Greenfield S, Apolone G, McNeil B J, Cleary P D
Health Institute, New England Medical Center, Boston, MA.
Med Care. 1993 Feb;31(2):141-54. doi: 10.1097/00005650-199302000-00005.
Co-existent or comorbid diseases are appreciated as prognostic factors in studies of quality and effectiveness of care when mortality is the end point. The need to measure and adjust for comorbidity in studies of postoperative hospital complications or long-term recovery from surgery has not been documented. In this study, we determined the impact of co-existent disease on post-operative complications and 1-year health-related quality of life in patients hospitalized for a total hip replacement. The study population consisted of a cohort of 356 patients who were hospitalized in four teaching hospitals in California and Massachusetts for a total hip replacement. Patients' medical records were reviewed to collect information regarding severity of illness, co-existent disease, and postoperative complications. The kind and amount of baseline preoperative co-existent disease was measured from medical record information at admission using a four level Index of co-existent Disease (ICED). Approximately 12 months after hospital discharge, 283 (80%) of the patients were surveyed by questionnaire. The presence and amount of co-existent disease were significant predictors of postoperative complications. The complication rates ranged from 3% to 41% between the lowest and highest levels of the ICED. Patients treated at the four study hospitals differed in functional outcomes 1 year after surgery. Functional outcomes were strongly related to ICED scores: patients in Level 4 ICED scored 26.8 points lower in instrumental activities of daily living than patients in Level 1. After controlling for gender, age, education, and marital status, ICED remained a significant predictor of functional status at 1 year. Furthermore, differences among hospitals in functional outcomes disappeared when the ICED was included in the model to adjust for patient characteristics at the time of surgery. A measure of co-existent disease was crucial in explaining differences among hospitals in recovery from total hip replacement patients.
当以死亡率作为终点指标时，并存疾病或共病被视为护理质量和有效性研究中的预后因素。在关于术后医院并发症或手术长期恢复的研究中，测量和调整共病情况的必要性尚未得到论证。在本研究中，我们确定了并存疾病对因全髋关节置换住院患者术后并发症及1年健康相关生活质量的影响。研究人群包括356名在加利福尼亚州和马萨诸塞州的四家教学医院因全髋关节置换住院的患者队列。查阅患者的病历以收集有关疾病严重程度、并存疾病和术后并发症的信息。使用四级并存疾病指数（ICED）从入院时的病历信息中测量术前基线并存疾病的种类和数量。出院后约12个月，通过问卷调查了283名（80%）患者。并存疾病的存在和数量是术后并发症的重要预测因素。ICED最低水平和最高水平之间的并发症发生率在3%至41%之间。在四家研究医院接受治疗的患者术后1年的功能结局存在差异。功能结局与ICED评分密切相关：ICED 4级的患者在日常生活工具性活动中的得分比1级患者低26.8分。在控制了性别、年龄、教育程度和婚姻状况后，ICED仍然是1年时功能状态的重要预测因素。此外，当将ICED纳入模型以调整手术时的患者特征时，医院之间功能结局的差异消失了。并存疾病的测量对于解释全髋关节置换患者医院间恢复差异至关重要。
