Individual Comorbid Conditions Research Articles

Incidence and Risk Factors for Acid-fast Bacillus/Fungal Culture Positivity in Primary, Conversion, and Revision Hip and Knee Arthroplasty.

Previous literature has reported minimal incidences of positive fungal/AFB cultures, questioning the routine use of these tests. With growing concern for excessive use, predictive factors for patients at higher risk for intraoperative AFB/fungal infections would help surgeons limit unnecessary testing. This study evaluates the positivity rate and predictive factors of positive fungal and/or acid-fast bacillus (AFB) cultures after primary, conversion, or revision hip and knee arthroplasty. Two hundred thirty-eight knee and hip procedures were done between January 2007 and 2022 where intraoperative AFB/fungal cultures were obtained. Procedures included primary total knee arthroplasty, primary total hip arthroplasty, conversion, first of two-stage, second of two-stage, irrigation and débridement polyexchange, and aseptic revision. Positivity rates of intraoperative AFB/fungal cultures were calculated as binomial exact proportions with 95% confidence intervals and are displayed as percentages. Univariable generalized linear mixed models estimated the unadjusted effects of demographics, individual comorbid conditions, and procedural characteristics on the logit of positive AFB/fungal cultures. Two hundred thirty-eight knee and hip procedures recorded an overall positivity rate of 5.8% for intraoperative AFB/fungal cultures. Aseptic revisions showed the lowest rates of positivity at 3.6%, while conversions showed the highest rates of positivity at 14.3%. The positivity rates are highest among patients who are male (9.0%), of Hispanic origin (12.0%), with body mass index <30 (6.4%), and a Charlson Comorbidity Index <5 (6.1%). History of a prior infection in the same surgical joint showed statistically significant influence of odds of culture positivity with an odds ratio of 3.47 (P-value: 0.039). Other demographic factors that we investigated including age, sex, race, ethnicity, body mass index, and Charlson Comorbidity Index did not show any notable influence on AFB/fungal positivity rates. These results suggest utility in obtaining routine intraoperative AFB/fungal cultures, given the relatively high positivity and poor predictive factors.

Medication-based Comorbidity Measures and Prostate Cancer Treatment Selection

IntroductionWe aimed to assess the association between comorbidities and prostate cancer management. Patients and methodsWe studied 12,603 South Australian men diagnosed with prostate cancer between 2003 and 2019. Comorbidity was measured one year prior to prostate cancer diagnosis using a medication-based comorbidity index (Rx-Risk). Binomial logistic regression analyses were used to assess the association between comorbidities and primary treatment selection (active surveillance, radical prostatectomy (RP), external beam radiotherapy (EBRT) with or without androgen deprivation therapy (ADT), brachytherapy, ADT alone, and watchful waiting (WW)). Certain common comorbidities within Rx-Risk (cardiac disorders, diabetes, chronic airway diseases, depression and anxiety, thrombosis, and chronic pain) were also assessed. All models were adjusted for sociodemographic and tumor characteristics. ResultsLikelihood of receiving RP was lower among men with Rx-Risk score ≥3 (odds ratio (OR) 0.62, 95%CI:0.56-0.69) and Rx-Risk 2 (OR 0.80, 95%CI:0.70-0.92) compared with no comorbidity (Rx-Risk ≤0). Men with high comorbidity (Rx-Risk ≥3) were more likely to have received ADT alone (OR 1.76, 95%CI:1.40-2.21), EBRT (OR 1.30, 95%CI:1.17-1.45) or WW (OR 1.49, 95%CI:1.19-1.88) compared with Rx-Risk ≤0. Pre-existing cardiac and respiratory disorders, thrombosis, diabetes, depression and anxiety, and chronic pain were associated with lower likelihood of selecting RP and higher likelihood of EBRT (except chronic airway disease) or WW (except diabetes and depression and anxiety). Cardiac disorders and thrombosis were associated with higher likelihood of selecting ADT alone. Furthermore, age had greater effect on treatment choice than the level of comorbidity. ConclusionHigh comorbidity burden was associated with primary treatment choice, with significantly less RP and more EBRT, WW and ADT alone among men with higher levels of comorbidity. Each of the individual comorbid conditions also influenced treatment selection.

Choosing Therapy for Moderate to Severe Crohn's Disease.

The availability of approved therapies for Crohn's disease has significantly increased over the past decade. To choose the appropriate therapy for the patient, ideally head to head studies, and data on positioning could help the provider individualize the decision. Due to the paucity of head-to-head trial data, we turn to network meta-analysis and real-world studies to help guide our treatment choices. Ultimately, the best approach is to consider each patient on an individual basis, taking into consideration the characteristics of their disease, individual risk factors, extra-intestinal manifestations, co-morbid conditions, patient age, cost, and personal preferences. In this review, we summarize the evidence comparing biologic as well as small molecule therapies for the treatment of moderate-to-severe Crohn's disease. We have summarized the evidence in relation to factors such as efficacy, fistulizing disease, pregnancy, infection risk, and co-existing conditions.

