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Higher Charlson Comorbidity Index Scores are Associated With Readmission After Orthopaedic Surgery

  • Clinical Research
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

The Charlson Comorbidity Index (CCI) originally was developed to predict mortality within 1 year of hospital admission in patients without trauma. As it includes factors associated with medical and surgical complexities, it also may be useful as a predictive tool for hospital readmission after orthopaedic surgery, but to our knowledge, this has not been studied.

Questions/purposes

We asked whether an increased score on the CCI was associated with (1) readmission, (2) an increased risk of surgical site infection or other adverse events, (3) transfusion risk, or (4) mortality after orthopaedic surgery.

Methods

A total of 30,129 orthopaedic surgeries performed between 2008 and 2011 without any orthopaedic surgery in the preceding 30 days were analyzed. International Classification of Diseases, 9th Revision codes were used to identify diagnoses, procedures, surgery-related adverse events, surgical site infection, and comorbidities as listed in the updated and reweighted CCI. A total of 913 patients (3.0%) were readmitted within 30 days after discharge; in 393 (1.4%) patients adverse events occurred; 417 patients (1.4%) had a surgical site infection develop; 211 (0.7%) needed transfusions, and 56 (0.2%) died within 30 days after surgery. Ordinary least squares regression analyses were used to determine whether the CCI was associated with these outcomes.

Results

The CCI accounted for 10% of the variation in readmissions. Every point increase in CCI score added an additional 0.45% risk in readmission for patients undergoing arthroplasty, 0.63% for patients undergoing trauma surgery, and 0.9% risk for patients undergoing spine surgery (all p < 0.01). The CCI was not associated with surgical site infection or other adverse events, but accounted for 8% of the variation in transfusion rate and 10% of the variation in mortality within 30 days of surgery.

Conclusions

The CCI can be used to estimate the risk of readmission after arthroplasty, hand and upper extremity surgery, spine surgery, and trauma surgery. It also can be used to estimate the risk of transfusion after arthroplasty, spine, trauma, and oncologic orthopaedic surgery and the risk of mortality after shoulder, trauma, and oncologic orthopaedic surgery.

Level of Evidence

Level IV, prognostic study. See the Instructions for Authors for a complete description of levels of evidence

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References

  1. Ahmed I, Chan JK, Jenkins P, Brenkel I, Walmsley P. Estimating the transfusion risk following total knee arthroplasty. Orthopedics. 2012;35:e1465–1471.

    Article  PubMed  Google Scholar 

  2. Arrigo RT, Kalanithi P, Cheng I, Alamin T, Carragee EJ, Mindea SA, Boakye M, Park J. Charlson score is a robust predictor of 30-day complications following spinal metastasis surgery. Spine (Phila Pa 1976). 2011;36:E1274–1280.

    Article  Google Scholar 

  3. Ashton CM, Kuykendall DH, Johnson ML, Wray NP, Wu L. The association between the quality of inpatient care and early readmission. Ann Intern Med. 1995;122:415–421.

    Article  PubMed  CAS  Google Scholar 

  4. Aynardi M, Jacovides CL, Huang R, Mortazavi SM, Parvizi J. Risk factors for early mortality following modern total hip arthroplasty. J Arthroplasty. 2013;28:517–520.

    Article  PubMed  Google Scholar 

  5. Benbassat J, Taragin M. Hospital readmissions as a measure of quality of health care: advantages and limitations. Arch Intern Med. 2000;160:1074–1081.

    Article  PubMed  CAS  Google Scholar 

  6. Burke RE, Coleman EA. Interventions to decrease hospital readmissions: keys for cost-effectiveness. JAMA Intern Med. 2013;173:695–698.

    Article  PubMed  Google Scholar 

  7. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–383.

    Article  PubMed  CAS  Google Scholar 

  8. Folk JW, Starr AJ, Early JS. Early wound complications of operative treatment of calcaneus fractures: analysis of 190 fractures. J Orthop Trauma. 1999;13:369–372.

    Article  PubMed  CAS  Google Scholar 

  9. Gabbe BJ, Magtengaard K, Hannaford AP, Cameron PA. Is the Charlson Comorbidity Index useful for predicting trauma outcomes? Acad Emerg Med. 2005;12:318–321.

