30-day mortality in patients after hip fracture surgery: A comparison of the Charlson Comorbidity Index score and ASA score used in two prediction models

Objective: To compare the Charlson Comorbidity Index (CCI) and American Society of Anesthesiologists (ASA) Physical Status Classification used in two prediction models for 30-day mortality after hip fracture surgery.Study Design and Setting: Data from 3651 patients (mean age: 83 years) from a Norwegian University Hospital were retrospectively obtained and randomly divided into two cohorts: a model cohort (n = 1825) to develop two prediction models with CCI and ASA as the main predictors, and a validation cohort (n = 1826) to assess the predictive ability of both models. A receiver operating characteristic (ROC) curve determined the best model to predict mortality.Results: Area under the ROC curve at 30 days was 0.726 (p = 0.988) for both the CCI- and ASA-model. The chosen cut-off-points on the ROC curve for CCI- and ASA-model corresponded to similar model sensitivities of 0.657 and specificities of 0.680 and 0.679, respectively. Hence, each model predicts correctly 66% (n = 96) of the mortalities and 68% (n = 1132 and n = 1131) of the survivals. 23% (n = 33) of the mortalities were predicted by neither model.Conclusion: The CCI- and ASA-model had equal predictive ability of 30-day mortality after hip fracture. Considering the effort involved in calculating Charlson Comorbidity Index score, the ASA score may be the preferred tool to predict the 30-day mortality after hip fracture.     

Comparing Comorbidity Polypharmacy Score and Charlson Comorbidity Index in predicting outcomes in older trauma patients

BackgroundThe Charlson Comorbidity Index (CCI) and Comorbidity Polypharmacy Score (CPS) may potentially risk-stratify older trauma patients more accurately than traditional trauma severity scores. We aim to evaluate if CCI or CPS are better predictors of mortality and discharge venue in such patients.MethodsWe conducted a retrospective study using registry data from two tertiary trauma centres. Patients aged 65 years and above who presented to the emergency departments (EDs) between January 2011 and December 2015 with traumatic injuries were included. Charts were reviewed for demographics, injury mechanism and severity, discharge outcomes, and types of comorbidities and medications used. Primary outcome was overall mortality; secondary outcomes included ED disposition and hospital discharge venue. Discriminatory power of the score(s) were compared using area under the receiver operating characteristic (AUROC) curve.ResultsThere were 2,750 patients, with overall female predominance (56.7%, 1,560/2,750) and median age of 78 years (interquartile range [IQR] 72 to 84 years). Median CCI score was 1 (IQR 0 to 2) and median CPS was 8 (IQR 4 to 12). Overall mortality was 9.4% (259/2,750). Every 1-point increase in CCI score resulted in increased odds of death by 16% (adjusted odds ratio 1.16, 95% confidence interval 1.07 to 1.26, p<0.001). Addition of CCI to the Injury Severity Score (ISS) increased the discriminatory power for mortality (AUROC for ISS = 0.832; AUROC for ISS with CCI = 0.843). Every 1-point increase in CCI was significantly associated with decreased odds of admission to a rehab facility by 8%. CPS did not predict mortality and discharge venue.ConclusionCCI, but not CPS, was a predictor of mortality. A higher CCI was associated with decreased odds of discharge to a subacute facility, likely related to underlying rehabilitation potential. Further studies should be undertaken to explore an integrated scoring system that considers injury severity, comorbidities, and polypharmacy.     