Adaptation and validation of a coding algorithm for the Charlson Comorbidity Index in administrative claims data using the SNOMED CT standardized vocabulary

ObjectivesThe Charlson comorbidity index (CCI), the most ubiquitous comorbid risk score, predicts one-year mortality among hospitalized patients and provides a single aggregate measure of patient comorbidity. The Quan adaptation of the CCI revised the CCI coding algorithm for applications to administrative claims data using the International Classification of Diseases (ICD). The purpose of the current study is to adapt and validate a coding algorithm for the CCI using the SNOMED CT standardized vocabulary, one of the most commonly used vocabularies for data collection in healthcare databases in the U.S.MethodsThe SNOMED CT coding algorithm for the CCI was adapted through the direct translation of the Quan coding algorithms followed by manual curation by clinical experts. The performance of the SNOMED CT and Quan coding algorithms were compared in the context of a retrospective cohort study of inpatient visits occurring during the calendar years of 2013 and 2018 contained in two U.S. administrative claims databases. Differences in the CCI or frequency of individual comorbid conditions were assessed using standardized mean differences (SMD). Performance in predicting one-year mortality among hospitalized patients was measured based on the c-statistic of logistic regression models.ResultsFor each database and calendar year combination, no significant differences in the CCI or frequency of individual comorbid conditions were observed between vocabularies (SMD ≤ 0.10). Specifically, the difference in CCI measured using the SNOMED CT vs. Quan coding algorithms was highest in MDCD in 2013 (3.75 vs. 3.6; SMD = 0.03) and lowest in DOD in 2018 (3.93 vs. 3.86; SMD = 0.02). Similarly, as indicated by the c-statistic, there was no evidence of a difference in the performance between coding algorithms in predicting one-year mortality (SNOMED CT vs. Quan coding algorithms, range: 0.725–0.789 vs. 0.723–0.787, respectively). A total of 700 of 5,348 (13.1%) ICD code mappings were inconsistent between coding algorithms. The most common cause of discrepant codes was multiple ICD codes mapping to a SNOMED CT code (n = 560) of which 213 were deemed clinically relevant thereby leading to information gain.ConclusionThe current study repurposed an important tool for conducting observational research to use the SNOMED CT standardized vocabulary.

Post covid syndrome and rheumatic diseases: focus on rheumatoid arthritis (own data)

Introduction. In modern reality postcovid syndrome (PCS) is characterized by clinical heterogeneity and multi-organ involvement, often presenting a differential diagnostic and therapeutic problem. However, in most studies of PCS, stratification of patients taking into account individual comorbid conditions was not performed. Thus, only an extremely small number of studies have been devoted to assessing the course of PCS in rheumatic diseasesPurpose. To characterize the features of the course of COVID-19 in patients with rheumatoid arthritis, as well as to conduct a comparative assessment of clinical and demographic parameters in groups of patients with rheumatoid arthritis, differentiated by the presence of PCS.Materials and methods. The material of the questionnaire which contained questions regarding socio-demographic data of respondents, information on rheumatological history, comorbid diseases, data on past COVID-19, including cases of re-infection, and PCS.Results.The study included 32 adult patients (29 women, 90%) with a reliable diagnosis of rheumatoid arthritis. Of the 32 patients who underwent COVID-19, in 23 cases it was possible to form a judgment about the presence or absence of PCS. To study PCS, 23 patients were stratified into two groups: 11 (47.8%) patients developed PCS (Group 1) and 12 patients had COVID-19 without consequences (Group 2). Both groups were represented predominantly by women (90.9% and 91.7%, respectively). In the general group 37.5% of patients with COVID-19 required inpatient treatment. The number of symptoms associated with COVID-19 did not correlate with RA activity, however, patients with higher RA activity were more likely to report increased arthralgia as a symptom of COVID-19. 47.8% of COVID-19 survivors experienced PCS. The average age, the number of comorbid diseases and the severity of RA symptoms at the time of COVID-19 were relatively higher in the group of patients with RA and PKS. Patients with PKS also noted a higher frequency of hospitalizations and a more severe course of COVID-19.Conclusions.A quantitative assessment of the risk of developing PKS is needed, which will serve as a basis for developing a strategy aimed at prevention, timely diagnosis and treatment of this syndrome in patients with RS. To this end, further studies on larger cohorts of patients are required.

