Community Need Index (CNI): a simple tool to predict emergency department utilization after hospital discharge from the trauma service

Abstract

BackgroundEmergency department (ED) visits after hospital discharge may reflect failure of transition of care to the outpatient setting. Reduction of postdischarge ED utilization represents an opportunity for quality improvement and cost reduction. The Community Need Index (CNI) is a Zip code-based score that accounts for a community’s unmet needs with respect to healthcare and is publicly accessible via the internet. The purpose of this study was to determine if patient CNI score is associated with postdischarge ED utilization among hospitalized trauma patients.MethodsLevel 1 trauma patient admitted between January 2014 and June 2016 were stratified by 30-day postdischarge ED utilization (yes/no). CNI is a nationwide Zip code-based score (1.0–5.0) and was determined per patient from the CNI website. Higher scores indicate greater barriers to healthcare per aggregate socioeconomic factors. Patients with 30-day postdischarge ED visits were compared with those without, evaluating for differences in CNI score and clinical and demographic characteristics.Results309 of 3245 patients (9.5%) used the ED. The ED utilization group was older (38.3±15.7 vs. 36.3±16.4 years, p=0.034), more injured (Injury Severity Score 10.4±8.7 vs. 7.7±8.0, p<0.001), and more likely to have had in-hospital complications (17.5% vs. 5.4%, p<0.001). Adjusted for patient age, injury severity, gender, race/ethnicity, penetrating versus blunt injury, alcohol above the legal limit, illicit drug use, the presence of one or more complications and comorbidities, hospital length of stay, and insurance category, CNI score ≥4 was associated with increased utilization (OR 2.0 [95% CI 1.4 to 2.9, p<0.001]).DiscussionCNI is an easily accessible score that independently predicts postdischarge ED utilization in trauma patients. Patients with CNI score ≥4 are at significantly increased risk. Targeted intervention concerning discharge planning for these patients represents an opportunity to decrease postdischarge ED utilization.Level of evidenceIII, Prognostic and Epidemiological.

Can social vulnerability indices predict county trauma fatality rates?

“…Center for Disease Control's Social Vulnerability Index was shown to be strongly associated with comorbidities in addition to being an accurate measure of surgical risk assessment. [8][9][10]21 Consistent with our findings, a 2018 single area study (focused on residents from a single county vs. nonresident patients from surrounding counties) determined that violent deaths are significantly higher in economically distressed areas by 52%, which falls within our nationwide estimates. 11 This prior study also showed that the DCI for the location of injury was a significant predictor in violent firearm events.…”

“…Multiple studies demonstrate the strength of existing indices regarding the identification of surgical risk, hospital discharge status, and readmission rates. [8][9][10] Prior work illustrates that distressed communities around a single trauma center predict youth gun violence and identified three census variables correlated with intentional trauma. 11,12 However, the association of social vulnerability indices with injury-related fatality rates on a broader scale remains unknown.…”

Disparities in Emergency Versus Elective Surgery: Comparing Measures of Neighborhood Social Vulnerability

“…20 The CNI has been used by Huang et al to predict emergency room visits after admission for trauma, demonstrating that patients with higher CNI had higher utilization of these resources after discharge. 11 Mehaffy et al have used the DCI in conjunction with the National Surgical Quality Improvement Program surgical risk calculator, demonstrating that addition of DCI to this calculator improves its performance. 12 Clearly these measures have value; however, there is no consensus with regards to which index should be used by surgeons studying outcomes disparities.…”

“…9 The SVI is not the only measure of social vulnerability that is being used in the surgical outcomes literature. [10][11][12] This study assesses the performance of the SVI as compared with three similar measures: the Area Deprivation Index (ADI), Community Needs Index (CNI), and Distressed Communities Index (DCI), which are measured at the census block group and zip code level, respectively. 3,13,14 Characteristics of the four measures are described and compared in Table 1.…”

Alignment of Community Benefit Spending and Initiatives to Improve Community Health: Is There Evidence of Progress?

“…Lastly, 2019 census tract-level SDOH data was extracted from the Census Bureau’s American Communities Survey and were also compiled into a modified Community Needs Index (CNI), which combines independent SDOH factors into a composite measure to indicate healthcare barriers, using the methodology developed by Dignity Health. 18,19 Census tract-level SDOH and CNI data were aggregated up to the hospital service areas (HSA) as defined by the Dartmouth Atlas of Health Care (http://www.dartmouthatlas.org/) as these are more representative of a hospital’s healthcare market or community. To summarize, each record in the data table contained the hospital’s community benefit expenditures, hospital characteristics, aggregate SDOH characteristics of its service area, the CNI, and details about its PPHI for the year 2019.…”