsframed by the Joanna Briggs Institute (JBI) protocol (22), a scoping review compendium.
The PRISMA Extension for Scoping Reviews (PRISMA-ScR) (23) was used to assist the systematicorganisation of the research sample, the search strategy, analysis of the studies and development of the findings.
Stage(1), the preliminary literature review, confirmed that the study was original and identified a significant literatureon which to base the research. This stage involved searching the Virtual Health Library and MEDLINE information sources, using the descriptors: “LACE”, “patient readmission”and “mortality”. On that occasion, the main index terms and keywords used were identified.
Stage (2) involved developing the research protocol, so as to establish criteria and ensure the process was transparent and replicable. The protocol was registered on the Open Science Framework (OSF) platform (https://doi.org/10.17605/OSF.IO/R6SME).
Stage (3) concentrated on information collection with a view to identifying predominant authors and journals by subject and year of publication. The JBI scoping reviewprotocol recommends constructing the title, objectives, research questionand inclusion criteriaon the basis of the mnemonic PCC (Population, Concept, Context), which was done in Stage (4).
In this way, theresearch questionwas formulated to reflect: Population – scientific production on the topic proposed for study; Concepts – Usability and applicabilityof the LACE Indexas a predictor of hospital readmissionand mortality; and Study Context– all and any service worldwide, thus arriving at the following guiding question: "How does the scientific production describe the usabilityand applicabilityof the LACE Indexas a predictor of early hospital readmissionand mortalityin the world literature?"
Data collection and organisation
Stage 5, involved formulating the eligibility criteria, which were selected on the PCC basis recommended by the JBI(22), as described in Table 1.
Table 1

No time restrictions were placed on the data base searches, which allowed studies from any period to be identified, thus broadening the scope of the results.
In Stage (6), on 25 October 2023, the following data bases were searched: LILACS and BIREME via the Virtual Health Library, MEDLINE via PubMed, Cochrane, CINAHL, Scopus and Embase and, as scoping reviews allow searches of the grey literature, Web of Science, the CAPES Catalogue of Theses and Dissertations and Google Academic®. In the search strategybased on the PCC mnemonic, “Population”and “Context”were expressed in such a way as to broaden the search filtering. For theLACE descriptor“Concept”(patient readmissionand mortality), the searches were conducted as in Table 2.
Table 2

Data analysis
In Stage (7), after the searches, one of theresearchers exported the files to the Rayyan QCRI®centralisation tool. Studies were selected by peer review, by two researchers and with blinding. First, one of theresearchersexcluded the duplicate articles and then a preliminary selection was made of studies by title and abstract in order to determine their relevance to the review and whether they met the inclusion or exclusion criteria. The preselected studies were read in full, once again ascertaining whether or not they met the eligibility criteria.
Then the blinding was removed from the Rayyan QCRI® software so as to identify any divergences between the reviewers. The researchersresolved conflicts by discussing them and deciding on the basis of the eligibility criteria, with a view to achieving consensus. The relevant data were extracted for later analysis, resulting in the final study sample.
Stage (8), discussion of theory, drew on prominent studies on the topic in question. Stage(9) involved extracting and coding the following data from the studies included in the final study sample: title, authors/date/country, objective and study type/level of evidence.The data were treated and summarised by topic, following the PRISMA-ScR guidelines. The content was analysed by careful, detailed reading of the studies, which were grouped by similarities, as shown in Figure 2.
Stage(10)involved assessing the evidence using the level of scientific evidenceclassification instrument of the Oxford Centre for Evidence-based Medicine (CEBM)(28).This is essential in order to guarantee the quality and reliability of the findings of this review and provides a sound basis for the conclusions and recommendations.
Lastly, Stage (11) consisted in presenting the findings (Table-3).
Ethics considerations
As this was a review study, it did not need to be submitted to a research ethics committee.