Activation of oxidative stress, comorbidity and survival of end-stage renal disease patients treated with hemodialysis

Abstract. The aim of the study was to analyze the characteristics of serum concentrations of oxidative stress (OS) markers depending on the quantitative assessment of comorbidity and taking into account the most informative indicators of OS, to prospectively assess changes in comorbid status, death rates and individual comorbid conditions in patients with end-stage renal disease (ESRD) treated with hemodialysis (HD).&#x0D; Methods. The cohort prospective open-label study included 156 patients with ESRD, treated with HD. The study was conducted in two stages. In the first – the structure and quantitative assessment of comorbid diseases, determination of serum concentrations of oxidative stress (OS) markers and their analysis depending on the comorbid status were studied. On the second – taking into account the defined threshold values (Cut-off) of the most informative markers of the OS, an assessment of changes in comorbid status, frequency of comorbid conditions and fatal events done. A modified polymorbidity index (MPI) was calculated to assess comorbid status. The concentration of OS serum markers was determined by spectrophotometric method. Statistical analysis was performed by using "MedCalc", version 19.3 (Ostend, Belgium).&#x0D; Results. Serum concentrations of all prooxidant markers were significantly higher and antioxidant markers were significantly lower in the HD patients with high comorbid status compared to those of patients with low comorbidity (p&lt;0.0001). Correlation analysis between MIP and the studied OS markers showed that the largest correlation (rho=0.874) was established with the serum concentration of malondialdehyde (MDAs). During the observation period in the group of patients with a concentration of MDAs &gt; 668.72 μmol/ml found a significant, compared with the group with a biomarker content ≤ 668.72 μmol/ml, an increase in the proportion of patients with chronic obstructive pulmonary disease (COPD) (by 81.84 % vs 28.48 %; p&lt;0.0001), cardiovascular diseases (CVD) (by 56.0 % vs 36.4 %; p=0.019) and cerebrovascular (CEVD) diseases (by 73.33 % vs 30.42 %; p&lt;0.0001). The proportion of patients with fractures in the group of patients with MDAs &gt; 668.72 μmol/l increased fourfold (p=0.0140). The increase in MIP is 34.11 % vs 17.1 % (p&lt;0.0001), five-year cumulative survival – 45.3 % vs 63.3 % (p=0.0312; HR – 2,1527, 95% CI: 1,2458 –3,7199), five-year CV survival – 61,6 % vs 80.8 % (p=0.0094; HR – 2.7955, 95% CI: 1.3664 – 5.7191) in groups with MDAs &gt; 668.72 and ≤ 668.72 μmol/ml, respectively.&#x0D; Conclusions. In patients with ESRD, treated with HD, serum concentrations of MDAs &gt; 668.72 μmol/l is a biochemical determinant of a significant increase, in the medium term, the number of comorbid conditions, deaths, fatal CV and CEVD events, the proportion of patients with COPD, fractures, CVD and CEVD, reduction of cumulative and CV survival.

Socioeconomic disparities in the prevalence of comorbid chronic conditions among Canadian adults with cancer

Objective To evaluate the prevalence of comorbid chronic conditions among Canadian adults with cancer and the impact of socioeconomic background on the distribution of these conditions. Methods Canadian Community Health Survey (CCHS) 2017–2018 dataset was accessed and individuals with complete information about cancer history were reviewed. The prevalence of the following 10 chronic conditions was reviewed: asthma, chronic obstructive pulmonary disease, arthritis, hypertension, hypercholesterolemia/hyperlipidemia, heart disease, stroke, diabetes, mood disorder, and anxiety disorder. Stratification of the prevalence was done according to age, sex, and racial subgroups. Multivariable logistic regression analysis was done to evaluate the association between sociodemographic characteristics and having multiple comorbid conditions. Results A total of 104,362 participants were included in the current study (including 10,782 participants with a history of cancer; and 93,580 participants without a history of cancer). Among all age, sex, and race strata, participants with a history of cancer were more likely to have multiple chronic conditions (p < 0.05 for all comparisons). The most common three individual comorbid conditions among participants with cancer were arthritis (40.2%), hypertension (36.1%), and hypercholesterolemia (25.2%); while the most common cancer-comorbidity triad among participants with cancer was cancer/arthritis/hypertension (17.7%). In a multivariable logistic regression analysis among participants with cancer, the following sociodemographic factors were associated with having multiple comorbid conditions: older age (OR for age 80+ versus age 18–20 years: 8.32; 95% CI: 5.17–13.39), indigenous racial group (OR: 1.94; 95% CI: 1.43–2.63) and lower income (OR for income ≥80,000 Canadian dollars (CAD) versus income: ≤20,000 CAD: 0.29; 95% CI: 0.23–0.37). Conclusion History of cancer is associated with a higher probability of many comorbid conditions. This excess comorbidity burden seems to be unequally shouldered by individuals in the lower socioeconomic stratum as well as minority populations.

