title: Assessing measures of comorbidity and functional status for risk adjustment to compare hospital performance for colorectal cancer surgery: a retrospective data-linkage study.
abstract: BACKGROUND
  Comparing outcomes between hospitals requires consideration of patient factors that could account for any observed differences. Adjusting for comorbid conditions is common when studying outcomes following cancer surgery, and a commonly used measure is the Charlson comorbidity index. Other measures of patient health include the ECOG performance status and the ASA physical status score. This study aimed to ascertain how frequently ECOG and ASA scores are recorded in population-based administrative data collections in New South Wales, Australia and to assess the contribution each makes in addition to the Charlson comorbidity index in risk adjustment models for comparative assessment of colorectal cancer surgery outcomes between hospitals.
  
  
  METHODS
  We used linked administrative data to identify 6964 patients receiving surgery for colorectal cancer in 2007 and 2008. We summarised the frequency of missing data for Charlson comorbidity index, ECOG and ASA scores, and compared patient characteristics between those with and without these measures. The performance of ASA and ECOG in risk adjustment models that also included Charlson index was assessed for three binary outcomes: 12-month mortality, extended length of stay and 28-day readmission. Patient outcomes were compared between hospital peer groups using multilevel logistic regression analysis.
  
  
  RESULTS
  The Charlson comorbidity index could be derived for all patients, ASA score was recorded for 78 % of patients and ECOG performance status recorded for only 24 % of eligible patients. Including ASA or ECOG improved the predictive ability of models, but there was no consistently best combination. The addition of ASA or ECOG did not substantially change parameter estimates for hospital peer group after adjusting for Charlson comorbidity index.
  
  
  CONCLUSIONS
  While predictive ability of regression models is maximised by inclusion of one or both of ASA score and ECOG performance status, there is little to be gained by adding ASA or ECOG to models containing the Charlson comorbidity index to address confounding. The Charlson comorbidity index has good performance and is an appropriate measure to use in risk adjustment to compare outcomes between hospitals.
authors.affiliation: Cancer Epidemiology and Services Research, Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.|National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, ACT, Australia.
authors.forename: Timothy A
authors.initials: TA
authors.lastname: Dobbins
authors.affiliation: Cancer Epidemiology and Services Research, Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.|Cancer Institute NSW, Sydney, NSW, Australia.|Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
authors.forename: Tim
authors.initials: T
authors.lastname: Badgery-Parker
authors.affiliation: Cancer Institute NSW, Sydney, NSW, Australia.
authors.forename: David C
authors.initials: DC
authors.lastname: Currow
authors.affiliation: Cancer Epidemiology and Services Research, Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia. jane.young@sydney.edu.au.|Cancer Institute NSW, Sydney, NSW, Australia. jane.young@sydney.edu.au.|Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District, Royal Prince Alfred Hospital, Sydney, NSW, Australia. jane.young@sydney.edu.au.
authors.forename: Jane M
authors.initials: JM
authors.lastname: Young
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015179:Colorectal Neoplasms / Q000601:surgery*; D015897:Comorbidity; D005260:Female; D006305:Health Status Indicators; D006801:Humans; D016247:Information Storage and Retrieval; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D012189:Retrospective Studies; D020379:Risk Adjustment / Q000379:methods*; D055815:Young Adult