    Article  PubMed  Google Scholar 

  10. Hardy JC, Hung M, Snow BJ, Martin CL, Tashjian RZ, Burks RT, Greis PE. Blood transfusion associated with shoulder arthroplasty. J Shoulder Elbow Surg. 2013; 22:233–239

    Article  PubMed  Google Scholar 

  11. Hendren S, Morris AM, Zhang W, Dimick J. Early discharge and hospital readmission after colectomy for cancer. Dis Colon Rectum. 2011;54:1362–1367.

    Article  PubMed  Google Scholar 

  12. Higuera CA, Elsharkawy K, Klika AK, Brocone M, Barsoum WK. 2010 Mid-America Orthopaedic Association Physician in Training Award: predictors of early adverse outcomes after knee and hip arthroplasty in geriatric patients. Clin Orthop Relat Res. 2011;469:1391–1400.

    Article  PubMed Central  PubMed  Google Scholar 

  13. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360:1418–2148.

    Article  PubMed  CAS  Google Scholar 

  14. Jordan CJ, Goldstein RY, Michels RF, Hutzler L, Slover JD, Bosco JA 3rd. Comprehensive program reduces hospital readmission rates after total joint arthroplasty. Am J Orthop (Belle Mead NJ). 2012;41:E147–151.

    PubMed  Google Scholar 

  15. Kadar A, Chechik O, Steinberg E, Reider E, Sternheim A. Predicting the need for blood transfusion in patients with hip fractures. Int Orthop. 2013;37:693–700.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Kocher RP, Adashi EY. Hospital readmissions and the Affordable Care Act: paying for coordinated quality care. JAMA. 2011;306:1794–1795.

    Article  PubMed  CAS  Google Scholar 

  17. Kurtz SM, Lau E, Ong KL, Carreon L, Watson H, Albert T, Glassman S. Infection risk for primary and revision instrumented lumbar spine fusion in the Medicare population. J Neurosurg Spine. 2012;17:342–347.

    Article  PubMed  Google Scholar 

  18. Mantilla CB, Wass CT, Goodrich KA, Johanns CJ, Kool ML, Zhu X, Corredor JA, Warner DO, Joyner MJ, Berry DJ, Schroeder DR, Sprung J. Risk for perioperative myocardial infarction and mortality in patients undergoing hip or knee arthroplasty: the role of anemia. Transfusion. 2011;51:82–91.

    Article  PubMed  Google Scholar 

  19. McCarthy D, Johnson MB, Audet AM. Recasting readmissions by placing the hospital role in community context. JAMA. 2013;309:351–352.

    Article  PubMed  CAS  Google Scholar 

  20. Memtsoudis SG, Ma Y, Chiu YL, Walz JM, Voswinckel R, Mazumdar M. Perioperative mortality in patients with pulmonary hypertension undergoing major joint replacement. Anesth Analg. 2010;111:1110–1116.

    Article  PubMed  Google Scholar 

  21. Memtsoudis SG, Pumberger M, Ma Y, Chiu YL, Fritsch G, Gerner P, Poultsides L, Valle AG. Epidemiology and risk factors for perioperative mortality after total hip and knee arthroplasty. J Orthop Res. 2012;30:1811–1821.

    Article  PubMed Central  PubMed  Google Scholar 

  22. Miller AG, Margules A, Raikin SM. Risk factors for wound complications after ankle fracture surgery. J. Bone Joint Surg Am. 2012;94:2047–2052.

    Article  PubMed  Google Scholar 

  23. Moore L, Thomas Stelfox H, Turgeon AF, Nathens AB, Sage NL, Emond M, Bourgeois G, Lapointe J, Gagné M. Rates, patterns, and determinants of unplanned readmission after traumatic injury: a multicentre cohort study. Ann Surg. 2013 Mar 8. [Epub ahead of print]

  24. Navaneethan U, Gutierrez NG, Jegadeesan R, Venkatesh PG, Butt M, Sanaka MR, Vargo JJ, Parsi MA. Delay in performing ERCP and adverse events increase the 30-day readmission risk in patients with acute cholangitis. Gastrointest Endosc. 2013;78:81–90.

