Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC.
Performance Services, Duke University Medical Center, Durham, NC.
J Arthroplasty. 2019 May;34(5):857-864. doi: 10.1016/j.arth.2019.01.044. Epub 2019 Jan 25.
Evolving reimbursement models increasingly compel hospitals to assume costs for 90-day readmission after total joint arthroplasty. Although risk assessment tools exist, none currently reach the predictive performance required to accurately identify high-risk patients and modulate perioperative care accordingly. Although unlikely to perform adequately alone, the Elixhauser index is a set of 31 variables that may lend value in a broader model predicting 90-day readmission.
Elixhauser comorbidities were examined in 10,022 primary unilateral total joint replacements, of which 4535 were hip replacements and 5487 were knee replacements, all performed between June 2013 and January 2018 at a single tertiary referral center. Data were extracted from electronic medical records using structured query language. After randomizing to derivation (80%) and validation (20%) subgroups, predictive models for 90-day readmission were generated and transformed into a system of weights based on each parameter's relative performance.
We observed 497 90-day readmissions (5.0%) during the study period, which demonstrated independent associations with 14 of the 31 Elixhauser comorbidity groups. A score created from the sum of each patient's weighted comorbidities did not lose substantial predictive discrimination (area under the curve: 0.653) compared to a comprehensive multivariable model containing all 31 unweighted Elixhauser parameters (area under the curve: 0.665). Readmission risk ranged from 3% for patients with a score of 0 to 27% for those with a score of 8 or higher.
The Elixhauser comorbidity score already meets or exceeds the predictive discrimination of available risk calculators. Although insufficient by itself, this score represents a valuable summary of patient comorbidities and merits inclusion in any broader model predicting 90-day readmission risk after total joint arthroplasty.
III.
不断演变的报销模式越来越迫使医院承担全关节置换术后 90 天再入院的费用。虽然存在风险评估工具，但目前没有一种工具能够达到准确识别高危患者并相应调整围手术期护理的预测性能要求。尽管不太可能单独发挥作用，但 Elixhauser 指数是一组 31 个变量，可能在预测全关节置换术后 90 天再入院风险的更广泛模型中具有价值。
在一家三级转诊中心，对 10022 例初次单侧全关节置换术（其中 4535 例髋关节置换术和 5487 例膝关节置换术）中的 Elixhauser 合并症进行了检查，这些手术均在 2013 年 6 月至 2018 年 1 月期间进行。使用结构化查询语言从电子病历中提取数据。在随机分为推导（80%）和验证（20%）亚组后，生成了 90 天再入院的预测模型，并根据每个参数的相对性能将其转换为权重系统。
在研究期间观察到 497 例 90 天再入院（5.0%），这与 31 个 Elixhauser 合并症组中的 14 个独立相关。与包含所有 31 个未加权 Elixhauser 参数的综合多变量模型（曲线下面积：0.665）相比，从每位患者加权合并症总和创建的评分并未失去实质性的预测区分度（曲线下面积：0.653）。再入院风险范围从评分 0 的患者的 3%到评分 8 或更高的患者的 27%。
Elixhauser 合并症评分已经达到或超过了现有风险计算器的预测区分度。虽然本身还不够，但该评分代表了患者合并症的有价值总结，值得纳入任何预测全关节置换术后 90 天再入院风险的更广泛模型。
III 级。
