Comparison of measures of comorbidity for predicting disability 12-months post-injury.
BACKGROUND
Understanding the factors that impact on disability is necessary to inform trauma care and enable adequate risk adjustment for benchmarking and monitoring. A key consideration is how to adjust for pre-existing conditions when assessing injury outcomes, and whether the inclusion of comorbidity is needed in addition to adjustment for age. This study compared different approaches to modelling the impact of comorbidity, collected as part of the routine hospital episode data, on disability outcomes following orthopaedic injury.


METHODS
12-month Glasgow Outcome Scale - Extended (GOS-E) outcomes for 13,519 survivors to discharge were drawn from the Victorian Orthopaedic Trauma Outcomes Registry, a prospective cohort study of admitted orthopaedic injury patients. ICD-10-AM comorbidity codes were mapped to four comorbidity indices. Cases with a GOS-E score of 7-8 were considered "recovered". A split dataset approach was used with cases randomly assigned to development or test datasets. Logistic regression models were fitted with "recovery" as the outcome and the performance of the models based on each comorbidity index (adjusted for injury and age) measured using calibration (Hosmer-Lemshow (H-L) statistics and calibration curves) and discrimination (Area under the Receiver Operating Characteristic (AUC)) statistics.


RESULTS
All comorbidity indices improved model fit over models with age and injuries sustained alone. None of the models demonstrated acceptable model calibration (H-L statistic p < 0.05 for all models). There was little difference between the discrimination of the indices for predicting recovery: Charlson Comorbidity Index (AUC 0.70, 95% CI: 0.68, 0.71); number of ICD-10 chapters represented (AUC 0.70, 95% CI: 0.69, 0.72); number of six frequent chronic conditions represented (AUC 0.70, 95% CI: 0.69, 0.71); and the Functional Comorbidity Index (AUC 0.69, 95% CI: 0.68, 0.71).


CONCLUSIONS
The presence of ICD-10 recorded comorbid conditions is an important predictor of long term functional outcome following orthopaedic injury and adjustment for comorbidity is indicated when assessing risk-adjusted functional outcomes over time or across jurisdictions.
Department of Epidemiology and Preventive Medicine, Monash University, The Alfred Centre, 99 Commercial Rd, Melbourne, Victoria 3004, Australia. belinda.gabbe@monash.edu
Belinda J
BJ
Gabbe
James E
JE
Harrison
Ronan A
RA
Lyons
Elton R
ER
Edwards
Peter A
PA
Cameron
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001842:Bone and Bones / Q000293:injuries; D015897:Comorbidity; D016001:Confidence Intervals; D004185:Disability Evaluation; D005260:Female; D023261:Glasgow Outcome Scale; D006801:Humans; D038801:International Classification of Diseases; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000379:methods*; D011237:Predictive Value of Tests; D011446:Prospective Studies; D020379:Risk Adjustment; D014947:Wounds and Injuries / Q000534:rehabilitation*; D055815:Young Adult