This study aims to investigate the validity of the Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI) as predictive tools for adverse outcomes following total ankle arthroplasty (TAA).
Methods
The Nationwide Readmissions Database (NRD) was queried from 2015 to 2020 to identify 29 705 patients undergoing primary TAA. Patients’ comorbidity was measured via CCI and ECI scores, and patients who experienced adverse postoperative outcomes (any complication, readmission, mortality, extended length of stay (LOS), and adverse discharge) were identified.
Results
Both the ECI and CCI comorbidity indices predicted mortality with excellent accuracy (Area under the Curve [AUC] = 0.88 for both). However, ECI outperformed CCI in predicting complications, extended LOS, and adverse discharge, although both had poor predictive capability for these outcomes.
Conclusion
These findings indicate that while ECI and CCI are capable of predicting postoperative mortality following TAA, there is a need for alternative models that better predict other postoperative adverse outcomes.
PugelyAJLuXAmendolaACallaghanJJMartinCTCramP.Trends in the use of total ankle replacement and ankle arthrodesis in the United States Medicare population. Foot Ankle Int. 2014;35(3):207-215. doi:10.1177/1071100713511606
2.
LawTYSabehKGRosasSHubbardZAltajarSRocheMW.Trends in total ankle arthroplasty and revisions in the Medicare database. Ann Transl Med. 2018;6(7):112. doi:10.21037/atm.2018.02.06
3.
KarzonALKadakiaRJColemanMMBariteauJTLabibSA.The rise of total ankle arthroplasty use: a database analysis describing case volumes and incidence trends in the United States between 2009 and 2019. Foot Ankle Int. 2022;43(11):1501-1510. doi:10.1177/10711007221119148
4.
ParachaNIdriziAGordonAMLamAWAbdelgawadAARaziAE.Utilization trends of total ankle arthroplasty and ankle fusion for tibiotalar osteoarthritis: a nationwide analysis of the United States population. Foot Ankle Spec. 2023;16(3):251-258. doi: 10.1177/19386400221110133
5.
TuckerWABarndsBLMorrisBL, et al. Nationwide analysis of total ankle replacement and ankle arthrodesis in Medicare patients: trends, complications, and cost. Foot Ankle Spec. 2022;15(3):201-208. doi:10.1177/1938640020950181
6.
VoskuijlTHagemanMRingD.Higher Charlson comorbidity index scores are associated with readmission after orthopaedic surgery. Clin Orthop Relat Res. 2014;472(5):1638-1644. doi:10.1007/s11999-013-3394-8
7.
VaradyNHGillinovSMYeungCMRudisillSSChenAF.The Charlson and Elixhauser scores outperform the American society of anesthesiologists score in assessing 1-year mortality risk after hip fracture surgery. Clin Orthop Relat Res. 2021;479(9):1970-1979. doi:10.1097/CORR.0000000000001772
8.
SinclairSTEmaraAKOrrMNMcConaghyKMKlikaAKPiuzziNS.Comorbidity indices in orthopaedic surgery: a narrative review focused on hip and knee arthroplasty. EFORT Open Rev. 2021;6(8):629-640. doi:10.1302/2058-5241.6.200124
9.
PulikŁPodgajnyMKaczyńskiWSarzyńskaSŁęgoszP. The update on instruments used for evaluation of comorbidities in total hip arthroplasty. Indian J Orthop. 2021;55(4):823-838. doi:10.1007/s43465-021-00357-x
10.
CharlsonMWellsMTUllmanRKingFShmuklerC.The Charlson comorbidity index can be used prospectively to identify patients who will incur high future costs. PLoS ONE. 2014;9(12):e112479. doi:10.1371/journal.pone.0112479
11.
CastroMADedivitisRARibeiroKC.Comorbidity measurement in patients with laryngeal squamous cell carcinoma. ORL J Otorhinolaryngol Relat Spec. 2007;69(3):146-152. doi:10.1159/000099223
12.
SinghBBhayaMSternJ, et al. Validation of the Charlson comorbidity index in patients with head and neck cancer: a multi-institutional study. Laryngoscope. 1997;107(11Pt1):1469-1475. doi:10.1097/00005537-199711000-00009
13.
GoldsteinLBSamsaGPMatcharDBHornerRD.Charlson index comorbidity adjustment for ischemic stroke outcome studies. Stroke. 2004;35(8):1941-1945. doi:10.1161/01.STR.0000135225.80898.1c
14.