Economic Burden of Stem Cell Transplant Among Patients with Multiple Myeloma

Introduction: Multiple Myeloma (MM) is a rare hematologic malignancy, accounting for 12% of all hematologic cancers. Conventional treatment includes a combination of induction chemotherapy followed by stem-cell transplantation (SCT) for younger patients without significant renal impairment. While the efficacy of SCT in various clinical settings of MM are frequently explored, real-world data on impact of SCT on healthcare resource use (HRU) and costs among patients with MM are limited. This study compared HRU and costs for MM patients with and without SCT in the US.Methods: This retrospective analysis used the MarketScan administrative claims data to select patients newly diagnosed with MM (ICD-9-CM 203.0x) and at least 18 years of age during 7/1/2006- 9/30/2015 (first MM diagnosis = index date). Continuous health plan enrollment for 12 months prior to (baseline) and >3 months after index date (minimum follow-up) was required. Patients were censored at the earliest of disenrollment, death (inpatient or from the social security administration [SSA] death index), or end of study period (12/31/2015). Per-patient per year (PPPY) all-cause and MM-related HRU and costs were calculated during follow-up and compared between patients with SCT versus [vs.] without SCT. MM-related HRU and medical costs required a MM diagnosis code on the claim (primary discharge diagnosis for hospitalizations, any position on the claim for outpatient services). Costs were adjusted to 2016 USD using the medical component of consumer price index. Propensity scores were used to match patients 1:1 on baseline demographic and comorbid conditions using the nearest neighbor approach to adjust for differences between patients with and without SCT.Results: Of the 14,229 newly diagnosed MM patients selected for analysis, 18.8% (N=2,669) received a SCT, of which 99.9% (N=2,667) were matched to MM patients without a SCT. Matched patients were well balanced on the following criteria: age (mean 56.7 [SD 8.2] and 57.4 [SD 8.5] years); gender (57.4% and 57.5% male); Charlson comorbidity index (mean 1.7 [SD 2.2] and 1.7 [SD 2.1]); baseline individual comorbid conditions (anemia [32.3% and 30.9%], renal impairment [7.0% and 6.5%], bone-related [32.6% and 30.3%], cardiac dysfunction [36.4% and 36.0%]). Total all-cause and MM-related healthcare costs PPPY were $114,242 and $110,116 higher among patients with a SCT (vs. patients without a SCT). Similarly, patients with a SCT (vs. patients without a SCT) incurred $55,663 and $49,803 higher all-cause and MM-related costs for hospitalizations, and $39,852 and $33,883 higher all-cause and MM-related costs for outpatient services. MM treatment costs (drug and administration costs) PPPY were also $26,430 higher among patients with a SCT (vs. patients without a SCT). Higher costs among patients with a SCT were driven by increased HRU for both inpatient and outpatient services across the majority of categories (Table). Among the subset linked to the SSA death index (SCT N= 1,553 and non-SCT N=1,583) the median survival time 907 vs 743 days (p<0.001) among patients with a SCT vs. patients without a SCT and the proportion with a death was 10.4% and 12.8% (p=0.042). The difference in median survival time between groups was less pronounced for patients with an index date in a later year; 2006-2011 vs. 2012-2015 (Table).Conclusions: Results show that among age-, gender-, and comorbidity- matched MM patients, management with SCT is associated with higher all-cause and MM-related HRU and costs and increased survival. An examination of the predictors of management with or without SCT and associated outcomes will inform the relative value of therapeutic strategies for MM patients as well as help optimally triage healthcare resources. [Display omitted] DisclosuresAilawadhi:Pharmacyclics: Research Funding; Novartis: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Takeda: Consultancy, Honoraria. Panjabi:Amgen Inc.: Employment, Equity Ownership. Princic:Truven Health Analytics, IBM Company: Employment. Fowler:Truven Health Analytics, IBM Company: Employment. Tran:Truven Health Analytics, IBM Company: Employment. Gatta:Amgen Inc.: Employment, Equity Ownership. Medhekar:Amgen Inc.: Employment, Equity Ownership.

Examination of individual and multiple comorbid conditions and health-related quality of life in older cancer survivors.

