Predicting 30-day readmission and mortality in long-term care residents: recalibration of LACE and development of LACE-2 in a Maltese retrospective cohort

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Objectives The Length of stay, Acuity of admission, Charlson Comorbidity Index, and Emergency department visits (LACE) index estimates 30-day risk of readmission or death after hospital discharge, but its performance in long-term care (LTC) populations is uncertain. We assessed the original LACE score in older adults discharged to LTC in Malta, refit the model, and derived a simplified two-variable alternative. Materials and Methods We conducted a retrospective cohort study of adults aged 65 years and older discharged from Malta’s main acute general hospital to LTC between September 2023 and September 2024. The original LACE score was assessed for 30-day unplanned readmission, 30-day mortality, and the combined outcome. Logistic models were refit locally. A simplified LACE-2 model was derived from prespecified LACE components. Discrimination was assessed using the C-statistic; calibration was assessed using calibration plots, calibration-in-the-large, calibration slope, Brier score, and the Hosmer–Lemeshow test. Results Among 1,389 LTC discharges, median age was 85 years and 67.9% were women. Thirty-day readmission occurred in 35.3%, mortality in 10.3%, and the combined outcome in 38.0%. The original LACE score showed modest discrimination and suboptimal calibration. Refit LACE improved calibration. LACE-2, comprising length of stay and ED visits, showed comparable discrimination for the combined outcome (C-statistic 0.71) and readmission (0.71), while mortality prediction was weaker across the cohort, with lower age-stratified performance in older groups. Conclusion In older adults discharged to LTC in Malta, LACE required local adaptation. LACE-2 retained similar discrimination for readmission-related outcomes with fewer variables but requires external validation.

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