LiuJHuangZGilbertsonDTFoleyRNCollinsAJ.An improved comorbidity index for outcome analyses among dialysis patients. Kidney Int. 2010;77(2):141-151. doi:10.1038/ki.2009.413
15.
CharlsonMEPompeiPAlesKLMacKenzieCR.A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373-383. doi:10.1016/0021-9681(87)90171-8
16.
ElixhauserASteinerCHarrisDRCoffeyRM.Comorbidity measures for use with administrative data. Med Care. 1998;36(1):8-27. doi:10.1097/00005650-199801000-00004
17.
GundtoftPHJorstadMErichsenJLSchmalHVibergB.The ability of comorbidity indices to predict mortality in an orthopedic setting: a systematic review. Syst Rev. 2021;10(1):234. doi:10.1186/s13643-021-01785-4
18.
LawtonCDButlerBADekkerRGPrescottAKadakiaAR.Total ankle arthroplasty versus ankle arthrodesis-a comparison of outcomes over the last decade. J Orthop Surg Res. 2017;12(1):76. doi:10.1186/s13018-017-0576-1
19.
ArmitageJNvan der MeulenJH, Royal College of Surgeons Co-morbidity Consensus Group. Identifying co-morbidity in surgical patients using administrative data with the Royal College of surgeons Charlson score. Br J Surg. 2010;97(5):772-781. doi:10.1002/bjs.6930
20.
NuttallMvan der MeulenJEmbertonM.Charlson scores based on ICD-10 administrative data were valid in assessing comorbidity in patients undergoing urological cancer surgery. J Clin Epidemiol. 2006;59(3):265-273.
21.
AndoKDoiTMoodySYOhkuniYSatoSKanekoN. The effect of comorbidity on the prognosis of acute lung injury and acute respiratory distress syndrome. Intern Med. 2012;51(14):1835-1840. doi:10.2169/internalmedicine.51.6434
22.
NúñezJENúñezEFácilaL, et al. [Prognostic value of Charlson comorbidity index at 30 days and 1 year after acute myocardial infarction]. Rev Esp Cardiol. 2004;57(9):842-849.
23.
AshASPosnerMASpeckmanJFrancoSYachtACBramwellL.Using claims data to examine mortality trends following hospitalization for heart attack in Medicare. Health Serv Res. 2003;38(5):1253-1262. doi:10.1111/1475-6773.00175
24.
CastroHHGAlencarAPBenseñorIMLotufoPAGoulartAC. Multimorbidities are associated to lower survival in ischaemic stroke: results from a Brazilian stroke cohort (EMMA Study). Cerebrovasc Dis. 2017;44(3-4):232-239. doi:10.1159/000479827
25.
LiljehultJChristensenTChristensenKB.Early prediction of one-year mortality in ischemic and haemorrhagic stroke. J Stroke Cerebrovasc Dis. 2020;29(4):104667. doi:10.1016/j.jstrokecerebrovasdis.2020.104667
26.
HanEKimTHKooHYooJHeoJHNamHS.Heterogeneity in costs and prognosis for acute ischemic stroke treatment by comorbidities. J Neurol. 2019;266(6):1429-1438. doi:10.1007/s00415-019-09278-0
27.
HallREPorterJQuanHReevesMJ.Developing an adapted Charlson comorbidity index for ischemic stroke outcome studies. BMC Health Serv Res. 2019;19(1):930. doi:10.1186/s12913-019-4720-y
28.
HuangYQGouRDiaoYS, et al. Charlson comorbidity index helps predict the risk of mortality for patients with type 2 diabetic nephropathy. J Zhejiang Univ Sci B. 2014;15(1):58-66. doi:10.1631/jzus.B1300109
29.
NgYYHungYNWuSCKoPJHwangSM.Progression in comorbidity before hemodialysis initiation is a valuable predictor of survival in incident patients. Nephrol Dial Transplant. 2013;28(4):1005-1012. doi:10.1093/ndt/gfs512
30.
Parés-BadellOBanquéMMaciàFCastellsXSalaM.Impact of comorbidity on survival by tumour location: breast, colorectal and lung cancer (2000-2014). Cancer Epidemiol. 2017;49:66-74. doi:10.1016/j.canep.2017.05.010
31.
DhakalPShostromVAl-KadhimiZSManessLJGundaboluKBhattVR.Usefulness of Charlson comorbidity index to predict early mortality and overall survival in older patients with acute myeloid leukemia. Clin Lymphoma Myeloma Leuk. 2020;20(12):804-812. doi:10.1016/j.clml.2020.07.002
32.
