A Comparison of the Charlson and Elixhauser Comorbidity Measures to Predict Inpatient Mortality After Proximal Humerus Fracture

Patient and Hospital Characteristics Associated with Admission Among Patients With Minor Isolated Extremity Firearm Injuries: A Propensity-Matched Analysis

Objective

To quantify the association between insurance and hospital admission following minor isolated extremity firearm injury.

Background

The association between insurance and injury admission has not been examined.

Methods

This was an observational retrospective cohort study of minor isolated extremity firearm injury captured in the Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases in 6 states (New York, Arkansas, Wisconsin, Massachusetts, Florida, and Maryland) from 2016 to 2017 among patients aged 16 years or older. The primary exposure was insurance. Admitted patients were propensity score matched to nonadmitted patients on age, extremity Abbreviated Injury Score, and Elixhauser Comorbidity Index with exact matching within hospital to adjust for selection bias. A general estimating equation logistic regression estimated the association between insurance and odds of admission in the matched cohort while controlling for sex, race, injury intent, injury type, hospital profit type, and trauma center designation with observations clustered by propensity score-matched pairs within hospital.

Results

A total of 8151 patients presented to hospital with a minor isolated extremity firearm injury between 2016 and 2017 in 6 states. Patients were 88.0% male, 56.6% Black, and 71.7% aged 16 to 36 years old, and 22.1% were admitted. A total of 2090 patients were matched on propensity for admission. Privately insured matched patients had 1.70 higher adjusted odds of admission and 95% confidence interval of 1.30 to 2.22, compared with uninsured after adjusting for patient and hospital characteristics.

Conclusions

Insurance was associated with hospital admission for minor isolated extremity firearm injury.

Factors affecting hospital admission, hospital length of stay and new discharge destination post proximal humeral fracture: a retrospective audit

BACKGROUND

Outcomes following proximal humeral fracture (PHF) may be impacted by a range of clinical, fracture and premorbid factors. The aim of this study was to examine factors impacting hospital admission; length of stay (LOS) and new discharge destination for patients presenting to hospital with PHF.

METHODS

Retrospective audit conducted at a tertiary health service. Data was collected from adult patients presenting to hospital with a PHF over a 54-month period. Fractures that were pathological or sustained during admission were excluded. Univariable and multivariable logistic and negative binomial regression were used to explore factors associated with hospital admission, LOS and new discharge destination.

RESULTS

Data were analyzed from 701 participants (age 70 years (IQR 60, 81); 72.8% female); 276 (39.4%) participants required a hospital admission. New discharge destination was required for 109 (15.5%) participants, of whom 49 (45%) changed from home alone to home with family/friend(s). Greater comorbidities, as indicated by the Charlson Comorbidity Index score, were associated with hospital admission, longer LOS and new discharge destination. Premorbid living situations of home with family/friend(s) or from an external care facility were associated with a decreased likelihood of hospital admission, shorter LOS and reduced risk of a new discharge destination. Surgical treatment was associated with shorter LOS. Older age and dementia diagnosis were associated with a new discharge destination.

CONCLUSIONS

Many factors potentially impact on the likelihood or risk of hospitalization, LOS and new discharge destination post PHF. Patients with greater comorbidities are more likely to have negative outcomes, while patients who had premorbid living situations of home with family/friend(s) or from an external care facility are more likely to have positive outcomes. Early identification of factors that may impact patient outcomes may assist timely decision making in hospital settings. Further research should focus on developing tools to predict hospital outcomes in the PHF population.

Effects of Transport to Trauma Centers on Survival Outcomes Among Severe Trauma Patients in Korea: Nationwide Age-Stratified Analysis

BACKGROUND

Previous studies showed that the prognosis for severe trauma patients is better after transport to trauma centers compared to non-trauma centers. However, the benefit from transport to trauma centers may differ according to age group. The aim of this study was to compare the effects of transport to trauma centers on survival outcomes in different age groups among severe trauma patients in Korea.

METHODS

Cross-sectional study using Korean national emergency medical service (EMS) based severe trauma registry in 2018-2019 was conducted. EMS-treated trauma patients whose injury severity score was above or equal to 16, and who were not out-of-hospital cardiac arrest or death on arrival were included. Patients were classified into 3 groups: pediatrics (age < 19), working age (age 19-65), and elderly (age > 65). The primary outcome was in-hospital mortality. Multivariable logistic regression analysis was conducted to evaluate the effect of trauma center transport on outcome after adjusting of age, sex, comorbidity, mechanism of injury, Revised Trauma Score, and Injury Severity Score. All analysis was stratified according to the age group, and subgroup analysis for traumatic brain injury was also conducted.

RESULTS

Overall, total of 10,511 patients were included in the study, and the number of patients in each age group were 488 in pediatrics, 6,812 in working age, and 3,211 in elderly, respectively. The adjusted odds ratio (95% confidence interval [CI]) of trauma center transport on in-hospital mortality from were 0.76 (95% CI, 0.43-1.32) in pediatrics, 0.78 (95% CI, 0.68-0.90) in working age, 0.71(95% CI, 0.60-0.85) in elderly, respectively. In subgroup analysis of traumatic brain injury, the benefit from trauma center transport was observed only in elderly group.

CONCLUSION

We found out trauma centers showed better clinical outcomes for adult and elderly groups, excluding the pediatric group than non-trauma centers. Further research is warranted to evaluate and develop the response system for pediatric severe trauma patients in Korea.

Predictive Ability of Comorbidity Indices for Surgical Morbidity and Mortality: a Systematic Review and Meta-analysis

BACKGROUND

Several contemporary risk stratification tools are now being used since the development of the Charlson Comorbidity Index (CCI) in 1987. The purpose of this systematic review and meta-analysis was to compare the utility of commonly used co-morbidity indices in predicting surgical outcomes.

METHODS

A comprehensive review was performed to identify studies reporting an association between a pre-operative co-morbidity measurement and an outcome (30-day/in-hospital morbidity/mortality, 90-day morbidity/mortality, and severe complications). Meta-analysis was performed on the pooled data.

RESULTS

A total of 111 included studies were included with a total cohort size 25,011,834 patients. The studies reporting the 5-item Modified Frailty Index (mFI-5) demonstrated a statistical association with an increase in the odds of in-hospital/30-day mortality (OR:1.97,95%CI: 1.55-2.49, p < 0.01). The pooled CCI results demonstrated an increase in the odds for in-hospital/30-day mortality (OR:1.44,95%CI: 1.27-1.64, p < 0.01). Pooled results for co-morbidity indices utilizing a scale-based continuous predictor were significantly associated with an increase in the odds of in-hospital/30-day morbidity (OR:1.32, 95% CI: 1.20-1.46, p < 0.01). On pooled analysis, the categorical results showed a higher odd for in-hospital/30-day morbidity (OR:1.74,95% CI: 1.50-2.02, p < 0.01). The mFI-5 was significantly associated with severe complications (Clavien-Dindo ≥ III) (OR:3.31,95% CI:1.13-9.67, p < 0.04). Pooled results for CCI showed a positive trend toward severe complications but were not significant.

CONCLUSION

The contemporary frailty-based index, mFI-5, outperformed the CCI in predicting short-term mortality and severe complications post-surgically. Risk stratification instruments that include a measure of frailty may be more predictive of surgical outcomes compared to traditional indices like the CCI.

