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      Practical considerations on the use of the charlson comorbidity index with administrative data bases

      , ,
      Journal of Clinical Epidemiology
      Elsevier BV

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          Abstract

          To develop a measure of the burden of comorbid disease from the MED-ECHO data base (Québec), the so-called Charlson index was adapted to International Classification of Disease (ICD-9) codes. The resulting comorbidity index was applied to the study of inpatient death in 33,940 patients with ischemic heart disease. Multiple logistic regression was used to relate inpatient death to its predictors, including gender, principal diagnosis, age, and the comorbidity index. Various transformations of the comorbidity score were performed, and their effect on the predictive accuracy was assessed. The comorbidity index was constantly and strongly associated with death. From a statistical viewpoint, the best results were obtained when the index was transformed into four dummy independent variables (the area under the receiver-operating curve is then 0.87). In a validation analysis performed on 1990-1991 MED-ECHO data (36,012 admissions with ischemic heart disease), the comorbidity index has the same statistical properties. We conclude that the Charlson index may be an efficient approach to risk adjustment from administrative data bases, although it should be tested on other conditions.

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          The meaning and use of the area under a receiver operating characteristic (ROC) curve.

          A representation and interpretation of the area under a receiver operating characteristic (ROC) curve obtained by the "rating" method, or by mathematical predictions based on patient characteristics, is presented. It is shown that in such a setting the area represents the probability that a randomly chosen diseased subject is (correctly) rated or ranked with greater suspicion than a randomly chosen non-diseased subject. Moreover, this probability of a correct ranking is the same quantity that is estimated by the already well-studied nonparametric Wilcoxon statistic. These two relationships are exploited to (a) provide rapid closed-form expressions for the approximate magnitude of the sampling variability, i.e., standard error that one uses to accompany the area under a smoothed ROC curve, (b) guide in determining the size of the sample required to provide a sufficiently reliable estimate of this area, and (c) determine how large sample sizes should be to ensure that one can statistically detect differences in the accuracy of diagnostic techniques.
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            Stratification of morbidity and mortality outcome by preoperative risk factors in coronary artery bypass patients. A clinical severity score.

            To relate morbidity and mortality risk to preoperative severity of illness in patients undergoing coronary artery bypass grafting. Retrospective analysis of 5051 patients using univariate and logistic regression to identify risk factors associated with perioperative morbidity and mortality. Prospective application of models to a subsequent 2-year validation cohort (n = 4069). Cleveland Clinic Foundation. All adult patients undergoing coronary artery bypass graft surgery between July 1, 1986, and June 30, 1988 (reference group), and July 1, 1988, and June 30, 1990 (validation group). Mortality and morbidity (myocardial infarction and use of intra-aortic balloon pump, mechanical ventilation for 3 or more days, neurological deficit, oliguric or anuric renal failure, or serious infection). Emergency procedure, preoperative serum creatinine levels of greater than 168 mumol/L, severe left ventricular dysfunction, preoperative hematocrit of 0.34, increasing age, chronic pulmonary disease, prior vascular surgery, reoperation, and mitral valve insufficiency were found to be predictive of mortality. In addition to these factors, diabetes mellitus, body weight of 65 kg or less [corrected], aortic stenosis, and cerebrovascular disease were predictive of morbidity. Logistic regression equations were developed, and a simple additive score for clinical use was designed by allocating each of these risk-factor values of 1 to 6 points. Both methods predict mortality. Increased morbidity was demonstrated with increases in score. The logistic or clinical models developed are superior to the currently available methods for comparing mortality outcome and provide previously unavailable information on morbidity based on preoperative status. The clinical scoring system is useful for preoperative estimates of morbidity and mortality risks.
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              Mortality and reoperation after open and transurethral resection of the prostate for benign prostatic hyperplasia.

              As part of an ongoing effort to evaluate alternative treatments for benign prostatic hyperplasia, we compared the outcomes of transurethral resection of the prostate with those of open prostatectomy. Men undergoing prostatectomy in Denmark (n = 36,703), Oxfordshire, England (n = 5284), and Manitoba, Canada (n = 12,090), were identified retrospectively through administrative data and followed for up to eight years. The cumulative percentage of patients undergoing a second prostatectomy was substantially higher after transurethral than after open prostatectomy (12.0 vs. 4.5 percent in Denmark, 12.0 vs. 1.8 percent in Oxfordshire, and 15.5 vs. 4.2 percent in Manitoba). The long-term age-specific mortality rates associated with transurethral prostatectomy as compared with open prostatectomy were also elevated in each country. The data on 1650 Canadian patients were used to investigate the contribution of coexisting morbid conditions to the elevated risk of death. The relative risk was 1.45 (95 percent confidence interval, 1.15 to 1.83) before risk adjustment and 1.45 (95 percent confidence interval, 1.15 to 1.84) after adjustment; the higher mortality was seen among low-risk as well as high-risk patients. These findings suggest that transurethral prostatectomy is less effective in overcoming urinary obstruction than the open operation. Our data also raise the possibility that transurethral prostatectomy may result in higher long-term mortality, although we cannot rule out potential confounding effects of unmeasured characteristics of patients.
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                Author and article information

                Journal
                Journal of Clinical Epidemiology
                Journal of Clinical Epidemiology
                Elsevier BV
                08954356
                December 1996
                December 1996
                : 49
                : 12
                : 1429-1433
                Article
                10.1016/S0895-4356(96)00271-5
                8991959
                b0a51b3c-85bb-4ef8-9dc7-d9277a504441
                © 1996

                https://www.elsevier.com/tdm/userlicense/1.0/

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