Differences in the Predictive value of Elixhauser Comorbidity Index and the Charlson Comorbidity indices in patients with hand infections

PurposeHand infections are a common source of potentially debilitating morbidity, particularly in patients with comorbid disease. We hypothesize that there is a difference in predictive value between two commonly used comorbidity indices for the prognosis of hand infections, which may have clinical implications in the management of these conditions.MethodsThe Nationwide Inpatient Sample 2001–2013 database was queried for hand infections using International Classification of Diseases, Ninth Revision codes. The Elixhauser (ECI) and Charlson (CCI) comorbidity scores were calculated based on validated sets of ICD-9 codes. Primary outcomes included mortality, prolonged length of stay (LOS, defined as >95 percentile), discharge destination, and postoperative complications. Indices were compared using receiver operating characteristic (ROC) curves and the areas under the curve (AUC). If confidence intervals overlapped, significance was determined using the DeLong method for correlated ROC curves. This is a validated, non-parametric comparison used for the calculation of the difference between two AUCs.ResultsA weighted total of 1,511,057 patients were included in this study. The majority were Caucasian (57.1%) males (61.4%). Complication rates included 0.9% mortality, 5.3% prolonged length of stay, 25.3% discharges to non-home destinations, and 5.3% post-operative complications. The ECI and CCI each demonstrated good predictive value for mortality, but poor predictive value for non-routine discharge, prolonged LOS, and post-operative complications. There was a significantly increased likelihood of each complication with increasing comorbidity score for both indices, with the greatest odds ratio in the ECI ≥4 cohort.ConclusionsThe CCI was superior in predicting mortality while the ECI was superior in predicting non-routine discharge, prolonged length of stay, and postoperative complications, but these indices may not be clinically relevant. While both represent good predictive models, a score specifically designed for patients with hand infections may have superior prognostic value.Level of evidenceLevel IV.     

Basal metabolic rate and Charlson Comorbidity Index are independent predictors of metabolic syndrome in patients with rheumatoid arthritis

ObjectiveTo prospectively analyze predictors of metabolic syndrome (MetS) in patients with rheumatoid arthritis (RA) during 2 years of follow-up.MethodsWe recruited 319 consecutive patients with RA who did not have MetS. MetS was defined in accordance with the modified National Cholesterol Education Program/Adult Treatment Panel III 2005 for Asian populations. Sociodemographic data, laboratory findings, disease activity data, and medication history were collected during face-to-face interviews at baseline and follow-up. Independent predictors of MetS were assessed by univariate and multivariate logistic regression analyses.ResultsOf the 247 patients with RA who completed the 2-year follow-up, 37 (15.0%) developed MetS. At baseline, these patients were older and had higher body mass index, waist circumference, waist-hip ratio, skeletal muscle mass, body fat mass, percent body fat, and Charlson Comorbidity Index scores, as well as lower basal metabolic rate (BMR). Moreover, these patients with MetS took less hydroxychloroquine and more oral hypoglycemic agents; they also had lower European Quality of Life Health-state Questionnaire scores. After exclusion of variables associated with MetS composition, multivariate analysis identified BMR (odds ratio [OR] = 0.205, 95% confidence interval [CI]: 0.078–0.541, P = 0.001) and Charlson Comorbidity Index score (OR = 2.191, 95% CI: 1.280–3.751, P = 0.004) as significant predictors of MetS.ConclusionsOur study showed that the annual incidence rate of MetS was 11.5% in patients with RA. Moreover, the development of MetS was associated with BMR and Charlson Comorbidity Index score at baseline.     

Comorbidities Can Predict Mortality of Kidney Transplant Recipients: Comparison With the Charlson Comorbidity Index

Background

Comorbid conditions are important in the survival of kidney transplant recipients. The weights assigned to comorbidities to predict survival may vary based on the type of index disease and advances in the management of comorbidities. We aimed to develop a modified Charlson comorbidity index (CCI) in renal allograft recipients (mCCI-KT), thereby improving risk stratification for mortality.

Relationship between the Charlson Comorbidity Index and cost of treating hip fractures: implications for bundled payment

BackgroundThe aim of this study is to investigate how the Charlson Comorbidity Index (CCI) scores contribute to increased length of stay (LOS) and healthcare costs in hip fracture patients.ResultsMultivariate linear regression analysis modeled the length of stay as a function of CCI score. Each unit increase in the CCI score corresponded to an increase in length of hospital stay and hospital costs incurred [effect size = 0.21; (0.0434–0.381); p = 0.014]. Patients with a CCI score of 2 (compared to a baseline CCI score of 0), on average, stayed 1.92 extra days in the hospital, and incurred $8,697.60 extra costs.ConclusionsThe CCI score is associated with length of stay and hospital costs incurred following treatment for hip fracture. The CCI score may be a useful tool for risk assessment in bundled payment plans.