Health Care for Inpatients with a Proximal Humeral Fracture - an Analysis of Health Insurance Data

The proximal humeral fracture is one of the most common fractures in the elderly. While epidemiological factors have been well studied, the influence of a proximal humeral fracture on morbidity, mortality and associated costs has not yet been adequately analysed.On a basis of 4.1 million insurance holders of the German public health insurance (GKV), patients with (study population, SP) and without (comparison group, VG) a proximal humeral fracture (pHF) were compared with regard to comorbidity, rehospitalisation, mortality, drug and aid needs as well as number of physician contacts. Study period was between 2012 and 2016.6068 patients of the SP met the inclusion and exclusion criteria (age 69.4 ± 14.3 years; male : female = 28.2% : 71.8%). 4781 patients (78.8%) received surgical, 1287 patients (21.2%) conservative treatment of the pHF. Rehospitalisations and visits to the general practitioner occurred more frequently in the SP vs. VG (p < 0.01). Contacts with specialists after pHF varied according to specialty, as did newly occurring diseases. Typical specialities for preventive examinations were significantly less common (gynaecology p < 0.01, pathology p < 0.01, dermatology p < 0.01). According to pHF, the costs of SP for drugs (2490.76 ± 1395.51 € vs. 2167.86 ± 1314.43 €; p = 0.04), medical therapies (867.01 ± 238.67 € vs. 393.26 ± 217.55 €; p < 0.01) and aids (821.02 ± 415.73 € vs. 513.52 ± 368.76 €; p < 0.01) were significantly above the VG. The two-year survival after pHF is lower in the SP than in the VG (p < 0.01).The results show increased morbidity and mortality as well as medical costs after a proximal humeral fracture. Preventive examinations and treatments are rarer. In the future, care concepts for patients with proximal humeral fractures should not only be optimised with regard to functional scores and reduced complication rates, but also with regard to quality of life and preservation of general health.

Complications of surgically treated pelvic ring injuries with associated genitourinary injuries

OBJECTIVE

Pelvic ring injuries are often associated with vascular and intrapelvic organ injuries including damage to the genitourinary system. The purpose of this study was to examine the relationship between surgically treated pelvic ring injuries and genitourinary injuries. The primary outcome was to determine the rate of post-operative complications including infection, urinary dysfunction, and sexual dysfunction. The secondary outcome was to determine if the time to surgery was associated with post-operative complications.

METHODS

Retrospective chart review from September 1, 2015 to December 31, 2019 of patients who sustained a pelvic ring injury which required surgical intervention. All patients with closed triradiate cartilage were included.

RESULTS

A total of 115 patients met the inclusion criteria, 12 patients with an associated genitourinary (GU) injury were included in the GU group and 103 without GU injury were placed in the non-GU group. The median (range) age of patients in the GU group was 49.5 years (20, 64) and 48 years (15, 92) in the control group (p = 0.92). Demographic characteristics including age, Injury Severity Score and Elixhauser comorbidity score were similar between groups. Within the GU group, five patients had an injury to their bladder, four to their urethra and three had an injury to their kidney. In the GU group, one patient developed a wound dehiscence and one developed a urinary tract infection with subsequent sepsis (17%), while in the non-GU group, one patient (1%) developed erectile dysfunction (p = 0.028). Regression analysis demonstrated that having concomitant pelvic ring and GU injuries, as well as the number of surgeries were variables associated with post-operative complications, while time to surgery was not.

DISCUSSION AND CONCLUSIONS

Pelvic ring injuries with concomitant genitourinary injuries were associated with increased odds of post-operative complications. No differences were noted in complication rates due to the time to surgery between groups.

Patient and Hospital Characteristics Associated With Delayed Diagnosis of Appendicitis

Importance

Racial disparities in timely diagnosis and treatment of surgical conditions exist; however, it is poorly understood whether there are hospital structural measures or patient-level characteristics that modify this phenomenon.

Objective

To assess whether patient race and ethnicity are associated with delayed appendicitis diagnosis and postoperative 30-day hospital use and whether there are patient- or systems-level factors that modify this association.

Design, Setting, and Participants

This population-based, retrospective cohort study used data from the Healthcare Cost and Utilization Project's state inpatient and emergency department (ED) databases from 4 states (Florida, Maryland, New York, and Wisconsin) for patients aged 18 to 64 years who underwent appendectomy from January 7, 2016, to December 1, 2017. Data were analyzed from January 1, 2016, to December 31, 2017.

Exposure

Delayed diagnosis of appendicitis, defined as an initial ED presentation with an abdominal diagnosis other than appendicitis followed by re-presentation within a week for appendectomy.

Main Outcomes and Measures

A mixed-effects multivariable Poisson regression model was used to estimate the association of delayed diagnosis of appendicitis with race and ethnicity while controlling for patient and hospital variables. A second mixed-effects multivariable Poisson regression model quantified the association of delayed diagnosis of appendicitis with postoperative 30-day hospital use.

Results

Of 80 312 patients who received an appendectomy during the study period (median age, 38 years [IQR, 27-50 years]; 50.8% female), 2013 (2.5%) experienced delayed diagnosis. In the entire cohort, 2.9% of patients were Asian or Pacific Islander, 18.8% were Hispanic, 10.9% were non-Hispanic Black, 60.8% were non-Hispanic White, and 6.6% were other race and ethnicity; most were privately insured (60.2%). Non-Hispanic Black patients had a 1.41 (95% CI, 1.21-1.63) times higher adjusted rate of delayed diagnosis compared with non-Hispanic White patients. Patients at hospitals with a more than 50% Black or Hispanic population had a 0.73 (95% CI, 0.59-0.91) decreased adjusted rate of delayed appendicitis diagnosis compared with hospitals with a less than 25% Black or Hispanic population. Conversely, patients at hospitals with more than 50% of discharges of Medicaid patients had a 3.51 (95% CI, 1.69-7.28) higher adjusted rate of delayed diagnosis compared with hospitals with less than 10% of discharges of Medicaid patients. Additional factors associated with delayed diagnosis included female sex, higher levels of patient comorbidity, and living in a low-income zip code. Delayed diagnosis was associated with a 1.38 (95% CI, 1.36-1.61) increased adjusted rate of postoperative 30-day hospital use.

Conclusions and Relevance

In this cohort study, non-Hispanic Black patients had higher rates of delayed appendicitis diagnosis and 30-day hospital use than White patients. Patients presenting to hospitals with a greater than 50% Black and Hispanic population were less likely to experience delayed diagnosis, suggesting that seeking care at a hospital that serves a diverse patient population may help mitigate the increased rate of delayed diagnosis observed for non-Hispanic Black patients.

Iron deficiency anemia is associated with increased medical and implant-related complications and length of stay for patients undergoing total shoulder arthroplasty

BACKGROUND

Iron deficiency anemia (IDA) is associated with decreased bone mineral density and osteoporosis; however, studies investigating the effects of IDA in patients undergoing primary total shoulder arthroplasty (TSA) have not been well studied. The purpose of this study is to utilize a nationwide administrative claims database to investigate whether patients with diagnosed IDA undergoing primary TSA have higher rates of 1) in-hospital length of stay (LOS); 2) medical complications; and 3) implant-related complications.

METHODS

A retrospective review from 2005 to 2014 was conducted using the Medicare Standard Analytical Files. Patients with IDA undergoing primary TSA were identified and matched to controls without IDA, in a 1:5 ratio by age, sex, and medical comorbidities. Outcomes analyzed included in-hospital LOS and 90-day medical and implant-related complications. Mann-Whitney U tests compared in-hospital LOS, and multivariate logistic regression was used to calculate odds ratios (ORs) on the effects of IDA on postoperative complications after adjusting for age, sex, and Elixhauser Comorbidity Index.

