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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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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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