Level of evidence

Level III.     

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).

Management of postoperative complications in spinal surgery patients with osteoporosis

Osteoporosis is a relatively common finding in patients undergoing spine surgery. Osteoporosis increases the risk for complications secondary to implant or bone union failure, including proximal junctional failure and pseudarthrosis. In cases of severe symptoms or progressive deformity, pathology-driven revision surgery may be required. In general, posterior surgery is commonly advocated in cases of fixed deformity with additional osteotomies and decompressions as needed. Conversely, an anterior approach is typically reserved for cases with flexible deformity and anterior compressive structures. In these cases, the use of autograft is also recommended in order to facilitate bone osseo-integration.     

Necrotizing fasciitis of the extremities in high and low Charlson Comorbidity Index: A multi-center retrospective cohort study

BackgroundNecrotizing fasciitis (NF) is a life-threatening and acute progressive soft tissue infection and needs early surgical intervention, that is, debridement or amputation. Surgical strategy or prognosis is influenced by the speed of progression and patients’ general condition, which can be calculated by the Charlson Comorbidity Index (CCI). The purpose of this study was to investigate the association between the CCI scores and prognosis of patients with NF of the upper/lower extremities.MethodsIn the retrospective cohort study, we analyzed patients with NF of the upper/lower extremities who were determined to undergo surgery by orthopedic surgeons at four tertiary hospitals between August 2003 and April 2016. We divided the patients into two groups, Group L (low CCI scores of 0–2) and Group H (high CCI scores of ≥3). The primary event of this study was defined as death or amputation. Mortality cases were included when amputation was informed with documented certification but patients died while waiting for surgery. We compared the patients’ background, laboratory data on admission, the laboratory risk indicator for necrotizing fasciitis (LRINEC) score, and primary outcome between the two groups.ResultsOf the 56 patients, 28 patients were classified into Group L and the other 28 patients into Group H. The data in this study showed that patients in Group H had lower white blood cell counts and hemoglobin and higher creatinine than Group L, but there was no difference in LRINEC scores between the two groups. Streptococcus pyogenes was the most common infectious agent in Group L (54%) but not in Group H (11%). Poorer outcome was observed in Group H compared with Group L (4 mortality and 16 amputation vs. no mortality and 9 amputation, P = 0.007).ConclusionsLaboratory data and causative microorganisms were different between high CCI and low CCI patients with NF. High CCI scores were associated with limb amputation or death caused by NF of the upper/lower extremities; whereas, low CCI scores were more likely associated with S. pyogenes monoinfection.     

Charlson Comorbidity Indices and In-hospital Deaths in Patients with Hip Fractures

Background

The Charlson Comorbidity Index (CCI) and its modifications are comorbidity-based measures that predict mortality. It was developed for patients without trauma and inconsistently predicted mortality and adverse events in several previous studies of patients with trauma.

Purpose

We therefore (1) determined whether the three different CCIs were predictors for in-hospital deaths in patients with hip fractures, (2) verified if the CCI mortality prediction had changed with time, (3) evaluated other predictors of in-hospital death in patients with hip fractures, and (4) determined if the CCI has predicted in-hospital adverse events.

Methods

We retrospectively reviewed a nationwide probability sample survey, the National Hospital Discharge Survey. More than 6 million adult patients with hip fractures and their associated comorbidities were scored by the original 1987 CCI, the 1994 age-adjusted CCI, and the 2011 updated, reweighted CCI. The three mortality indices’ predictive values and predictors of in-hospital adverse events were compared.