RESULTS

A total of 17,689 patients with IDA and 88,445 without IDA participated in the matched-cohort analysis, with no differences in age, gender, and comorbidities (P = .99). IDA patients were found to have significantly longer in-hospital LOS (3-days vs. 2-days, P < .0001). IDA patients were also found to have significantly higher odds of 90-day implant-related complications (OR: 1.65, P < .0001), such as periprosthetic joint infections (OR: 1.80, P < .0001) and 90-day medical complications (OR: 2.87, P < .0001), including blood transfusions (OR: 10.37, P < .0001).

CONCLUSION

Patients with IDA undergoing primary TSA have significantly longer in-hospital LOS, and medical and implant-related complications. Patients were 10 times more likely to undergo a blood transfusion and 2 times more likely to have a periprosthetic fracture.

Comorbidity scores reported in anatomic and reverse total shoulder arthroplasty: a systematic review

BACKGROUND

Due to the aging population, the number of reverse shoulder arthroplasty (RSA) and anatomic shoulder arthroplasty (TSA) continue to increase annually. Although outcome measures are frequently reported in literature for patients who undergo shoulder arthroplasty, no studies have analyzed reporting of patient comorbidities in this population. The purpose of this study was to evaluate reporting of comorbidity indices in shoulder arthroplasty literature and assess how this reporting may inform management and outcomes.

METHODS

A database was compiled systematically using PubMed to identify articles pertaining to shoulder arthroplasty published between 2019 and 2021. The search terms, "reverse shoulder arthroplasty" and "anatomic shoulder arthroplasty," were used to identify clinical studies. Non-clinical (e.g., translational and basic science) and review articles were excluded. Included studies were then analyzed for reporting of comorbidity indices.

RESULTS

A total of 199 articles were included in this review and reported comorbidities. Of these, 15.6% (31 of 199) pertained to TSA, while 84.4% (168 of 199) pertained to RSA. Within this review, 57.8% (115 of 199) articles utilized comorbidity scores, while 42.2% (84 of 199) reported only comorbid diagnoses. Among the scores utilized, the American Society of Anesthesiologists (ASA) physical status classification system was the most widely used among both the TSA (52.9%, 9 of 17) and the RSA studies (58.2%, 57 of 98). Additional scores within the RSA literature included the Charlson Comorbidity Index (CCI) (35.3%, 6 of 17), the Charlson Comorbidity Index by Deyo et al. (J Clin Epidemiol. 45(6):613-9, 1992) (CCI-Deyo; 5.9%, 1 of 17), the Modified Charlson Comorbidity Index (modified-CCI) (5.9%, 1 of 17), the Elixhauser et al. (Med Care. 36(1):8-27, 1998) Comorbidity Measure (ECM) (11.8%, 2 of 17), and the Modified Frailty Index (mFI) (5.9%, 1 of 17). With the TSA literature, the additional comorbidity scores included the CCI (30.6%, 30 of 98), the CCI-Deyo (6.1%, 6 of 98), the modified-CCI (1.0%, 1 of 98), the ECM (8.2%, 8 of 98), the Factor-5 modified Frailty Index (mFI-5) (1.0%, 1 of 98), and the mFI (1.0%, 1 of 98).

CONCLUSION

The reporting of comorbidity indices is an important factor when considering patient outcomes and complications reported in shoulder arthroplasty literature. Although the reporting of these scores appears to be more prevalent in current literature, there is no standard or consistency in terms of which scores are reported. Given this diversity in comorbidity scores, further research is necessary to develop a single standardized score to properly analyze the effect of comorbidities on shoulder arthroplasty patient outcomes.

Growing Racial Disparities in the Utilization of Adult Spinal Deformity Surgery: An Analysis of Trends From 2004 to 2014

STUDY DESIGN

Retrospective.

OBJECTIVE

The purpose of this study was to assess trends in utilization rates of adult spinal deformity (ASD) surgery, as well as perioperative surgical metrics between Black and White patients undergoing operative treatment for ASD in the United States.

SUMMARY OF BACKGROUND DATA

Racial disparities in access to care, complications, and surgical selection have been shown to exist in the field of spine surgery. However, there is a paucity of data concerning racial disparities in the management of ASD patients.

METHODS

Adult patients undergoing ASD surgery from 2004 to 2014 were identified in the nationwide inpatient sample (NIS). Utilization rates, major complications rates, and length of stay (LOS) for Black patients and White patients were trended over time. Utilization rates were reported per 1,000,000 people and determined using annual census data among subpopulations stratified by race. All reported complication rates and prolonged hospital stay rates are adjusted for Elixhauser Comorbidity Index, income quartile by zip code, and insurance payer status.

RESULTS

From 2004 to 2014, ASD utilization for Black patients increased from 24.0 to 50.9 per 1,000,000 people, whereas ASD utilization for White patients increased from 29.9 to 73.1 per 1,000,000 people, indicating a significant increase in racial disparities in ASD utilization (P-trend < 0.001). There were no significant differences in complication rates or rates of prolonged hospital stay between Black and White patients across the time period studied (P > 0.05 for both).

CONCLUSION

Although Black and White patients undergoing ASD surgery do not differ significantly in terms of postoperative complications and length of hospital stay, there is a growing disparity in utilization of ASD surgery between White and Black patients from 2004 to 2014 in the United States. There is need for continued focus on identifying ways to reduce racial disparities in surgical selection and perioperative management in spine deformity surgery.Level of Evidence: 3.

Comorbidity indices in orthopaedic surgery: a narrative review focused on hip and knee arthroplasty

Comorbidity indices currently used to estimate negative postoperative outcomes in orthopaedic surgery were originally developed among non-orthopaedic patient populations.

While current indices were initially intended to predict short-term mortality, they have since been used for other purposes as well.

As the rate of hip and knee arthroplasty steadily rises, understanding the magnitude of the effect of comorbid disease on postoperative outcomes has become increasingly more important.

Currently, the ASA classification is the most commonly used comorbidity measure and is systematically recorded by the majority of national arthroplasty registries.

Consideration should be given to developing an updated, standardized approach for comorbidity assessment and reporting in orthopaedic surgery, especially within the setting of elective hip and knee arthroplasty.

Cite this article: EFORT Open Rev 2021;6:629-640. DOI: 10.1302/2058-5241.6.200124

The ability of comorbidity indices to predict mortality in an orthopedic setting: a systematic review

BACKGROUND

Several comorbidity indices have been created to estimate and adjust for the burden of comorbidity. The objective of this systematic review was to evaluate and compare the ability of different comorbidity indices to predict mortality in an orthopedic setting.

METHODS

A systematic search was conducted in Embase, MEDLINE, and Cochrane Library. The search were constructed around two primary focal points: a comorbidity index and orthopedics. The last search were performed on 13 June 2019. Eligibility criteria were participants with orthopedic conditions or who underwent an orthopedic procedure, a comparison between comorbidity indices that used administrative data, and reported mortality as outcome. Two independent reviewers screened the studies using Covidence. The area under the curve (AUC) was chosen as the primary effect estimate.

RESULTS

Of the 5338 studies identified, 16 met the eligibility criteria. The predictive ability of the different comorbidity indices ranged from poor (AUC < 0.70) to excellent (AUC ≥ 0.90). The majority of the included studies compared the Elixhauser Comorbidity Index (ECI) and the Charlson Comorbidity Index (CCI). In-hospital mortality was reported in eight studies reporting AUC values ranging from 0.70 to 0.92 for ECI and 0.68 to 0.89 for CCI. AUC values were generally lower for all other time points ranging from 0.67 to 0.78. For 1-year mortality the overall effect size ranging from 0.67 to 0.77 for ECI and 0.69 to 0.77 for CCI.

CONCLUSION

The results of this review indicate that the ECI and CCI can equally be used to adjust for comorbidities when analyzing mortality in an orthopedic setting.

TRIAL REGISTRATION

The protocol for this systematic review was registered on PROSPERO, the International Prospective Register of Systematic Reviews on 13 June 2019 and can be accessed through record ID 133,871.