PurposeOlder cancer survivors (≥ 65 years at diagnosis) are at high-risk for multimorbidity (2 + comorbid conditions). However, few studies have utilized a generalizable sample of older cancer survivors to understand how individual comorbid conditions, as opposed to total comorbidity burden, are associated with health-related quality of life (HRQOL). We examined associations between HRQOL outcomes (pain, fatigue, physical function), individual comorbidities (cardiovascular disease [CVD], lung disease, diabetes, arthritis) and total comorbidity (cancer-only, cancer + 1 condition, cancer + 2 or more conditions). MethodsUtilizing a population-based sample of 2019 older cancer survivors, we tested associations between comorbid conditions and the HRQOL outcomes using generalized linear models. HRQOL domains were assessed using Patient-Reported Outcome Measurement Information System® (PROMIS®) measures. Comorbidity was assessed via self-report.ResultsCancer survivors with lung disease reported significantly worse physical functioning (β = − 4.96, p < 0.001), survivors with arthritis reported significantly higher pain (β = 4.37, p < 0.001), and survivors with CVD reported significantly higher fatigue (β = 3.45, p < 0.001) compared to survivors without each condition. Having cancer + 1 condition was not as strongly associated with all outcomes as when individual conditions were tested (e.g. pain: β = 3.09, p < 0.001). Having 2+ comorbidities had a stronger association with all outcomes (e.g. physical function: β = − 7.51, p < 0.001) than examining conditions individually.ConclusionsKnowing the specific comorbid condition profile of an older cancer survivor provides insight into specific HRQOL outcomes that may be impaired in cancer survivorship, but understanding total comorbidity burden, regardless of the specific conditions, sheds light on survivors at-risk for multiple impairments in HRQOL. This information, taken together, can inform risk-stratified survivorship care. Electronic supplementary materialThe online version of this article (10.1007/s11136-020-02713-0) contains supplementary material, which is available to authorized users.

Return to Work Guidelines Following Neurosurgical Procedures.

Recovery time following surgical procedures is a consideration every practicing surgeon must deliberate upon throughout his or her career. The decision to restrict patients from returning to work or various activities encountered on a daily basis following an operation is dependent on many factors. Surgeons must take into account patient population, individual comorbid conditions, complexity and length of surgery, immediate postoperative course, and baseline functional abilities. Thus, returning to work and various activities, including physical activity, work-related activity, and recreational activity alike, following invasive procedures is individualized from patient to patient. Most spinal procedures are performed by neurosurgeons or orthopedic surgeons. This article suggests a framework to guide appropriate return to work and activity escalation time frames following various spinal procedures.

Mortality and Health Care Utilization Among Medicare Patients Undergoing Emergency General Surgery vs Those With Acute Medical Conditions

Emergency general surgery (EGS) represents 11% of hospitalizations, and almost half of these hospitalized patients are older adults. Older adults have high rates of mortality and readmissions after EGS, yet little is known as to how these outcomes compare with acute medical conditions that have been targets for quality improvement. To examine whether Medicare beneficiaries who undergo EGS experience similar 1-year outcomes compared with patients admitted with acute medical conditions. This population-based, retrospective cohort study using Medicare claims data from January 1, 2008, to December 31, 2014, included adults 65 years or older with at least 1 year of Medicare claims who had urgent or emergency admissions for 1 of the 5 highest-burden EGS procedures (partial colectomy, small-bowel resection, peptic ulcer disease surgery, lysis of adhesions, or laparotomy) or a primary diagnosis of an acute medical condition (pneumonia, heart failure, or acute myocardial infarction). Patients undergoing EGS and those with acute medical conditions were matched 1:1 in a 2-step algorithm: (1) exact match by hospital or (2) propensity score match with age, sex, race/ethnicity, Charlson Comorbidity Index, individual comorbid conditions, claims-based frailty index, year of admission, and any intensive care unit stay. Data analysis was performed from July 16, 2018, to November 13, 2019. Partial colectomy, small-bowel resection, peptic ulcer disease surgery, lysis of adhesions, or laparotomy or a primary diagnosis pneumonia, heart failure, or acute myocardial infarction. One-year mortality, postdischarge health care utilization (emergency department visit, additional hospitalization, intensive care unit stay, or total hospital encounters), and days at home during 1 year. A total of 481 417 matched pairs (mean [SD] age, 78.9 [7.8] years; 272 482 [56.6%] female) with adequate covariate balance were included in the study. Patients undergoing EGS experienced higher 30-day mortality (60 683 [12.6%] vs 56 713 [11.8%], P < .001) yet lower 1-year mortality (142 846 [29.7%] vs 158 385 [32.9%], P < .001) compared with medical patients. Among 409 363 pairs who survived discharge, medical patients experienced higher rates of total hospital encounters in the year after discharge (4 vs 3 per person-year; incidence rate ratio, 1.31; 95% CI, 1.30-1.32) but had similar mean days at home compared with patients undergoing EGS (293 vs 309 days; incident rate ratio, 1.004; 95% CI, 1.004-1.004). In this study, older patients undergoing EGS had similarly high 1-year rates of mortality, hospital use, and days away from home as acutely ill medical patients. These findings suggest that EGS should also be targeted for national quality improvement programs.