Results

For patients with hip fractures, all three CCI variations predicted in-hospital mortality. The receiver operating curves (ROC) of the models were less than 0.68, but they improved when we used statistical models that included age, sex, concomitant injuries, and other comorbidities not contained in the CCI models (ROC > 0.74). The age-adjusted CCI accuracy was slightly better than the other two CCIs. Adverse events during hospital stays were associated with a higher CCI, pertrochanteric fracture (versus transcervical), abdominal, chest, or head trauma, atrial fibrillation, multiple fractures, female sex, and longer hospital stays; however, the accuracy of this model was poor (ROC = 0.65).

Conclusions

While all three CCI variations predicted in-hospital mortality in patients with hip fractures, other factors may be of value in patients with trauma.     

Thromboembolic complications after spinal surgery in trauma patients

Background Deep venous thrombosis (DVT) and pulmonary embolism (PE) may be significant complications following spinal surgery. The incidence rate ranges from 0.5% to 2.5% in patients with symptomatic thromboembolic disease and up to 15% in patients with non-symptomatic thrombotic complications. We determined the incidence of symptomatic thromboembolism after spinal surgery in patients with postoperative systemic prophylaxis and investigated general and specific risk factors for development of this disease.

Patients and methods We analyzed the clinical records of 978 patients who had undergone surgery of the spine because of trauma and who had been admitted to our level-I trauma center between 1980 and 2004. Spinal procedures included anterior and/or posterior spinal fusion, video-assisted thoracoscopic fusion, and spinal decompression. Symptomatic thromboembolic disease was diagnosed when patients showed significant clinical signs or symptoms of DVT or PE. In cases of DVT, diagnosis was confirmed by duplex scan of the lower limbs; in cases of PE, diagnosis was confirmed by CT-scanning of the thorax or at post mortem.

Results The incidence rate of symptomatic thromboembolic complications was 2.2% (n 22). 17 patients showed clinical signs of deep venous thrombosis, with 4 of them developing pulmonary embolism subsequently. The other 5 patients developed pulmonary embolism without prior clinical signs of deep venous thrombosis. 6 patients died because of thromboembolic disease. Thromboembolic complications were more frequent in older patients and among males, as well as in patients with regular tobacco consumption and obesity. Thromboembolic complications were also seen more frequently in patients with surgical procedures at the lumbar spine, in patients with anterior spinal fusion, and in those with motor deficits in the lower extremities.

Interpretation We found a rather low rate of clinically significant thromboembolic complications after spinal surgery because of trauma, compared to the results reported in the literature. Level of spinal surgery, surgical approach, and motor deficits in the lower extremities were identified as specific risk factors for DVT or PE. Age, sex, obesity and regular smoking were identified as general risk factors.     

Thromboembolic complications after spinal surgery in trauma patients

Background?Deep venous thrombosis (DVT) and pulmonary embolism (PE) may be significant complications following spinal surgery. The incidence rate ranges from 0.5% to 2.5% in patients with symptomatic thromboembolic disease and up to 15% in patients with non-symptomatic thrombotic complications. We determined the incidence of symptomatic thromboembolism after spinal surgery in patients with postoperative systemic prophylaxis and investigated general and specific risk factors for development of this disease.

Patients and methods?We analyzed the clinical records of 978 patients who had undergone surgery of the spine because of trauma and who had been admitted to our level-I trauma center between 1980 and 2004. Spinal procedures included anterior and/or posterior spinal fusion, video-assisted thoracoscopic fusion, and spinal decompression. Symptomatic thromboembolic disease was diagnosed when patients showed significant clinical signs or symptoms of DVT or PE. In cases of DVT, diagnosis was confirmed by duplex scan of the lower limbs; in cases of PE, diagnosis was confirmed by CT-scanning of the thorax or at post mortem.

Results?The incidence rate of symptomatic thromboembolic complications was 2.2% (n 22). 17 patients showed clinical signs of deep venous thrombosis, with 4 of them developing pulmonary embolism subsequently. The other 5 patients developed pulmonary embolism without prior clinical signs of deep venous thrombosis. 6 patients died because of thromboembolic disease. Thromboembolic complications were more frequent in older patients and among males, as well as in patients with regular tobacco consumption and obesity. Thromboembolic complications were also seen more frequently in patients with surgical procedures at the lumbar spine, in patients with anterior spinal fusion, and in those with motor deficits in the lower extremities.