Improving the In-Hospital Mortality Prediction of Diabetes ICU Patients Using a Process Mining/Deep Learning Architecture

Diabetes intensive care unit (ICU) patients are at increased risk of complications leading to in-hospital mortality. Assessing the likelihood of death is a challenging and time consuming task due to a large number of influencing factors. Healthcare providers are interested in the detection of ICU patients at higher risk, such that risk factors can possibly be mitigated. While such severity scoring methods exist, they are commonly based on a snapshot of the health conditions of a patient during the ICU stay and do not specifically consider a patient's prior medical history. In this paper, a process mining/deep learning architecture is proposed to improve established severity scoring methods by incorporating the medical history of diabetes patients. First, health records of past hospital encounters are converted to event logs suitable for process mining. The event logs are then used to discover a process model that describes the past hospital encounters of patients. An adaptation of Decay Replay Mining is proposed to combine medical and demographic information with established severity scores to predict the in hospital mortality of diabetes ICU patients. Significant performance improvements are demonstrated compared to established risk severity scoring methods and machine learning approaches using the Medical Information Mart for Intensive Care III dataset.

Validity of comorbidity adjustment scores in estimating in-hospital mortality in individual subgroups of race/ethnicity

Aim: To examine the validity of race/ethnicity-specific comorbidity adjustment scores in estimating in-hospital mortality. Materials & methods: Using 2007-2014 data from the State Inpatient Databases (SID), we compared the performance of derived race/ethnicity-specific composite scores to the existing scores and binary Elixhauser comorbidity measures at estimating in-hospital mortality. Results: In the overall validation sample (N = 9,564,277), our index (c = 0.80; 95% CI: 0.79-0.80) discriminated better than the van Walraven score (c = 0.79; 95% CI: 0.79-0.79), SID 29 (c = 0.78; 95% CI: 0.78-0.79) and SID 30 (c = 0.78; 95% CI: 0.78-0.78), but was not superior to the binary indicators (c = 0.80; 95% CI: 0.80-0.80). Similar findings were observed in individual populations of White and Black patients. All models showed weak calibration. Conclusion: Race/ethnicity-specific indexes discriminated slightly better than existing composite measures at modeling in-hospital mortality in individual subgroups of race/ethnicity.

Predicting in-hospital mortality for dementia patients after hip fracture surgery - A comparison between the Charlson Comorbidity Index (CCI) and the Elixhauser Comorbidity Index

BACKGROUND

Considerable in-hospital mortality was reported in geriatric patients with dementia sustaining femoral neck or inter-trochanteric fracture. We intended to establish a predictive model of in-hospital mortality for dementia patients after hip fracture surgery.

METHODS

We collected 8080 registrants ≧ 65 years old from the subset (LHID2000) of the National Health Insurance Research Database (NHIRD) that met the following inclusion criteria:1. Admitted with the ICD of hip fracture; 2. Underwent operation of hip fracture during the same hospitalization; 3. Co-existing diagnosis of dementia (ICD-9-CM codes 290). The co-morbidity was recorded according to validated Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI) from the diagnoses of hospitalization. The main outcome measure was in-hospital mortality that was defined as death being reported during hospitalization. The comparison of predictability was conducted by Receiver operating characteristic (ROC) curves and the area under the ROC curve (AUC) among different predictive models.

RESULTS

The Charlson Comorbidity Index (CCI) score and Elixhauser Comorbidity Index (ECI) score showed similar ability in predicting in-hospital mortality (AUC = 0.653, 95% CI = 0.611-0.695 for CCI; AUC = 0.624, 95% CI = 0.582-0.665 for ECI, p = 0.0717). By adding age grouping (≥80 yrs = 1, 65-80 yrs = 0) and gender difference (Male = 1, Female = 0), these two models were shifted to models CCI_new1 and ECI_new1. Consequently, the AUC greatly increased in the CCI_new1 (AUC = 0.682, 95% CI = 0.643-0.722). It therefore provided better prediction of in-hospital mortality than ECI_new1 (AUC = 0.651, 95% CI = 0.611-0.691) (p = 0.0444).

CONCLUSIONS

Utilizing the CCI with addition of grouping for age and gender provides a better prediction for in-hospital mortality than the ECI among elderly patients with concomitant dementia and hip fracture who underwent surgical intervention.

Use of a 5-item modified Fragility Index for risk stratification in patients undergoing surgical management of proximal humerus fractures

Hypothesis

We hypothesized that the modified Fragility Index (mFI) would predict complications in patients older than 50 years who underwent operative intervention for a proximal humerus fracture.

Methods

We retrospectively reviewed the American College of Surgeons National Surgery Quality Improvement Program database, including patients older than 50 years who underwent open reduction and internal fixation of a proximal humerus fracture. A 5-item mFI score was then calculated for each patient. Postoperative complications, readmission and reoperation rates as well as length of stay (LOS) were recorded. Univariate as well as multivariable statistical analyses were performed, controlling for age, sex, body mass index, LOS, and operative time.

Results

We identified 2,004 patients (median age, 66 years; interquartile range: 59-74), of which 76.2% were female. As mFI increased from 0 to 2 or greater, 30-day readmission rate increased from 2.8% to 6.7% (P-value = .005), rate of discharge to rehabilitation facility increased from 7.1% to 25.3% (P-value < .001), and rates of any complication increased from 6.5% to 13.9% (P-value < .001). Specifically, the rates of renal and hematologic complications increased significantly in patients with mFI of 2 or greater (P-value = .042 and P-value < .001, respectively). Compared with patients with mFI of 0, patients with mFI of 2 or greater were 2 times more likely to be readmitted within 30 days (odds ratio = 2.2, P-value .026). In addition, patients with mFI of 2 or greater had an increased odds of discharge to a rehabilitation center (odds ratio = 2.3, P-value < .001). However, increased fragility was not significantly associated with an increased odds of 30-day reoperation or any complication after controlling for demographic data, LOS, and operative time.

Conclusion

An increasing level of fragility is predictive of readmission and discharge to a rehabilitation center after open reduction and internal fixation of proximal humerus fractures. Our data suggest that a simple fragility evaluation can help inform surgical decision-making and counseling in patients older than 50 years with proximal humerus fractures.

Factors affecting in-hospital cost and mortality of patients with stroke: Evidence from a case study in a tertiary hospital in China

OBJECTIVE

The study aims to investigate the factors causing the difference of stroke patients' in-hospital cost and study these factors on health outcome in terms of mortality.

METHODS

Eight hundred and sixty-two in-patients with stroke in a tertiary hospital in China from 2017 to 2019 were included in the database. Descriptive statistics indexes were used to describe patients' in-hospital cost and mortality. Based on Elixhauser coding algorithms, multiple linear regression and logistic regressions (LRs) were used to evaluate the impact of factors identified from univariate analysis on in-hospital cost and mortality, respectively. In addition to LRs, a comparison study was then carried out with random forest, gradient boosting decision tree and artificial neural network.

RESULTS

Factors affecting both cost and mortality are age, discharged day-of-week, length of stay, stroke subtype, other neurological disorders, renal failure, fluid and electrolyte disorders and total number of comorbidities.

CONCLUSION

With the increase of age, the mortality rate of in-patients (except for the juvenile) with stroke increases and the cost of hospitalization decreases. Intracerebral haemorrhage is the most devastating stroke for its highest mortality in short length of stay. Medical services should focus on these specific comorbidities.

Combining Charlson and Elixhauser scores with varying lookback predicated mortality better than using individual scores

OBJECTIVE

To investigate variation in the presence of secondary diagnosis codes in Charlson and Elixhauser comorbidity scores and assess whether including a 1-year lookback period improved prognostic adjustment by these scores individually, and combined, for 30-day mortality.