Arteriovenous Fistula Use in the United States and Dialysis Facility–Level Comorbidity Burden

Patients with multiple comorbid conditions are less likely to use an arteriovenous fistula (AVF) for hemodialysis vascular access. Some dialysis facilities have high rates of AVF placement despite having patients with many comorbid conditions. This study describes variation in facility-level use of AVFs across the facility-level burden of patient comorbid conditions. Retrospective cohort study. Medicare patients receiving hemodialysis for 1 year or more in US dialysis facilities. Facility-level burden of patient comorbid conditions; patient characteristics. Odds of AVFs versus other access types; facility-level use of AVFs. Facility-level comorbidity burden was calculated by summing individual comorbid conditions, determining the average per patient, then defining 11 groups based on facility percentile ranking. Generalized estimating equations with a logit link were used to estimate the odds of AVF placement at the patient level. For the facility-level analysis, a generalized estimating equation model with the identity link was fit to characterize the percentage of AVF use at each facility. Overall, AVF use was 65.8% in 315,919 prevalent hemodialysis patients among 5,813 facilities. After adjustment for patient characteristics, AVF use was 0.27, 0.30, 1.05, and 1.74 percentage points lower than the median among facilities in the 61st to 70th, 71st to 80th, 81st to 90th, and 91st to 99th percentiles of comorbidity, respectively, and 0.42, 0.63, 1.34, and 1.90 percentage points higher than the median among facilities in the 31st to 40th, 21st to 30th, 11th to 20th, and 1st to 10th percentiles of comorbidity, respectively. Facilities in the greater than99th percentile of comorbidity burden had AVFuse that was 3.47 percentage points lower than the median. Facilities in the less than 1st percentile ofcomorbidity burden had AVF use that was 2.64 percentage points greater than the median. Limited to Medicare dialysis-dependent patients treated for 1 year or more. After adjustment for patient characteristics, we found small differences in facility rates of AVF use except in the extremes of high or low levels of comorbidity burden. Our study demonstrates that dialysis facilities with a relatively highpatient comorbidity burden can achieve similar fistula rates as facilities with healthier patients. Although high comorbidity burden does not explain low facility AVF use, additional study is needed to understand differences in AVF use rates between facilities with similar comorbidity burdens.

Comorbidity in adults with traumatic brain injury and all-cause mortality: a systematic review

ObjectivesComorbidity in traumatic brain injury (TBI) has been recognised to alter the clinical course of patients and influence short-term and long-term outcomes. We synthesised the evidence on the effects of...

Non-Cardiovascular Comorbidities as Evaluated by Elixhauser Comorbidity Score in Individuals Undergoing TAVR

ABSTRACT Background: To explore the relationship between comorbidity burden and mortality, peri-procedural complications, and length of stay in patients treated with TAVR in the National Inpatient Sample (NIS). Patients undergoing transcatheter aortic valve replacement (TAVR) often have multiple comorbidities. Whilst the impact of individual comorbid conditions on clinical outcomes following TAVR has been previously assessed, the impact of more global measures of comorbidity remains unknown in this cohort. To explore the relationship between comorbidity burden and mortality, peri-procedural complications, and length of stay in patients treated with TAVR NIS. Methods: TAVR procedures were identified between 2011 and 2014 and comorbidities were defined by the Elixhauser classification system (ECS) consisting of 30 comorbidity measures. Endpoints included in-hospital mortality, periprocedural complications, and length of stay. Patients were classified based on their ECS in five categories (ECS I < 0, ECS II = 0, ECS III = 1–5, ECS IV = 6–13, ECS V ≥ 14). Results: A total of 40,604 TAVR patients were identified. Mean age was 81.2 ± 8.5 years. Patients with ECS category V accounted for more than 40% of the cohort and experienced almost a 2.5-fold increase in in-hospital mortality (OR 2.42, 95% CI: 1.28–4.56), acute kidney injury (OR: 6.23, 95% CI: 4.13–9.41), major bleeding (OR: 2.26, 95% CI: 1.71–2.99), post-procedural stroke or TIA (OR: 2.02, 95% CI: 1.08–3.78). It was also associated with a mean 4.14-day increased length of stay (95% CI: 3.67 to 4.65) compared to patients with lower ECS category after adjusting for confounding factors. Conclusions: Our study of over 40,000 TAVRs shows that Elixhauser comorbidity score was independently associated with higher mortality, periprocedural complications, and length of stay. Global comorbidity burden is an important consideration for risk stratification in patients undergoing TAVR.

Development of a New Comorbidity Assessment Tool for Specific Prediction of Perioperative Mortality in Contemporary Patients Treated with Radical Cystectomy.