RESULTS
In all, 329 studies and documents were identified as having research potential. Of these, 153 were excluded as duplicates, resulting in 176 publications for analysis of titles and abstracts. After this, 99 studieswere discarded as not addressing the review question, leaving 77 for more detailed analysis. During complete review, 49 studieswere excluded on the eligibility criteria.
The finalsample final consisted of 28 studies, which were analysed and included in this review, as in Figure 1.
A total of 27 authors were selected, of whom only 4% (n = 1) had published more than one article on the subject. Most of the publications (88%; n = 25) originated in international journals, predominantly in English, distributed as follows: 39.2% (n = 11) in the USA, 14.4% (n = 4) in Canada, 14.4% (n = 4) in the United Kingdom, 10.7% (n = 3) in Australia, 3.5% (n = 1) in Singapore, 7.1 % (n = 2) in South Korea and 10.7 % (n = 3) in Brazil.
The studiesthat made up the sample were published between 2011 and 2023, the highest percentages being in 2019, 2020 and 2022 with 14.4% (n = 4) in each year. On examining the evidence, 89% (n = 25) of the studieswere found to be retrospective cohorts, 3.5% (n = 1) a prospective cohort, both with level of evidence 3;3.5% (n = 1)was asystematic review;and 3.5% (n = 1),a randomised clinical trial, the latter two both with level of evidence 1.
Coding of the studies produced three groups, which could be classified by similarity. Thus, 57.2% (n = 16) contained passages relating to the use and application of the LACE Indexas a predictor of readmissionand mortality; 35.7% (n = 10) mentioned use of the LACE Indexas a predictor de early hospital readmission; and 7.1%, use of the LACE Indexas a predictorof mortality.
The LACE Indexwas applied to populationsofall kinds, as in Figure 2:to medical patientsin 35.7% of the studies (n = 10); to patientswith cardiac problemsin 21.4% (n = 6); to oncological patientsin 10.7% (n = 3); to surgicalpatientsin 10.7% (n = 3); to neurosurgicalpatientsin 3.5% (n = 1); to patientsin palliative carein 3.5% (n = 1); to patientswith community-acquired pneumoniain 3.5% (n = 1); and to patientswith COVID-19 in 3.5% (n = 1).

Figure 2
Table 3
Figure 3

DISCUSSION

This scoping review demonstrated the applicabilityof the LACE Indexas a tool for predicting early hospital readmissionand mortality, corroborating the findings of a number of studies with foreign populations(4,8,9). Nonetheless, analysis of the results revealed important limitations and gaps in the literature, which need to be addressed in future research.
The LACE Indexhas been widely used in different clinical contexts to predict hospital readmissionsand mortality(2,20,43,46).Studies reviewed indicated that the index is particularly useful in medical, cardiological and oncological patients, because of its ability to integrate variables, such as length of stay, acute admission, comorbiditiesand number of emergency department visits within 6 months prior to the current admission(11,12,27,28,35).
Despite its widespread use, most of the studiesreviewed were retrospective cohorts, limiting their ability to establish causality and predict future events prospectively(18,33,36). This lack of robust prospective studies suggests an urgent need for research that can validate and refine the use of the LACE Indexin different populationsand health contexts and explore its potential for integrating with other predictive tools(12,33).
Studiesin the United Kingdomand Canadafind the LACE Indexto be a simple, effective risk assessment tool, but they point to a need for specific adjustments to different populations(13,14).Researchhas shown that including additional variables, such as socioeconomic and social supportfactors (20,41,47), and using the index in combination with other predictive tools can improve its accuracy in predicting readmissionsand mortality(19,24,39).
This reviewalso showed that most of the studiesaddressed foreign populations, particularly in developed countries, while developing countries, such as Brazil, were under-represented(11,27,35). This gap reveals the need for more local research to assess the applicabilityand efficacy of the LACE Indexin different socioeconomicand cultural contexts.Variations in performance when applied to different populationspose the challenge of creating a single model that can be widely used. Thatideal model would not only assist prevention programmes in patient screening, but also enable results to be compared between hospitalsand regions(2,17).
Accordingly, the LACE Indexcan be a rapid, effective approach to identifying patientsat high risk of readmissionand mortality and thus permitting early interventions. However, it is essential that practitioners be aware of the index’s limitations and consider other clinical and social factors that may influence results.
In addition, encouraging the adoption of integrated approaches that combine the LACE Indexwith other tools and clinical data may yield more accurate predictions and better quality of post-discharge care.

CONCLUSION
The findings reveal that the LACE Indexis widely used and considered effective in a variety of clinical contexts.However, the, predominance of retrospectivestudies and the lack of robust, prospective research point to a need for more studiesto validate and refine use of the LACE Index.
It is recommended that future research include prospective studiesand randomised clinical trials to confirm the LACE Index’s effectiveness, as well as to explore integrating it with other predictive tools. It is particularly essential to consider adapting the index to different populationsand socioeconomic contexts, especially in developing countries.
On the base of these findings, health practitioners and managers can use the LACE Indexas a complementary tool to improve the quality of care and reduce hospital readmission ratesand mortality, thus contributing to a more efficient, evidence-based health care system.

CONFLICTOF INTEREST
The authors declare there is no conflict of interest.

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