STUDY DESIGN AND SETTING

We analyzed inpatient admissions from January 1, 2007 to May 18, 2018 in Oxfordshire, UK. Comorbidity scores were calculated using secondary diagnostic codes in the diagnostic-dominant episode, and primary and secondary codes from the year before. Associations between scores and 30-day mortality were investigated using Cox models with natural cubic splines for nonlinearity, assessing fit using Akaike Information Criteria.

RESULTS

The 1-year lookback improved model fit for Charlson and Elixhauser scores vs. using diagnostic-dominant methods. Including both, and allowing nonlinearity, improved model fit further. The diagnosis-dominant Charlson score and Elixhauser score using a 1-year lookback, and their interaction, provided the best comorbidity adjustment (reduction in AIC: 761 from best single score model).

CONCLUSION

The Charlson and Elixhauser score calculated using primary and secondary diagnostic codes from 1-year lookback with secondary diagnostic codes from the current episode improved individual predictive ability. Ideally, comorbidities should be adjusted for using both the Charlson (diagnostic-dominant) and Elixhauser (1-year lookback) scores, incorporating nonlinearity and interactions for optimal confounding control.

The 5-Factor Modified Frailty Index Predicts Complications, Hospital Admission, and Mortality Following Arthroscopic Rotator Cuff Repair

INTRODUCTION

The purpose of this study is to evaluate the utility of the modified frailty index-5 (mFI-5) as a predictor for postoperative complications in patients undergoing arthroscopic rotator cuff repair (RCR).

METHODS

The National Surgical Quality Improvement Program database was queried for patients undergoing arthroscopic RCR between 2006 and 2016. The mFI-5, a 5-factor score comprising comorbid diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functional status limiting independence, was calculated for each patient. Multivariate logistic regression models were used to evaluate the mFI-5 score as a predictor for complications including medical complications, surgical-site infections, hospital admission, discharge to a facility, and mortality.

RESULTS

In total, 24,477 patients met criteria for inclusion. The mFI-5 was a strong predictor for medical complications (P < .001), hospital admission (P < .001), length of stay (P = .007), and discharge to a facility (P = .001) but not surgical-site infections (P = .153). For each point increase in mFI-5 score, the risk for a medical complication increased by 66%, readmission by 52%, and adverse discharge by 45%. However, of all the measured complications, the mFI-5 was the strongest predictor for mortality, with the risk more than doubling for each increase in mFI-5 point (odds ratio 2.66, P = .025).

CONCLUSIONS

The mFI-5 is a sensitive tool for predicting life-threatening medical complications, hospital admission, increased length of stay, adverse discharge, and mortality following arthroscopic RCR. The 5 comorbidities comprising the mFI-5 are easily obtained through the patient history, making it a practical clinical tool for identifying high-risk patients, informing preoperative counseling, and improving value-based health care.

LEVEL OF EVIDENCE

Level III, prognostic.

Risk Factors for Readmission After Surgical Treatment of Slipped Capital Femoral Epiphysis

Slipped capital femoral epiphysis (SCFE) is a common, surgically treated adolescent hip condition. This study sought to evaluate postoperative complications and factors associated with hospital readmission using a nationally representative database. The 2013 Healthcare Cost and Utilization Project's Nationwide Readmissions Database was queried to analyze the incidence of acute readmission and complications for all patients with SCFE. Patients were separated based on 3 different operative approaches (open procedures, closed procedures, or both) and were compared based on choice of procedure, clinical characteristics, patient demographics, comorbidities, and complications. Univariate and multivariate techniques were used to predict readmission and complications. A total of 1082 patients with SCFE were identified; 58 (5.9%) were readmitted within 90 days of the index surgery, and 47 (73.4%) underwent a "closed" surgery, including 18 bilateral (27.4%). Increasing age and shorter primary length of stay were protective against readmission. Patients with the comorbidity of hypothyroidism were 47.4 times more likely to be readmitted. Obesity, sex, and median household income were not predictive of readmission. Patients readmitted were more likely to have undergone an index procedure of closed reduction or both an open and closed reduction procedure. This study is the first to report national SCFE readmission and complication rates and allows pediatric orthopedic surgeons to have a better understanding of associated risk factors. [Orthopedics. 2019; 42(6):e507-e513.].

Frailty Predicts Medical Complications, Length of Stay, Readmission, and Mortality in Revision Hip and Knee Arthroplasty

BACKGROUND

The purpose of this study is to evaluate the 5-factor modified frailty index (mFI-5) as a predictor of postoperative complications, readmission, and mortality in patients undergoing revision hip and knee arthroplasty.

METHODS

A retrospective analysis of the American College of Surgeon's National Surgical Quality Improvement Program's database for patients undergoing revision total hip arthroplasty (rTHA) and revision total knee arthroplasty (rTKA) between the years 2005 and 2016 was conducted. The 5-factor score, which includes presence of comorbid diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functional status, was calculated for each patient. Multivariate logistic regression models were used to assess the relationship between the mFI-5 and postoperative complications while controlling for demographic variables.

RESULTS

In total, 13,948 patients undergoing rTHA and 16,304 patients undergoing rTKA were identified. The mFI-5 was a strong predictor of serious medical complications (cardiac arrest, myocardial infarction, septic shock, pulmonary embolism, postoperative dialysis, reintubation, and prolonged ventilator requirement), discharge to a facility, total length of stay, readmission, and mortality (P ≤ .007).

CONCLUSION

The mFI-5 predicts serious medical complications, increased length of stay, discharge to a facility, hospital readmission, and mortality in patients undergoing rTHA and rTKA. All the variables within the mFI-5 are easily obtained through the patient history, allowing for a practical clinical tool that hospitals and physicians can use to identify at-risk patients, educate and engage patients and their families in a shared decision-making conversation, and guide perioperative care in order to optimize patient outcomes.

LEVEL OF EVIDENCE

III.

New Five-Factor Modified Frailty Index Predicts Morbidity and Mortality in Geriatric Hip Fractures

INTRODUCTION

Although the 11-factor modified frailty index (mFI-11) has been shown to predict adverse outcomes in elderly patients undergoing surgery for hip fractures, the newer 5-factor index has not been evaluated in this population. The goal of this study is to evaluate the mFI-5 as a predictor of morbidity and mortality in elderly patients undergoing surgical management for hip fractures.

METHODS

The NSQIP database was queried for patients 60 years of age and older who underwent surgical management for hip fractures between 2005 and 2016. The 5-factor score, which comprised diabetic status, history of COPD or current pneumonia, congestive heart failure, hypertension requiring medication, and nonindependent functional status, was calculated for each patient. Multivariate logistic regression models were used to assess the relationship between the mFI-5 and 30-day postoperative complications.

RESULTS

A total of 58,603 patients were identified. After adjusting for comorbidities, the mFI-5 was a strong predictor for total complications, serious medical complications (cardiac arrest, myocardial infarction, septic shock, pulmonary embolism, postoperative dialysis, reintubation, and prolonged ventilator requirement), surgical site infections, readmission, extended hospital length of stay, and mortality (P ≤ 0.008). For each point increase, the risk for any complication increased by 29.8%, serious medical complications 35.4%, surgical site infections 14.7%, readmission 24.6%, and mortality 33.7%.

