The Impact of Longitudinal Data-Completeness of Electronic Health Record Data on the Prediction Performance of Clinical Risk Scores

The impact of electronic health record (EHR) discontinuity (i.e., receiving care outside of a given EHR system) on EHR-based risk prediction is unknown. We aimed to assess the impact of EHR-continuity on the performance of clinical risk scores. The study cohort consisted of patients aged = 65 years with = 1 EHR encounter in the 2 networks in Massachusetts (MA; 2007/1/1-2017/12/31, internal training and validation dataset), and one network in North Carolina (NC; 2007/1/1-2016/12/31, external validation dataset) that were linked with Medicare claims data. Risk scores were calculated using EHR data alone vs. linked EHR-claims data (not subject to misclassification due to EHR-discontinuity): (i) combined comorbidity score (CCS), (ii) claim-based frailty score (CFI), (iii) CHAD(2)DS(2)-VASc, and (iv) Hypertension, Abnormal renal/liver function, Stroke, Bleeding, Labile, Elderly, and Drugs (HAS-BLED). We assessed the performance of CCS and CFI predicting death, CHAD(2)DS(2)-VASc predicting ischemic stroke, and HAS-BLED predicting bleeding by area under receiver operating characteristic curve (AUROC), stratified by quartiles of predicted EHR-continuity (Q1-4). There were 319,740 patients in the MA systems and 125,380 in the NC system. In the external validation dataset, AUROC for EHR-based CCS predicting 1-year risk of death was 0.583 in Q1 (lowest) EHR-continuity group, which increased to 0.739 in Q4 (highest) EHR-continuity group. The corresponding improvement in AUROC was 0.539 to 0.647 for CFI, 0.556 to 0.637 for CHAD(2)DS(2)-VASc, and 0.517 to 0.556 for HAS-BLED. The AUROC in Q4 EHR-continuity group based on EHR alone approximates that based on EHR-claims data. The prediction performance of four clinical risk scores was substantially worse in patients with lower vs. high EHR-continuity.