    Article  PubMed  Google Scholar 

  25. Neuhaus V, King J, Hageman MG, Ring DC. Charlson comorbidity indices and in-hospital deaths in patients with hip fractures. Clin Orthop Relat Res. 2013;471:1712–1719.

    Article  PubMed  Google Scholar 

  26. Quan H, Li B, Couris CM, Fushimi K, Graham P, Hider P, Januel JM, Sundararajan V. Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol. 2011;173:676–682.

    Article  PubMed  Google Scholar 

  27. Sanders RD, Bottle A, Jameson SS, Mozid A, Aylin P, Edger L, Ma D, Reed MR, Walters M, Lees KR, Maze M. Independent preoperative predictors of outcomes in orthopedic and vascular surgery: the influence of time interval between an acute coronary syndrome or stroke and the operation. Ann Surg. 2012;255:901–907.

    Article  PubMed  Google Scholar 

  28. Schneider EB, Hyder O, Brooke BS, Efron J, Cameron JL, Edil BH, Schulick RD, Choti MA, Wolfgang CL, Pawlik TM. Patient readmission and mortality after colorectal surgery for colon cancer: impact of length of stay relative to other clinical factors. J Am Coll Surg. 2012;214:390–398; discussion 398–399.

    Article  PubMed  Google Scholar 

  29. Schumer RA, Chae JS, Markert RJ, Sprott D, Crosby LA. Predicting transfusion in shoulder arthroplasty. J Shoulder Elbow Surg. 2010;19:91–96.

    Article  PubMed  Google Scholar 

  30. Shu CC, Lin YF, Hsu NC, Ko WJ. Risk factors for 30-day readmission in general medical patients admitted from the emergency department: a single centre study. Intern Med J. 2012;42:677–682.

    Article  PubMed  Google Scholar 

  31. Singh JA, Jensen MR, Harmsen WS, Gabriel SE, Lewallen DG. Cardiac and thromboembolic complications and mortality in patients undergoing total hip and total knee arthroplasty. Ann Rheum Dis. 2011;70:2082–2088.

    Article  PubMed Central  PubMed  Google Scholar 

  32. SooHoo NF, Eagan M, Krenek L, Zingmond DS. Incidence and factors predicting pulmonary embolism and deep venous thrombosis following surgical treatment of ankle fractures. Foot Ankle Surg. 2011;17:259–262.

    Article  PubMed  Google Scholar 

  33. Soohoo NF, Farng E, Lieberman JR, Chambers L, Zingmond DS. Factors that predict short-term complication rates after total hip arthroplasty. Clin Orthop Relat Res. 2010;468:2363–2371.

    Article  PubMed Central  PubMed  Google Scholar 

  34. SooHoo NF, Lieberman JR, Ko CY, Zingmond DS. Factors predicting complication rates following total knee replacement. J Bone Joint Surg Am. 2006;88:480–485.

    Article  PubMed  Google Scholar 

  35. Teixeira A, Trinquart L, Raphael M, Bastianic T, Chatellier G, Holstein J. Outcomes in older patients after surgical treatment for hip fracture: a new approach to characterise the link between readmissions and the surgical stay. Age Ageing. 2009;38:584–589.

    Article  PubMed  Google Scholar 

  36. Viens NA, Hug KT, Marchant MH, Cook C, Vail TP, Bolognesi MP. Role of diabetes type in perioperative outcomes after hip and knee arthroplasty in the United States. J Surg Orthop Adv. 2012;21:253–260.

    Article  PubMed  Google Scholar 

  37. Zekry D, Loures Valle BH, Graf C, Michel JP, Gold G, Krause KH, Herrmann FR. Prospective comparison of 6 comorbidity indices as predictors of 1-year post-hospital discharge institutionalization, readmission, and mortality in elderly individuals. J Am Med Dir Assoc. 2012;13:272–278.

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA, 02114, USA

    Timothy Voskuijl MD, Michiel Hageman MD & David Ring MD, PhD

Authors
  1. Timothy Voskuijl MD
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  2. Michiel Hageman MD
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  3. David Ring MD, PhD
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Corresponding author

Correspondence to David Ring MD, PhD.