CONCLUSIONS

The mFI-5 is an independent predictor of postoperative morbidity and mortality in elderly patients undergoing surgery for hip fractures. This clinical tool can be used by hospitals and surgeons to identify high-risk patients, accurately council patients and families with transparency, and guide perioperative care to optimize patient outcomes.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Coding algorithms for defining Charlson and Elixhauser co-morbidities in Read-coded databases

Background

Comorbidity measures, such as the Charlson Comorbidity Index (CCI) and Elixhauser Method (EM), are frequently used for risk-adjustment by healthcare researchers. This study sought to create CCI and EM lists of Read codes, which are standard terminology used in some large primary care databases. It also aimed to describe and compare the predictive properties of the CCI and EM amongst patients with hip fracture (and matched controls) in a large primary care administrative dataset.

Methods

Two researchers independently screened 111,929 individual Read codes to populate the 17 CCI and 31 EM comorbidity categories. Patients with hip fractures were identified (together with age- and sex-matched controls) from UK primary care practices participating in the Clinical Practice Research Datalink (CPRD). The predictive properties of both comorbidity measures were explored in hip fracture and control populations using logistic regression models fitted with 30- and 365-day mortality as the dependent variables together with tests of equality for Receiver Operating Characteristic (ROC) curves.

Results

There were 5832 CCI and 7156 EM comorbidity codes. The EM improved the ability of a logistic regression model (using age and sex as covariables) to predict 30-day mortality (AUROC 0.744 versus 0.686). The EM alone also outperformed the CCI (0.696 versus 0.601). Capturing comorbidities over a prolonged period only modestly improved the predictive value of either index: EM 1-year look-back 0.645 versus 5-year 0.676 versus complete record 0.695 and CCI 0.574 versus 0.591 versus 0.605.

Conclusions

The comorbidity code lists may be used by future researchers to calculate CCI and EM using records from Read coded databases. The EM is preferable to the CCI but only marginal gains should be expected from incorporating comorbidities over a period longer than 1 year.

Electronic supplementary material

The online version of this article (10.1186/s12874-019-0753-5) contains supplementary material, which is available to authorized users.

High-Risk Comorbidity Combinations in Older Patients Undergoing Emergency General Surgery

BACKGROUND/OBJECTIVES

Over a million older patients in the United States are admitted yearly for emergency general surgery (EGS) conditions. Seven procedure types dominate: colon, small bowel, gallbladder, ulcer disease, adhesiolysis, appendix, and laparotomy operations. A higher comorbidity burden is known to increase mortality in this population, but the impact of specific comorbidity combinations is unknown. Our objectives were to (1) characterize the distribution of procedures, comorbidities, and outcomes for older patients undergoing EGS; and (2) apply a data-driven approach (association rule mining) to identify comorbidity combinations associated with disproportionately high mortality.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of patients 65 years and older who underwent one of the seven procedures previously cited, taken from the 2011 Nationwide Inpatient Sample. A total of 280 885 patient encounters were identified.

MEASUREMENTS

In-hospital mortality, procedures, and comorbidities based on the Elixhauser Comorbidity Index.

RESULTS

Overall mortality was 5.6%. The most common procedures were gallbladder (33.7%), ulcer surgery (21.5%), and adhesiolysis (21.0%). Mortality increased for all procedures as patients aged. Comorbidities associated with the highest mortality included coagulopathy (adjusted odds ratio [aOR] = 3.74; 95% confidence interval [CI] = 3.41-4.11; p < .001), fluid and electrolyte disorders (FED) (aOR = 2.89; 95% CI = 3.66-3.14; p < .001), and liver disease (aOR = 1.89; 95% CI = 1.61-2.22; p < .001). Three-way comorbidity combinations most highly associated with mortality were coagulopathy, FED, and peripheral vascular disease (aOR = 5.10; 95% CI = 4.17-6.24; p < .001), and coagulopathy, FED, and chronic pulmonary disease (aOR = 4.83; 95% CI = 4.00-5.82; p < .001).

CONCLUSION

For older patients, combinations of comorbidities portend additional risk beyond single comorbidities, and the associated risk burden is driven by the specific constellation of comorbidities present. Future work must continue to examine the effect of co-occurring diseases to provide personalized and realistic prognostication for older patients undergoing EGS. J Am Geriatr Soc 67:503-510, 2019.

The Charlson Index Is Insufficient to Control for Comorbidities in a National Trauma Registry

BACKGROUND

The Charlson Comorbidity Index (CCI) is frequently used to control for confounding by comorbidities in observational studies, but its performance as such has not been studied. We evaluated the performance of CCI and an alternative summary method, logistic principal component analysis (LPCA), to adjust for comorbidities, using as an example the association between insurance and mortality.

MATERIALS AND METHODS

Using all admissions in the National Trauma Data Bank 2010-2015, we extracted mortality, payment method, and 36 International Classification of Disease, Ninth Revision-derived comorbidities. We estimated odds ratios (ORs) for the association between uninsured status and mortality before and after adjusting for CCI, LPCA, and separate covariates. We also calculated standardized mean differences (SMDs) of comorbidity variables before and after weighting the sample using inverse probability of treatment weights for CCI, LPCA, and separate covariates.

RESULTS

In 4,936,880 admissions, most (68.3%) had at least one comorbidity. Considerable imbalance was observed in the unweighted sample (mean SMD = 0.086, OR = 1.17), which was almost entirely eliminated by inverse probability of treatment weights on separate covariates (mean SMD = 0.012, OR = 1.36). The CCI performed similarly to the unweighted sample (mean SMD = 0.080, OR = 1.25), whereas two LPCA axes were better able to control for confounding (mean SMD = 0.04, OR = 1.31). Using covariate adjustment, the CCI accounted for 56.1% of observed confounding, whereas two LPCA axes accounted for 91.3%.

CONCLUSIONS

The use of the CCI to adjust for confounding may result in residual confounding, and alternative strategies should be considered. LPCA may be a viable alternative to adjusting for each comorbidity when samples are small or positivity assumptions are violated.

New 5-Factor Modified Frailty Index Predicts Morbidity and Mortality in Primary Hip and Knee Arthroplasty

BACKGROUND

While the 11-factor modified frailty index (mFI) has been shown to predict adverse outcomes in patients undergoing total joint arthroplasty, the 5-factor index has not been evaluated in this patient population. The goal of this study was to evaluate the utility of the mFI-5 as a predictor of morbidity and mortality in patients undergoing primary total hip and knee arthroplasty.

METHODS

A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program's database for patients undergoing total hip arthroplasty and total knee arthroplasty between the years 2005 and 2016 was conducted. The 5-factor score, which includes the presence of comorbid diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functional status, was calculated for each patient. Multivariate logistic regression models were used to assess the relationship between the mFI-5 and postoperative complications while controlling for demographic variables.

RESULTS

One hundred forty thousand one hundred fifty-eight patients undergoing total hip arthroplasty and 226,398 patients undergoing total knee arthroplasty were identified. After adjusting for demographic variables and comorbid conditions, logistic regression analyses revealed that the mFI-5 was a strong predictor for total complications, Clavien-Dindo grade IV complications (cardiac arrest, myocardial infarction, septic shock, pulmonary embolism, postoperative dialysis, reintubation, and prolonged ventilator requirement), surgical site infections, readmission, and 30-day mortality (P < .001).

CONCLUSIONS

The mFI-5 is an independent predictor of postoperative complications including life-threatening medical complications, surgical site infections, hospital readmission, and 30-day mortality after primary hip and knee arthroplasty. This clinical tool can be used to identify high-risk surgical patients and guide preoperative counseling to optimize outcomes.

LEVEL OF EVIDENCE

III.

Predicting adverse events, length of stay, and discharge disposition following shoulder arthroplasty: a comparison of the Elixhauser Comorbidity Measure and Charlson Comorbidity Index

BACKGROUND

Rising health care expenditures and the adoption of bundled-care initiatives require efficient resource allocation for shoulder arthroplasty. To determine a reliable and accessible metric for implementing perioperative care pathways, we compared the accuracy of the Elixhauser Comorbidity Measure (ECM) and Charlson Comorbidity Index (CCI) for predicting adverse events and postoperative discharge destination after shoulder arthroplasty.

