Discordant Care as a Computable Phenotype: Real-Time Detection of Routine Protocol Completion Without Cognitive Patient Engagement Predicts Hospital Mortality in the ICU"

BackgroundQuality measurement in intensive care emphasizes task completion--whether assessments were documented and protocols followed. Electronic health record (EHR) systems capture these signals in real time, yet current metrics cannot distinguish task completion from cognitive clinical engagement. A prior analysis demonstrated that omission of orientation assessment predicted a 4.29-fold increase in hospital mortality among low-acuity ICU patients [1]. Whether combining this marker with routine task-completion data yields a computable phenotype with independent prognostic value has not been studied. ObjectiveTo define, validate, and characterize "discordant care"--a computable EHR phenotype defined as completion of [≥]6 of 8 routine nursing assessments without orientation assessment documentation--as a predictor of hospital mortality, distinguishing patient-level confounding from care process signal. MethodsRetrospective cohort study using MIMIC-IV v3.1 (2008-2022), including 46,004 adult ICU stays with SOFA scores 0-2 and length of stay [≥]24 hours in non-neurological ICUs. Primary exposure: discordant care, computed from structured nursing flowsheet data within 24 hours of admission. Primary outcome: hospital mortality. Progressive covariate adjustment included mechanical ventilation, sedation, and diagnosis. ResultsDiscordant care was present in 8891 patients (19.3%), with 69.7% mechanically ventilated versus 25.3% of concordant patients. Two overlapping signals were identified: a patient-level signal driven by ventilation/sedation (full adjustment OR 1.19, 95% CI 1.09-1.30) and a care process signal in non-ventilated patients (OR 2.14, 1.87-2.44; N=30,314). Among non-ventilated SOFA 0 patients, OR was 2.60 (2.13-3.18; N=16,295). The signal was present across all 7 major diagnosis categories. Quantitative bias analysis indicated unmeasured delirium could attenuate but likely not fully explain the non-ventilated signal. ConclusionsDiscordant care identifies two phenomena: a patient-level signal from ventilation/sedation and a care process signal where assessable patients receive routine care without cognitive engagement (OR 2.14-2.60). This care process signal is invisible to existing quality metrics and detectable in real time. Prospective validation with systematic delirium screening is needed.