Interpretation?We found a rather low rate of clinically significant thromboembolic complications after spinal surgery because of trauma, compared to the results reported in the literature. Level of spinal surgery, surgical approach, and motor deficits in the lower extremities were identified as specific risk factors for DVT or PE. Age, sex, obesity and regular smoking were identified as general risk factors.     

The societal costs of femoral neck fracture patients treated with internal fixation

Summary

The study rationale was to provide a detailed overview of the costs for femoral neck fracture treatment with internal fixation in the Netherlands. Mean total costs per patient at 2-years follow-up were €19,425. Costs were higher for older, less healthy patients. Results are comparable to internationally published costs.

Introduction

The aim of this study was to provide a detailed overview of the cost and healthcare consumption of patients treated for a hip fracture with internal fixation. A secondary aim was to compare costs of patients who underwent a revision surgery with patients who did not.

Methods

The study was performed alongside the Dutch sample of an international randomized controlled trial, concerning femoral neck fracture patients treated with internal fixation. Patient characteristics and healthcare consumption were collected. Total follow-up was 2 years. A societal perspective was adopted. Costs included hospital costs during primary stay and follow-up, and costs related to rehabilitation and changes in living situation. Costs were compared between non-revision surgery patients, implant removal patients, and revision arthroplasty patients.

Results

A total of 248 patients were included (mean age 71 years). Mean total costs per patient at 2-years follow-up were €19,425. In the non-revision surgery patients total costs were €17,405 (N?=?137), in the implant removal patients €10,066 (N?=?38), and in the revision arthroplasty patients €26,733 (N?=?67). The main contributing costs were related to the primary surgery, admission days, physical therapy, and revision surgeries.

Conclusions

The main determinant was the costs of admission to a rehabilitation center/nursing home. Costs were specifically high in elderly with comorbidity, who were less independent pre-fracture, and have a longer admission to the hospital and/or a nursing home. Costs were also higher in revision surgery patients. The 2-years follow-up costs in our study were comparable to published costs in other Western societies.     

Bipolar hemiarthroplasty in unstable intertrochanteric fractures in elderly patients. The predictive value of the Charlson Comorbidity Index in 1-year mortality

BackgroundHip fractures have a significant impact on morbidity and mortality in the elderly. Aims: We retrospectively evaluated the predictive role of the Charlson Comorbidity Index (CCI) for 1-year mortality in elderly patients with unstable intertrochanteric hip fractures (ITHF) treated with bipolar hemiarthroplasty. The secondary objective was to identify other relationships, if any, between the variables recorded and mortality.MethodsWe included ≥75-year-old patients with unstable ITHF treated with bipolar hemiarthroplasty. We recorded patient gender, age, Body Mass Index, pre-fracture walking ability (Parker Mobility score, modified Harris Hip Score), America Society of Anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI), time to surgery, time to mobilization, hospital stay, and postoperative complications. Uni- and multivariate logistic regression analysis were performed. Sensitivity and specificity were calculated using a ROC curve.ResultsA total of 135 patients with a mean age of 87.34 ± 5.5 years were included. The overall 1-year mortality rate was 18.5%. The CCI (OR 1.64 CI 95% 1.21–2.23; p 0.00821) and postoperative complications (OR 3.5 CI 95% 1.19–10.23 p 0.0202) were identified as independent predictors of 1-year mortality in the univariate regression and confirmed in the multivariate regression. CCI sensitivity to predict 1-year mortality was 80%.ConclusionCCI has shown acceptable sensitivity in the prediction of 1-year mortality in elderly patients with unstable ITHF treated with bipolar hemiarthroplasty. It is of utmost importance to prevent postoperative complications due to their significant impact on 1-year mortality.