MATERIALS AND METHODS

The National Inpatient Sample was queried for patients who underwent total shoulder arthroplasty or reverse total shoulder arthroplasty between 2002 and 2014. Logistic regression models were constructed with basic demographic variables and either the ECM or the CCI to predict inpatient deaths, complications, extended length of stay, and discharge disposition. The predictive discrimination of each model was evaluated using the concordance statistic (C-statistic).

RESULTS

We identified a total of 90,491 patients. The model incorporating both basic demographic variables and the complete set of ECM comorbidity variables provided the best predictive model, with a C-statistic of 0.867 for death, 0.752 for extended length of stay, and 0.81 for nonroutine discharge. The model's discrimination for postoperative complications was good, with C-statistics ranging from 0.641 to 0.879.

CONCLUSION

A predictive model using the ECM outperforms models using the CCI for anticipating resource utilization following shoulder arthroplasty. Our results may assist value-based reimbursement methods to promote quality of care and reduce health care expenditures.

Diagnostic Discordance, Health Information Exchange, and Inter-Hospital Transfer Outcomes: a Population Study

BACKGROUND

Studying diagnostic error at the population level requires an understanding of how diagnoses change over time.

OBJECTIVE

To use inter-hospital transfers to examine the frequency and impact of changes in diagnosis on patient risk, and whether health information exchange can improve patient safety by enhancing diagnostic accuracy.

DESIGN

Diagnosis coding before and after hospital transfer was merged with responses from the American Hospital Association Annual Survey for a cohort of patients transferred between hospitals to identify predictors of mortality.

PARTICIPANTS

Patients (180,337) 18 years or older transferred between 473 acute care hospitals from NY, FL, IA, UT, and VT from 2011 to 2013.

MAIN MEASURES

We identified discordant Elixhauser comorbidities before and after transfer to determine the frequency and developed a weighted score of diagnostic discordance to predict mortality. This was included in a multivariate model with inpatient mortality as the dependent variable. We investigated whether health information exchange (HIE) functionality adoption as reported by hospitals improved diagnostic discordance and inpatient mortality.

KEY RESULTS

Discordance in diagnoses occurred in 85.5% of all patients. Seventy-three percent of patients gained a new diagnosis following transfer while 47% of patients lost a diagnosis. Diagnostic discordance was associated with increased adjusted inpatient mortality (OR 1.11 95% CI 1.10-1.11, p < 0.001) and allowed for improved mortality prediction. Bilateral hospital HIE participation was associated with reduced diagnostic discordance index (3.69 vs. 1.87%, p < 0.001) and decreased inpatient mortality (OR 0.88, 95% CI 0.89-0.99, p < 0.001).

CONCLUSIONS

Diagnostic discordance commonly occurred during inter-hospital transfers and was associated with increased inpatient mortality. Health information exchange adoption was associated with decreased discordance and improved patient outcomes.

Incidence and outcomes of humeral fractures in the older person

Humeral fractures are not well understood and thus we examined the incidence and outcomes of elderly humeral fractures at a single institution over a 3-year period. We found increasing incidence in humeral fractures with increasing age and negative outcomes comparable to hip fractures.

INTRODUCTION

In this study, we report the incidence of humeral fractures in the older patient and their outcomes, including new nursing homes discharges and mortality, residing in the metropolitan referral area of a Sydney tertiary referral hospital.

METHODS

All admissions between 2013 and 2016, of patients aged 65 years or more, presenting to hospital with humeral fractures were reviewed. The data was explored primarily for outcomes (mortality and new admissions to residential aged care facility) and secondarily for clinical association with humeral fractures.

RESULTS

Two hundred eighty-one episodes of humeral fracture were identified. Incidence peaked in the above 85-year-old group at 670 per 100,000 persons per year. Proximal fractures were accounted for 84.3% of the cohort. 12.8% received operative management. The in-hospital mortality rate was 3.6%. Gender was a significant predictor for mortality (OR = 5.8, 95% CI 1.3-28.5, p value = 0.0032) with males six times more likely to experience in-hospital mortality compared to females. 17.8% of participants were admitted to a new nursing home. Logistical regression demonstrated age (OR = 1.10, 95% CI 1.04-1.17; p value = 0.001) and Charlson comorbidity index (OR = 1.32, 95% CI 1.04-1.66; p value = 0.02) were predictors of admission to a new nursing home.

CONCLUSION

Humeral fractures are common in the older population and cause a substantial amount of new nursing home admissions and mortality. Further study is required to ascertain appropriate guidelines for treatment and rehabilitation.

Multimorbidity Analysis According to Sex and Age towards Cardiovascular Diseases of Adults in Northeast China

Non-communicable diseases (NCDs) are great challenges in public health, where cardiovascular diseases (CVD) accounted for the large part of mortality that caused by NCDs. Multimorbidity is very common in NCDs especially in CVD, thus multimorbidity could make NCDs worse and bring heavy economic burden. This study aimed to explore the multimorbidity among adults, especially the important role of CVD that played in the entire multimorbidity networks. A total of 21435 participants aged 18-79 years old were recruited in Jilin province in 2012. Weighted networks were adopted to present the complex relationships of multimorbidity, and Charlson Comorbidity Index (CCI) was used to evaluate the burden of multimorbidity. The prevalence of CVD was 14.97%, where the prevalence in females was higher than that in males (P < 0.001), and the prevalences of CVD increased with age (from 2.22% to 38.38%). The prevalence of multimorbidity with CVD was 96.17%, and CVD could worsen the burden of multimorbidity. Multimorbidity and multimorbidity with CVD were more marked in females than those in males. And the prevalence of multimorbidity was the highest in the middle-age, while the prevalence of multimorbidity with CVD was the highest in the old population.

Discriminative Ability for Adverse Outcomes After Surgical Management of Hip Fractures: A Comparison of the Charlson Comorbidity Index, Elixhauser Comorbidity Measure, and Modified Frailty Index

OBJECTIVES

The Charlson comorbidity index (CCI), Elixhauser comorbidity measure (ECM), and modified frailty index (mFI) have been associated with mortality after hip fracture. The present study compares the clinically informative discriminative ability of CCI, ECM, and mFI, as well as demographic characteristics for predicting in-hospital adverse outcomes after surgical management of hip fractures.

METHODS

Patients undergoing hip fracture surgery were selected from the 2013 National Inpatient Sample. The discriminative ability of CCI, ECM, and mFI, as well as demographic factors for adverse outcomes were assessed using the area under the curve analysis from receiver operating characteristic curves. Outcomes included the occurrence of any adverse event, death, severe adverse events, minor adverse events, and extended hospital stay.

RESULTS

In total, 49,738 patients were included (mean age: 82 years). In comparison with CCI and mFI, ECM had the significantly largest discriminative ability for the occurrence of all outcomes. Among demographic factors, age had the sole or shared the significantly largest discriminative ability for all adverse outcomes except extended hospital stay. The best performing comorbidity index (ECM) outperformed the best performing demographic factor (age) for all outcomes.