ChangHJChenPCYangCCSuYCLeeCC.Comparison of Elixhauser and Charlson methods for predicting oral cancer survival. Medicine (Baltimore). 2016;95(7):e2861. doi:10.1097/MD.0000000000002861
33.
ShinNHanECWonS, et al. The prognoses and postoperative outcomes of patients with both colorectal cancer and liver cirrhosis based on a nationwide cohort in Korea. Ann Surg Treat Res. 2020;99(2):82-89.
34.
LakomkinNGozVLajamCMIorioRBoscoJA3rd. Higher modified Charlson index scores are associated with increased incidence of complications, transfusion events, and length of stay following revision hip arthroplasty. J Arthroplasty. 2017;32(4):1121-1124. doi:10.1016/j.arth.2016.11.014
35.
GoltzDERyanSPHowellCBAttarianDBolognesiMPSeylerTM.A weighted index of Elixhauser comorbidities for predicting 90-day readmission after total joint arthroplasty. J Arthroplasty. 2019;34(5):857-864. doi:10.1016/j.arth.2019.01.044
36.
MooreBJWhiteSWashingtonRCoenenNElixhauserA.Identifying increased risk of readmission and in-hospital mortality using hospital administrative data: the AHRQ Elixhauser comorbidity index. Med Care. 2017;55(7):698-705. doi:10.1097/MLR.0000000000000735
37.
MelfiCHollemanEArthurDKatzB.Selecting a patient characteristics index for the prediction of medical outcomes using administrative claims data. J Clin Epidemiol. 1995;48(7):917-926. doi:10.1016/0895-4356(94)00202-2
38.
SchneeweissSMaclureM.Use of comorbidity scores for control of confounding in studies using administrative databases. Int J Epidemiol. 2000;29(5):891-898. doi:10.1093/ije/29.5.891
39.
OndeckNTBohlDDBovonratwetPMcLynnRPCuiJJGrauerJN.Discriminative ability of Elixhauser’s comorbidity measure is superior to other comorbidity scores for inpatient adverse outcomes after total hip arthroplasty. J Arthroplasty. 2018;33(1):250-257. doi:10.1016/j.arth.2017.08.032
40.
TravenSAReevesRASloneHSWaltonZJ.Frailty predicts medical complications, length of stay, readmission, and mortality in revision hip and knee arthroplasty. J Arthroplasty. 2019;34(7):1412-1416.
41.
VargasMSanchezGGordonAM, et al. Comparison of patient-demographics, causes, and costs of 90-day readmissions following primary total shoulder arthroplasty for glenohumeral osteoarthritis. J Orthop. 2022;31:52-56. doi:10.1016/j.jor.2022.03.009
42.
HumphriesWJainNPietrobonRSocolowskiFCookCHigginsL.Effect of the Deyo score on outcomes and costs in shoulder arthroplasty patients. J Orthop Surg (Hong Kong). 2008;16(2):186-191. doi:10.1177/230949900801600212
43.
GordonMStarkASköldenbergOGKärrholmJGarellickG.The influence of comorbidity scores on re-operations following primary total hip replacement: comparison and validation of three comorbidity measures. Bone Joint J. 2013;95-B(9):1184-1191. doi:10.1302/0301-620X.95B9.31006
44.
SinghJAClevelandJD.Age, race, comorbidity, and insurance payer type are associated with outcomes after total ankle arthroplasty. Clin Rheumatol. 2020;39(3):881-890. doi:10.1007/s10067-019-04826-5
45.
VallabhaneniNGuareschiASEichingerJKFriedmanRJ.Supplemental oxygen is associated with increased complications and readmission following total shoulder arthroplasty. Semin Arthroplasty JSES. 2023;33(3):512-518. doi:10.1053/j.sart.2023.03.008
46.
BrandnerGTGuareschiASEichingerJKFriedmanRJ.Impact of opioid dependence on outcomes following total shoulder arthroplasty. J Shoulder Elbow Surg. 2024;33(1):82-89. doi:10.1016/j.jse.2023.05.040
47.
BoettcherMLSchellLGuareschiASEichingerJKFriedmanRJ.Impact of different body mass index cutoff points on complication rates following primary total shoulder arthroplasty. Semin Arthroplasty JSES. 2023;33(4):652-658. doi:10.1053/j.sart.2023.06.014
48.
HarrellFEJrLeeKLCaliffRMPryorDBRosatiRA.Regression modelling strategies for improved prognostic prediction. Stat Med. 1984;3(2):143-152. doi:10.1002/sim.4780030207
49.
van WalravenCAustinPCJenningsAQuanHForsterAJ. A modification of the Elixhauser comorbidity measures into a point system for hospital death using administrative data. Med Care. 2009;47(6):626-633. doi:10.1097/MLR.0b013e31819432e5
50.
