What Kairos would have caught
Looking back at the past 6 months on the panel: where the signals were present, how early they were detectable, and what proactive contact would have been worth.
One of the four readmissions had no detectable prodrome, a true unpredictable event. The other three are below.
Case detail
Three readmissions, three signals, what would have changed
Daughter's MyChart message at day 25 post-discharge matched the prodrome signature from his prior three admissions: fatigue plus reduced PO intake without overt edema.
Same-week proactive nurse callback before symptoms progressed. Pattern was deterministic: three prior prodromes, all in the same post-discharge window.
Home weight log showed a 4-pound gain over 72 hours at day 17 post-discharge; coincided with a 5-day gap in furosemide refill on the pharmacy feed.
Cross-source signal joining vitals + pharmacy refill. Neither alone met threshold; together they did.
Home pulse-ox feed (Bluetooth) trended from 94% baseline to 89% over 6 days. Tiotropium adherence dropped to 40% over the same window.
Adherence-weighted vitals trend, catching the SpO2 drift in the context of a known COPD adherence dip.
Guideline gap analysis
Panel-wide opportunities flagged against current society guidelines
HFrEF + adequate eGFR meets Class 1a recommendation per 2022 AHA/ACC HF guidelines.
EF ≤ 40% on ACE-I; guideline-preferred substitution for mortality benefit if tolerated.
High-risk ASCVD on low/moderate-intensity statin where high-intensity is indicated.
Last lipid / CMP / HbA1c outside the 14-month surveillance window for actively managed conditions.
Intervention success rate
Across 12 interventions on the 5 detailed patients
"Missed" means the documented expected outcome did not occur and no follow-up intervention was attempted. Most of these are the moments Kairos surfaces as actionable insights on the panel today.