CONCLUSION

Among both comorbidity indices and demographic factors, the ECM had the best overall discriminative ability for adverse outcomes after surgical management of hip fractures. The use of this index in correctly identifying patients at risk for postoperative complications may help set appropriate patient expectations, assist in optimizing prophylaxis regimens for medical management, and adjust reimbursements. More widespread use of this measure for hip fracture studies may be appropriately considered.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Discriminative ability of commonly used indices to predict adverse outcomes after poster lumbar fusion: a comparison of demographics, ASA, the modified Charlson Comorbidity Index, and the modified Frailty Index

BACKGROUND CONTEXT

As research tools, the American Society of Anesthesiologists (ASA) physical status classification system, the modified Charlson Comorbidity Index (mCCI), and the modified Frailty Index (mFI) have been associated with complications following spine procedures. However, with respect to clinical use for various adverse outcomes, no known study has compared the predictive performance of these indices specifically following posterior lumbar fusion (PLF).

PURPOSE

This study aimed to compare the discriminative ability of ASA, mCCI, and mFI, as well as demographic factors including age, body mass index, and gender for perioperative adverse outcomes following PLF.

STUDY DESIGN/SETTING

A retrospective review of prospectively collected data was performed.

PATIENT SAMPLE

Patients undergoing elective PLF with or without interbody fusion were extracted from the 2011-2014 American College of Surgeons National Surgical Quality Improvement Program (NSQIP).

OUTCOME MEASURES

Perioperative adverse outcome variables assessed included the occurrence of minor adverse events, severe adverse events, infectious adverse events, any adverse event, extended length of hospital stay, and discharge to higher-level care.

METHODS

Patient comorbidity indices and characteristics were delineated and assessed for discriminative ability in predicting perioperative adverse outcomes using an area under the curve analysis from the receiver operating characteristics curves.

RESULTS

In total, 16,495 patients were identified who met the inclusion criteria. The most predictive comorbidity index was ASA and demographic factor was age. Of these two factors, age had the larger discriminative ability for three out of the six adverse outcomes and ASA was the most predictive for one out of six adverse outcomes. A combination of the most predictive demographic factor and comorbidity index resulted in improvements in discriminative ability over the individual components for five of the six outcome variables.

CONCLUSION

For PLF, easily obtained patient ASA and age have overall similar or better discriminative abilities for perioperative adverse outcomes than numerically tabulated indices that have multiple inputs and are harder to implement in clinical practice.

Discriminative Ability of Elixhauser's Comorbidity Measure is Superior to Other Comorbidity Scores for Inpatient Adverse Outcomes After Total Hip Arthroplasty

BACKGROUND

Identifying patients at highest risk for a complex perioperative course following total hip arthroplasty (THA) is more important than ever in order to educate patients, optimize outcomes, and to minimize cost and length of stay. There are no known studies comparing the clinically relevant discriminative ability of 3 commonly used comorbidity indices for adverse outcomes following THA: Elixhauser Comorbidity Measure (ECM), the Charlson Comorbidity Index (CCI), and the modified Frailty Index (mFI).

METHODS

Patients undergoing THA were extracted from the 2013 National Inpatient Sample. The discriminative ability of ECM, CCI, and mFI, as well as the demographic factors age, body mass index, and gender for the occurrence of index admission Centers for Medicare & Medicaid Services procedure-specific complication measures, extended length of hospital stay, and discharge to a facility were assessed using the area under the curve analysis from receiver operating characteristic curves.

RESULTS

ECM outperformed CCI and mFI for the occurrence of all 5 adverse outcomes. Age outperformed gender and obesity for the occurrence of all 5 adverse outcomes. ECM (the best performing comorbidity index) outperformed age (the best performing demographic factor) in discriminative ability for the occurrence of 3 of 5 adverse outcomes.

CONCLUSION

The less commonly used ECM outperformed the more often utilized CCI and newer mFI as well as demographic factors in correctly preoperatively identifying patients' probabilities of experiencing an adverse outcome suggesting that wider adoption of ECM should be considered in both identifying likelihoods of adverse patient outcomes and for research purposes in future studies.

A systematic review of spinal research conducted using the National Surgical Quality Improvement Program

BACKGROUND CONTEXT

Over the course of the last decade, interest in the use of large data repositories for clinical research in orthopedic and spine surgery has grown substantially. Detractors maintain that the clinical relevance of research conducted using large registries is limited, and that the academic influence of such studies is minimal. Such contentions have not been empirically evaluated.

PURPOSE

This study sought to perform a systematic review of spinal research conducted using the National Surgical Quality Improvement Program (NSQIP).

STUDY DESIGN

This is a systematic review.

OUTCOME MEASURES

Impact factor (IF) of the journal of publication and number of citations of published articles conducted using the NSQIP.

METHODS

Orthopedic and spine-specific NSQIP articles published from January 1, 2007 to July 31, 2015, were identified through a query of PubMed or Medline, Embase, Web of Science, and Scopus. Articles were classified by journal of publication, year of publication, study topic, study purpose, and method of statistical analysis. Spine surgical publications were compared with other orthopedic research conducted using the NSQIP. The primary dependent variables for the purposes of statistical testing were IF of the journal in which the article was published and the number of citations for each publication. Negative binomial regression was used to evaluate the characteristics of papers associated with increased IF and number of citations.

RESULTS

Of the 1,525 articles identified in the initial search, 114 studies were considered eligible for inclusion in the systematic review. The average IF for the journals publishing orthopedic NSQIP articles was 2.75 (standard deviation [SD] 1.22, range 0-5.28), whereas it was 2.52 (SD 0.81, range 1.38-5.28) for spinal research. The average number of citations per article was 6.08 (SD 10.9, range 0-69) and 6.4 (SD 12.0, range 0-69) for spine-specific studies. Following negative binomial regression, only IF (regression coefficients [RC] 0.31; 95% confidence intervals [CI] 0.08, 0.55) and the year of publication (RC -1.29; 9% CI -1.64, -0.95) were found to have a statistically significant association with number of citations. Among spine-specific research articles, only the year of publication was found to influence the number of citations (RC -1.29; 95% CI -1.94, -0.64).

CONCLUSIONS

Our findings indicate that the academic impact of orthopedic and spine surgical research conducted using NSQIP is highly variable, with most publications found to have relatively low impact. As our evaluation of study characteristics associated with high-impact publications and increased citations were unable to uncover factors that are likely translatable, we suggest following research design guidelines that highlight best practices when using large datasets for orthopedic research.

Does "6-Clicks" Day 1 Postoperative Mobility Score Predict Discharge Disposition After Total Hip and Knee Arthroplasties?

BACKGROUND

The use of inpatient rehabilitation services after total joint arthroplasty (TJA) is an important driver of episode-of-care costs. We determined the utility of a new standardized instrument collected during the immediate postoperative period, the Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" Mobility score, in predicting discharge disposition after TJA and its accuracy in estimating prolonged hospital stay, readmissions, and emergency department (ED) visits.

METHODS

Using our institutional database, we retrospectively reviewed 744 patients undergoing primary total hip (40%) or knee (60%) arthroplasty for osteoarthritis during 2014. The AM-PAC Mobility score was prospectively collected by physical therapists within 24 hours of surgery. We constructed 2 multivariable logistic regression models for each study outcome: (1) a base model containing age, sex, Charlson Comorbidity Index, and procedure type and (2) the AM-PAC model including the aforementioned variables and this score. The predictive performance of these models was assessed and compared using the area under the receiver operating characteristic (AUC) curve.

RESULTS

The AM-PAC model provided better prediction of discharge disposition (AUC = 0.777) than the base model (AUC = 0.716; 22% relative improvement). Although the AM-PAC model performed 32% and 27% better than the base model in estimating prolonged hospital stay and ED visits, the model's predictive performance was poor (prolonged stay: AUC = 0.639; ED visit: AUC = 0.658). The AM-PAC model also showed poor discrimination of readmissions (AUC = 0.657), and there was no relative improvement in predictive performance compared to that of the base model.

CONCLUSION

The AM-PAC "6-Clicks" Mobility score is a valid, simple tool for predicting discharge disposition after TJA.