The Deyo adaptation of the Charlson comorbidity index (DaCCI), which relies on 17 comorbid condition groupings defined with 200 ICD-9-CM diagnostic codes, lacks specificity in the context of radical cystectomy (RC) for bladder cancer (BCa). We attempted to develop a new comorbidity assessment tool based on individual comorbid conditions and/or BCa manifestations for specific prediction of perioperative mortality after RC. We relied on 7076 T1-T4 nonmetastatic BCa patients treated with RC between 2000 and 2009 in the SEER-Medicare linked database. Within the development cohort (n = 6076), simulated annealing (SA) was used to identify (1) individual comorbid conditions, (2) individual BCa manifestations, and (3) the combination of both, that satisfy the criteria of maximal accuracy and parsimony for prediction of 90-day mortality after RC, after adjusting for several confounders. The accuracy of the newly identified groups of individual comorbid conditions and/or BCa manifestations and of the original DaCCI was tested in a 1000-patient external validation cohort. The combination of six individual comorbid conditions and two individual BCa disease manifestations (type II diabetes without complications, anemia, chronic obstructive pulmonary disease, congestive heart failure, aortocoronary bypass, cardiomegaly, urinary tract infection, and hydronephrosis), and seven individual comorbid conditions (type II diabetes without complications, anemia, chronic obstructive pulmonary disease, congestive heart failure, aortocoronary bypass, osteoarthrosis, and cardiomegaly) respectively showed 71.1 and 70.2% accuracy versus 68.0% for the original DaCCI. These new approaches are specific to contemporary RC patients and represent simpler methods compared with the original DaCCI, without any compromise in accuracy.

Prediction of Complications in Radical Prostatectomy Prostate Cancer Patients: Simulated Annealing versus Co-Morbidity Indexes

Background: The Deyo/Charlson co-morbidity index (CCI) and Klabunde co-morbidity index (KCI) co-morbidity indexes represent outdated indexes when the endpoint of complications after radical prostatectomy (RP) is considered. A novel group of co-morbidities derived from International Classification of Diseases-9 diagnostic codes in a contemporary RP database could provide better accuracy. Research Design, Subjects and Measures: We relied on 20,484 patients with clinically localized non-metastatic prostate cancer treated with RP between 2000 and 2009 in the Surveillance, Epidemiology, and End Results-Medicare linked database. We examined 2 endpoints, namely, 90-day medical complication rate and 90-day surgical complication rate after RP. Simulated annealing (SA) was used to develop a novel co-morbidity index. Finally, the newly identified groups of co-morbid conditions were compared with the CCI and Klabunde indexes. Results: Our SA identified 10 and 7 individual co-morbid conditions able to predict 90-day medical and surgical complications respectively. This novel model showed improved predictive accuracy over CCI and KCI for the 2 endpoints considered (respectively: 59.4 vs. 58.1 and 58.0% for medical complications, 58.0 vs. 56.8 and 56.7% for surgical complications). Conclusions: The newly defined groupings of co-morbid conditions resulted in better ability to predict the 2 endpoints of interest compared to CCI and KCI. However, the gain was marginal. This implies that better tools should be defined to more accurately predict these outcomes.

Current Risk Adjustment and Comorbidity Index Underperformance in Predicting Post-Acute Utilization and Hospital Readmissions After Joint Replacements: Implications for Comprehensive Care for Joint Replacement Model.

To compare the performances of 3 comorbidity indices, the Charlson Comorbidity Index, the Elixhauser Comorbidity Index, and the Centers for Medicare & Medicaid Services (CMS) risk adjustment model, Hierarchical Condition Category (HCC), in predicting post-acute discharge settings and hospital readmission for patients after joint replacement. A retrospective study of Medicare beneficiaries with total knee replacement (TKR) or total hip replacement (THR) discharged from hospitals in 2009-2011 (n = 607,349) was performed. Study outcomes were post-acute discharge setting and unplanned 30-, 60-, and 90-day hospital readmissions. Logistic regression models were built to compare the performance of the 3 comorbidity indices using C statistics. The base model included patient demographics and hospital use. Subsequent models included 1 of the 3 comorbidity indices. Additional multivariable logistic regression models were built to identify individual comorbid conditions associated with high risk of hospital readmissions. The 30-, 60-, and 90-day unplanned hospital readmission rates were 5.3%, 7.2%, and 8.5%, respectively. Patients were most frequently discharged to home health (46.3%), followed by skilled nursing facility (40.9%) and inpatient rehabilitation facility (12.7%). The C statistics for the base model in predicting post-acute discharge setting and 30-, 60-, and 90-day readmission in TKR and THR were between 0.63 and 0.67. Adding the Charlson Comorbidity Index, the Elixhauser Comorbidity Index, or HCC increased the C statistic minimally from the base model for predicting both discharge settings and hospital readmission. The health conditions most frequently associated with hospital readmission were diabetes mellitus, pulmonary disease, arrhythmias, and heart disease. The comorbidity indices and CMS-HCC demonstrated weak discriminatory ability to predict post-acute discharge settings and hospital readmission following joint replacement.