Additional information

Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

Appendices

Appendix 1. ICD-9 codes for variables used in this study*

Diagnosis

Corresponding ICD-9 codes

Surgical site infection

 Other specified local infections of skin and subcutaneous tissue

686.8

 Unspecified local infection of skin and subcutaneous tissue

686.9

 Unspecified infection of bone, site unspecified

730.90

 Unspecified infection of bone, shoulder region

730.91

 Unspecified infection of bone, upper arm

730.92

 Unspecified infection of bone, forearm

730.93

 Unspecified infection of bone, hand

730.94

 Unspecified infection of bone, pelvic region and thigh

730.95

 Unspecified infection of bone, lower leg

730.96

 Unspecified infection of bone, ankle and foot

730.97

 Unspecified infection of bone, other specified sites

730.98

 Unspecified infection of bone, multiple sites

730.99

 Infection and inflammatory reaction due to unspecified device, implant, and graft

996.60

 Infection and inflammatory reaction due to internal joint prosthesis

996.66

 Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft

996.67

 Infection and inflammatory reaction due to other internal prosthetic device, implant, and graft

996.69

 Infected postoperative seroma

998.51

 Other postoperative infection

998.59

 Posttraumatic wound infection not elsewhere classified

958.3

Surgical adverse event

 Unspecified mechanical complication of internal orthopedic device, implant, and graft

996.40

 Other mechanical complication of prosthetic joint implant

996.47

 Other mechanical complication of other internal orthopedic device, implant, and graft

996.49

 Other complications due to internal joint prosthesis

996.77

 Other complications due to other internal orthopedic device, implant, and graft

996.78

 Other complications due to other internal prosthetic device, implant, and graft

996.79

 Complications of unspecified reattached extremity

996.90

 Complications of reattached hand

996.92

 Complications of reattached finger(s)

996.93

 Complications of reattached upper extremity, other and unspecified

996.94

 Complication of reattached foot and toe(s)

996.95

 Complication of other specified reattached body part

996.99

 Unspecified complication of amputation stump

997.60

 Other amputation stump complication

997.69

 Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation

E878.1

 Amputation of limb(s) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation

E878.5

 Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation

E878.8

 Unspecified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation

E878.9

  1. * Four- and five-digit codes are included under the respective three and four-digit codes; Additional coding information is available at: www.findacode.com/.

Appendix 2. Comorbidities as listed in the updated CCI with corresponding ICD 9 codes as used in this study*

Diagnosis

Corresponding ICD9 codes

Congestive heart failure

398.91, 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, 425.4–425.9, 428.x

Dementia

290.x, 294.1, 331.2

Chronic pulmonary disease

416.8, 416.9, 490.x–505.x, 506.4, 508.1, 508.8

Rheumatologic disease

446.5, 710.0–710.4, 714.0–714.2, 714.8, 725.x

Mild liver disease

070.22, 070.23, 070.32, 070.33, 070.44, 070.54, 070.6, 070.9, 570.x, 571.x, 573.3, 573.4, 573.8, 573.9, V42.7

Diabetes with chronic complications

250.4–250.7

Hemiplegia or paraplegia

334.1, 342.x, 343.x, 344.0, 344.6, 344.9

Renal disease

403.01, 403.11, 403.91, 404.02, 404.03, 404.12, 404.13, 404.92, 404.93, 582.x, 583.0–583.7, 585.x, 586.x, 588.0, V42.0, V45.1, V56x

Any malignancy, including leukemia and lymphoma

140.x–172.x, 174.x–195.8, 200.x–208.x, 238.6

Moderate or severe liver disease

456.0–456.2, 572.2–572.8

Metastatic solid tumor

196.x–199.x

HIV/AIDS

042.x–044.x

  1. * Four- and five-digit codes are included under the respective three and four-digit codes; additional coding information is available at: www.findacode.com/.

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Voskuijl, T., Hageman, M. & Ring, D. Higher Charlson Comorbidity Index Scores are Associated With Readmission After Orthopaedic Surgery. Clin Orthop Relat Res 472, 1638–1644 (2014). https://doi.org/10.1007/s11999-013-3394-8

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  • DOI: https://doi.org/10.1007/s11999-013-3394-8

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