Secondary Logo

Journal Logo

Institutional members access full text with Ovid®

What Associations Exist Between Comorbidity Indices and Postoperative Adverse Events After Total Shoulder Arthroplasty?

Fu, Michael C., MD, MHS; Ondeck, Nathaniel T., MD; Nwachukwu, Benedict U., MD, MBA; Garcia, Grant H., MD; Gulotta, Lawrence V., MD; Verma, Nikhil N., MD; Grauer, Jonathan N., MD

Clinical Orthopaedics and Related Research®: April 2019 - Volume 477 - Issue 4 - p 881–890
doi: 10.1097/CORR.0000000000000624
CLINICAL RESEARCH
Buy
SDC

Background Comorbidity indices like the modified Charlson Comorbidity Index (mCCI) and the modified Frailty Index (mFI) are commonly reported in large database outcomes research. It is unclear if they provide greater association and discriminative ability for postoperative adverse events after total shoulder arthroplasty (TSA) than simple variables.

Questions/purposes Using a large research database to examine postoperative adverse events after anatomic and reverse TSA, we asked: (1) Which demographic/anthropometric variable among age, sex, and body mass index (BMI) has the best discriminative ability as measured by receiver operating characteristics (ROC)? (2) Which comorbidity index, among the American Society of Anesthesiologists (ASA) classification, the mCCI, or the mFI, has the best ROC? (3) Does a combination of a demographic/anthropometric variable and a comorbidity index provide better ROC than either variable alone?

Methods Patients who underwent TSA from 2005 to 2015 were identified from the National Surgical Quality Improvement Program (NSQIP). This multicenter database with representative samples from more than 600 hospitals in the United States was chosen for its prospectively collected data and documented superiority over administrative databases. Of an initial 10,597 cases identified, 70 were excluded due to missing age, sex, height, weight, or being younger than 18 years of age, leaving a total of 10,527 patients in the study. Demographics, medical comorbidities, and ASA scores were collected, while BMI, mCCI and mFI were calculated for each patient. Though all required data variables were found in the NSQIP, the completeness of data elements was not determined in this study, and missing data were treated as being the null condition. Thirty-day outcomes included postoperative severe adverse events, any adverse events, extended length of stay (LOS, defined as > 3 days), and discharge to a higher level of care. ROC analysis was performed for each variable and outcome, by plotting its sensitivity against one minus the specificity. The area under the curve (AUC) was used as a measure of model discriminative ability, ranging from 0 to 1, where 1 represents a perfectly accurate test, and 0.5 indicates a test that is no better than chance.

Results Among demographic/anthropometric variables, age had a higher AUC (0.587–0.727) than sex (0.520–0.628) and BMI (0.492–0.546) for all study outcomes (all p < 0.050), while ASA (0.580–0.630) and mFI (0.568–0.622) had higher AUCs than mCCI (0.532–0.570) among comorbidity indices (all p < 0.050). A combination of age and ASA had higher AUCs (0.608–0.752) than age or ASA alone for any adverse event, extended LOS, and discharge to higher level of care (all p < 0.05). Notably, for nearly all variables and outcomes, the AUCs showed fair or moderate discriminative ability at best.

Conclusion Despite the use of existing comorbidity indices adapted to large databases such as the NSQIP, they provide no greater association with adverse events after TSA than simple variables such as age and ASA status, which have only fair associations themselves. Based on database-specific coding patterns, the development of database- or NSQIP-specific indices may improve their ability to provide preoperative risk stratification.

Level of Evidence Level III, diagnostic study.

M.C. Fu, N. T. Ondeck, L. V. Gulotta Hospital for Special Surgery, New York, NY, USA

B. U. Nwachukwu, G. H. Garcia, N. N. Verma Rush University Medical Center, Department of Orthopedic Surgery, Chicago, IL, USA

J. N. Grauer Yale University School of Medicine, Department of Orthopaedics & Rehabilitation, New Haven, CT, USA

M. C. Fu Hospital for Special Surgery 535 E 70th St. New York, NY 10021 Email: fum@hss.edu

One of the authors certifies that he (LVG), or a member of his immediate family, has received or may receive payments or benefits, in an amount of USD 10,000 to USD 100,000 from Zimmer Biomet, outside the submitted work, and is a member of the HSS Journal editorial board.

One of the authors certifies that he (NNV), has received research support, in an amount of USD 10,000 to USD 100,000 from Arthrex, in an amount of USD 100,001 to USD 1,000,000 from Smith & Nephew, in an amount of USD 10,000 to USD 100,000, from Athletico, in an amount of USD 10,000 to USD 100,000 from ConMed Linvatec, has received or may receive publishing royalties and financial support, in an amount of USD less than USD 10,000 from Arthroscopy, in an amount of USD less than USD 10,000 from Vindico Medical, in an amount of USD less than USD 10,000 from Orthopedics Hyperguide; has received or may receive intellectual property royalties, in an amount of USD 10,000 to USD 100,000 from Smith & Nephew; is a consultant for an amount of USD less than USD 10,000 for Minivasive, is a consultant for an amount of USD less than USD 10,000 for Orthospace, is a consultant for an amount of USD 10,000 to USD 100,000, for Arthrex; stock or stock options in an amount of USD 10,000 to USD 100,000 from Cymedica, stock or stock options in an amount of USD 10,000 to USD 100,000 from Minivasive, stock or stock options in an amount of USD 10,000 to USD 100,000 from Omeros, all outside the submitted work; has patents with royalties paid for 9913709 – soft tissue repair method, 20180049757, 9872688; is a board or committee member for AOSSM, ASES, AANA, editorial or governing board for Journal of Knee Surgery, Slack Inc.

One of the authors certifies that he (JNG), or a member of his immediate family, has received or may receive personal fees during the study period, in an amount of USD less than USD 10,000, from TIDI products, in an amount less than USD 10,000 from Medtronic, in an amount less than USD 10,000 from Bioventus, in an amount of USD 10,000 to USD 100,000, from Stryker, all outside the submitted work; is a clinical trial subinvestigator with Pfizer, Spinal Kinetics, Orthofix and is a fellow of the American College of Surgeons.

One of the authors certifies that he (MCF) is a member of the HSS Journal editorial board.

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.

Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that his institution waived approval for the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.

This work was performed at Yale University School of Medicine, Department of Orthopaedics & Rehabilitation, New Haven, CT, USA.

Received August 25, 2018

Accepted December 07, 2018

© 2019 Lippincott Williams & Wilkins LWW
You currently do not have access to this article

To access this article:

Note: If your society membership provides full-access, you may need to login on your society website