Thoracoabdominal aortic aneurysm repair: open, endovascular, or hybrid?

Successful repair of complex thoracoabdominal aortic aneurysms requires careful surgical planning based on anatomic and patient considerations. Not only are surgical considerations key, but also post-operative care, regardless of surgical approach, can dramatically impact both short- and long-term outcomes. While open repair has been the gold standard for decades, the technical challenges associated with operative repair, a specialty approach requisite for good outcomes, and the unique challenges in the post-operative care of these patients have given providers pause when considering operative intervention. The relatively recent development of elegant endovascular and hybrid approaches to this problem has shown improved short-term morbidity and reasonable durability. Here, we discuss these three techniques for correction of complex thoracoabdominal aortic aneurysms to provide some guidance for optimization of outcomes based on individual patient anatomy and comorbid conditions.

Comparison of comorbidity measures to predict postoperative lung cancer survival in the National Cancer Database (AFT-03).

6519 Background: Comprehensive assessment of comorbidity in cancer registries is critical for comparative effectiveness research. The National Cancer Database (NCDB) measures comorbidity with a diagnosis code-based Charlson Comorbidity Index (CCI) abstracted from discharge abstracts or billing face sheets. However, the prognostic performance of this code-based CCI has not been compared with a medical chart-based CCI or individual comorbid conditions in a nationally representative sample of patients with lung cancer. Methods: Through a special study of the NCDB, cancer registrars performed chart abstraction for 18 perioperative comorbid conditions for 9,640 randomly selected patients with stage I-III non-small cell lung cancer resected in 2006-07 at 1,150 Commission on Cancer-accredited facilities. We compared the prognostic performance of the NCDB code-based categorical CCI (0, 1, 2+), special study chart-based continuous CCI, and individual comorbid conditions in 3 separate Cox proportional hazards models for 5-year postoperative overall survival. All models adjusted for demographic and clinical characteristics. Results: Median age was 67 (IQR 60-74). The most common comorbidities were COPD (40%) and CAD (21%). Five-year postoperative overall survival was 55.5%. Agreement between the code- and chart-based CCIs was 51.9% with the code-based CCI underestimating comorbidity for 36.2% patients. The model including individual comorbid conditions had the best prognostic performance (R2 0.196, C index 0.654). COPD, CAD, CHF, dementia, diabetes, moderate/severe renal and liver disease, peripheral vascular disease, psychiatric disorder, and substance abuse were independently associated with decreased survival. The chart-based CCI model (R2 0.189, C index 0.650) predicted postoperative survival better than the code-based CCI model (R2 0.181, C index 0.645). Conclusions: The NCDB code-based CCI underestimates comorbidity in patients with surgically resected lung cancer. The chart-based CCI and data on individual comorbid conditions improved prognostic performance and would be valuable additions to the NCDB to strengthen comparative effectiveness research.

Improving Risk Adjustment Above Current Centers for Disease Control and Prevention Methodology Using Electronically Available Comorbid Conditions.

OBJECTIVE To identify comorbid conditions associated with surgical site infection (SSI) among patients undergoing renal transplantation and improve existing risk adjustment methodology used by the Centers for Disease Control and Prevention National Healthcare Safety Network (NHSN). PATIENTS Patients (≥18 years) who underwent renal transplantation at University of Maryland Medical Center January 1, 2010-December 31, 2011. METHODS Trained infection preventionists reviewed medical records to identify surgical site infections that developed within 30 days after transplantation, using NHSN criteria. Patient demographic characteristics and risk factors for surgical site infections were identified through a central data repository. International Statistical Classification of Disease, Ninth Revision, Clinical Modification codes were used to analyze individual component comorbid conditions and calculate the Charlson and Elixhauser comorbidity indices. These indices were compared with the current NHSN risk adjustment methodology. RESULTS A total of 441 patients were included in the final cohort. In bivariate analysis, the Charlson components of cerebrovascular disease, peripheral vascular disease, and rheumatologic disorders and Elixhauser components of obesity, rheumatoid arthritis, and weight loss were significantly associated with the outcome. A model utilizing the variables from the NHSN methodology had a c-statistic of 0.56 (95% CI, 0.48-0.63), whereas a model that also included comorbidities from the Charlson and Elixhauser indices had a c-statistic of 0.65 (95% CI, 0.58-0.73). The model with all 3 risk adjustment scores performed best and was statistically different from the NHSN model alone, demonstrated by improvement in the c statistic (0.65 vs 0.56). CONCLUSION Risk adjustment models should incorporate electronically available comorbid conditions. Infect Control Hosp Epidemiol 2016;1-6.