📊 ReadmitRisk Platform - Combined Executive Report

Comprehensive analysis across MIMIC-IV ICU, UCI Diabetes, and National Geographic datasets

📋 Platform Overview: This report synthesizes insights from three complementary datasets: MIMIC-IV ICU clinical data (211K admissions, 2008-2019), UCI Diabetes multi-hospital data (71K patients, 1999-2008), and CMS Hospital Readmissions Reduction Program geographic data (205 hospitals, 5 states). Together, these provide comprehensive readmission risk intelligence across care settings and geographies.

282,872
Total Patients Analyzed
205
Hospitals Benchmarked
$2.0B
Combined Cost Exposure

Executive Summary

The ReadmitRisk platform provides multi-dimensional readmission risk intelligence by integrating three distinct data sources:

  1. MIMIC-IV ICU Data: Deep clinical features for critically ill populations
  2. UCI Diabetes Data: General diabetes population risk patterns
  3. CMS Geographic Data: Hospital performance benchmarks and penalty exposure

This combined approach enables healthcare organizations to: (a) identify high-risk patients using validated ML models, (b) benchmark provider performance against national standards, and (c) prioritize interventions based on evidence-based ROI projections.

🎯 Key Strategic Insight

ICU populations show 5.5× higher high-risk prevalence (54.2%) compared to general diabetes populations (9.9%). Organizations must deploy differentiated care management strategies: intensive transitional care for ICU survivors vs. medication management and outpatient coordination for general medical/surgical patients.

Dataset Comparison

Metric MIMIC-IV
(ICU)		 UCI Diabetes
(General Pop)		 CMS Geographic
(National)
Sample Size 211,354 admissions 71,518 patients 205 hospitals
Readmission Rate 20.5% 8.8% 15.5% (avg across 5 states)
High-Risk % 54.2% (≥60%) 9.9% (≥60%) N/A
Model AUC 0.630 (Gradient Boosting) 0.564 (Logistic Regression) N/A
Features 60+ clinical variables 12 administrative variables State/hospital aggregates
Time Period 2008-2019 1999-2008 Current (2023)
Cost Exposure $1.92B (high-risk cohort) $78.5M (high-risk cohort) $21M penalties (5 states)

MIMIC-IV ICU Population

🏥 Best for: Post-ICU transitional care programs, critical illness survivors, mechanically ventilated patients

Key Findings

  • 54.2% classified as high-risk (≥60%) - far exceeding general populations
  • Top risk drivers: Age (36.5%), procedure count (10.3%), lab abnormalities (bilirubin 8.9%, potassium 7.1%)
  • 114,589 patients in high-risk cohort with $1.92B cost exposure
  • 20.5% overall readmission rate vs. 26.3% in high-risk cohort

Recommended Actions

  • Implement ICU-to-home transitional care programs with 48-hour home health visits
  • Deploy clinical pharmacists for medication reconciliation (avg 20+ meds)
  • Screen for post-ICU syndrome (PICS) and provide cognitive/physical rehabilitation
  • Establish post-ICU recovery clinics for complex patients

UCI Diabetes Population

💊 Best for: General medical/surgical populations, diabetes-specific programs, multi-hospital systems

Key Findings

  • 9.9% classified as high-risk (≥60%) - typical for general populations
  • Top risk drivers: Total prior visits (4.36 coefficient), number of medications (0.28), lab procedures (0.10)
  • 7,083 high-risk patients representing $78.5M cost exposure
  • Outpatient visits show strong protective effect (-3.12 coefficient)

Recommended Actions

  • Strengthen discharge-to-outpatient handoffs (follow-up within 7 days)
  • Deploy nurse-led phone calls within 48-72 hours for medication adherence
  • Implement diabetes-specific education programs before discharge
  • Focus on polypharmacy management and deprescribing protocols

CMS Geographic Data

🗺️ Best for: Provider network optimization, value-based contracting, regional quality improvement

Key Findings

  • 205 hospitals across 5 states (AL, AK, AR, AZ, CA) tracked for CMS penalty exposure
  • $21M total penalty exposure across analyzed states
  • Regional variation: 16.2% (CA) to 14.9% (AK) average readmission rate
  • Individual hospital penalties range from $560K to $2.08M annually

Recommended Actions

  • Map provider networks against hospital penalty tiers
  • Engage high-penalty hospitals in quality improvement partnerships
  • Deploy care managers in geographic areas with highest penalty concentration
  • Structure value-based contracts to reward below-benchmark performance

Integrated Risk Stratification Strategy

Patient Segment Risk Level Primary Dataset Intervention Strategy Expected Reduction
ICU Survivors Critical (80%+) MIMIC-IV ICU transitional care + home health 25-35%
Complex Chronic Very High (70-80%) UCI + MIMIC Case management + pharmacist 20-30%
Diabetes/Multi-morbid High (60-70%) UCI Diabetes Nurse calls + outpatient coordination 15-25%
High-Penalty Hospitals Regional Focus CMS Geographic Quality collaboratives + SDOH screening 10-20%

Combined ROI Analysis

Based on intervention effectiveness literature and platform risk stratification:

ICU Population (MIMIC-IV - 68,962 critical patients)

Intervention Cost/Patient Patients Targeted Readmissions Prevented Savings Net ROI
ICU Transitional Care $850 68,962 4,827 (28% of expected) $72.4M $13.8M (24% ROI)

General Population (UCI - 7,083 high-risk patients)

Intervention Cost/Patient Patients Targeted Readmissions Prevented Savings Net ROI
Transitional Care Mgmt $300 7,083 425 (20% reduction) $6.4M $4.3M (200% ROI)

Technology Integration Roadmap

Phase 1: Risk Scoring Integration (Months 1-3)

Phase 2: Intervention Deployment (Months 4-6)

Phase 3: Outcomes Tracking (Months 7-12)

Strategic Recommendations

1. Deploy Differentiated Care Models by Acuity

ICU and general populations require fundamentally different transitional care approaches. Allocate highest-intensity resources (home health, pharmacists, case managers) to ICU survivors; leverage lower-cost nurse calls and outpatient coordination for general medical/surgical patients.

2. Geographic Targeting for Provider Engagement

Use CMS geographic data to prioritize quality improvement partnerships with hospitals showing high penalty rates. These facilities offer greatest opportunity for penalty reduction and collaborative gain.

3. Real-Time EHR Integration

Embed risk scoring into discharge workflow to enable proactive intervention deployment rather than retrospective case-finding. Target <72 hour activation for all high-risk patients.

4. Measure and Iterate

Establish baseline readmission rates by risk tier, then track quarterly performance. Use local outcomes data to retrain models and adjust intervention intensity to optimize ROI.

📑 Detailed Report Links

MIMIC-IV Analysis

ICU population risk analysis with 211K admissions

UCI Diabetes Analysis

General population diabetes risk analysis

Geographic Analysis

CMS hospital penalty and regional benchmarks

MIMIC Methodology

Data extraction and feature engineering details

UCI Methodology

Model training and validation approach

Geographic Methodology

CMS data processing and analysis methods

ReadmitRisk Platform | Combined Executive Report

Generated: January 2026 | Integrates MIMIC-IV (2008-2019), UCI Diabetes (1999-2008), and CMS HRRP data

Platform Dashboard: View Interactive Dashboard

GitHub Repository: github.com/NateDevIO/readmit-risk