GronbeckCCoteMPLiebermanJRHalawiMJ.Risk stratification in primary total joint arthroplasty: the current state of knowledge. Arthroplast Today. 2019;5(1):126-131. doi:10.1016/j.artd.2018.10.002
51.
MenendezMENeuhausVRingD.Inpatient mortality after orthopaedic surgery. Int Orthop. 2015;39(7):1307-1314. doi:10.1007/s00264-015-2702-1
52.
MeyrAJSansostiLE.An evaluation of basic demographic characteristics in foot and ankle surgery from the American College of surgeons national surgical quality improvement program. J Foot Ankle Surg. 2022;61(5):996-1000. doi:10.1053/j.jfas.2021.12.027
53.
MenendezMENeuhausVvan DijkCNRingD.The Elixhauser comorbidity method outperforms the Charlson index in predicting inpatient death after orthopaedic surgery. Clin Orthop Relat Res. 2014;472(9):2878-2886. doi:10.1007/s11999-014-3686-7
54.
SharabianiMTAylinPBottleA.Systematic review of comorbidity indices for administrative data. Med Care. 2012;50(12):1109-1118. doi:10.1097/MLR.0b013e31825f64d0
55.
InacioMCSPrattNLRougheadEEGravesSE. Evaluation of three co-morbidity measures to predict mortality in patients undergoing total joint arthroplasty. Osteoarthritis Cartilage. 2016;24(10):1718-1726. doi:10.1016/j.joca.2016.05.006
56.
SambandamSSenthilTSerbinPViswanathanVKMounasamyVWukichD.Analysis of baseline characteristics, length of stay, cost of care, complications and subgroup analysis of patients undergoing total ankle arthroplasty-a large database study. J Foot Ankle Surg. 2023;62(2):310-316. doi:10.1053/j.jfas.2022.08.007
57.
de GrootVBeckermanHLankhorstGBouterL. How to measure comorbidity: a critical review of available methods. J Clin Epidemiol. 2004;57(3):323. doi:10.1016/j.jclinepi.2003.09.002
58.
SouthernDAQuanHGhaliWA.Comparison of the Elixhauser and Charlson/Deyo methods of comorbidity measurement in administrative data. Med Care. 2004;42(4):355-360. doi:10.1097/01.mlr.0000118861.56848.ee
59.
YurkovichMAvina-ZubietaJAThomasJGorenchteinMLacailleD.A systematic review identifies valid comorbidity indices derived from administrative health data. J Clin Epidemiol. 2015;68(1):3-14. doi:10.1016/j.jclinepi.2014.09.010
60.
SaltzmanCL.Perspective on total ankle replacement. Foot Ankle Clin. 2000;5(4):761-775.
61.
KrauseFGSchmidT.Ankle arthrodesis versus total ankle replacement: how do I decide. Foot Ankle Clin. 2012;17(4):529-543.
62.
GougouliasNEKhannaAMaffulliN.History and evolution in total ankle arthroplasty. Br Med Bull. 2009;89:111-151.
63.
BozicKJBashyalRKAnthonySGChiuVShulmanBRubashHE.Is administratively coded comorbidity and complication data in total joint arthroplasty valid. Clin Orthop Relat Res. 2013;471(1):201-205. doi:10.1007/s11999-012-2352-1
64.
CharlsonMECarrozzinoDGuidiJPatiernoC.Charlson comorbidity index: a critical review of clinimetric properties. Psychother Psychosom. 2022;91(1):8-35. doi:10.1159/000521288
65.
NguforCVan HoutenHCaffoBSShahNDMcCoyRG.Mixed effect machine learning: a framework for predicting longitudinal change in hemoglobin A1c. J Biomed Inform. 2019;89:56-67. doi:10.1016/j.jbi.2018.09.001
66.
StroupWW.Generalized Linear Mixed Models: Modern Concepts, Methods and Applications. CRC press; 2012.
67.
HajjemALarocqueDBellavanceF.Generalized mixed effects regression trees. Stat Probab Lett. 2017;126:114-118.
68.
GreeneMERolfsonOGordonMGarellickGNemesS.Standard comorbidity measures do not predict patient-reported outcomes 1 year after total hip arthroplasty. Clin Orthop Relat Res. 2015;473(11):3370-3379. doi:10.1007/s11999-015-4195-z
