Abstract
Objective
To examine whether commonly used comorbidity indexes (Deyo-Charlson comorbidity index,
Elixhauser comorbidity index, the Centers for Medicare and Medicaid Services [CMS]
comorbidity tiers) capture comorbidities in the acute traumatic and nontraumatic SCI
inpatient rehabilitation population.
Design
Retrospective cross-sectional study.
Participants
Data were obtained from the Uniform Data System for Medical Rehabilitation from October
1, 2015 to December 31, 2017 for adults with spinal cord injury (SCI) (Medicare-established
Impairment Group Codes 04.110-04.230, 14.1, 14.3). This study included SCI discharges
(N=66,235) from 833 inpatient rehabilitation facilities.
Main Outcome Measures
International Classification of Diseases–10th Revision–Clinical Modifications (ICD-10-CM) codes were used to assess 3 comorbidity indexes (Deyo-Charlson comorbidity
index, Elixhauser comorbidity index, CMS comorbidity tiers). The comorbidity codes
that occurred with >1% frequency were reported. The percentages of discharges for
which no comorbidities were captured by each comorbidity index were calculated.
Results
Of the total study population, 39,285 (59.3%) were men and 11,476 (17.3%) were tetraplegic.
The mean number of comorbidities was 14.7. There were 13,939 distinct ICD-10-CM comorbidity
codes. There were 237 comorbidities that occurred with >1% frequency. The Deyo-Charlson
comorbidity index, Elixhauser comorbidity index, and the CMS tiers did not capture
comorbidities of 58.4% (95% confidence interval, 58.08%-58.84%), 29.4% (29.07%-29.76%),
and 66.1% (65.73%-66.46%) of the discharges in our study, respectively, and 28.8%
(28.42%-29.11%) of the discharges did not have any comorbidities captured by any of
the comorbidity indexes.
Conclusion
Commonly used comorbidity indexes do not reflect the extent of comorbid disease in
the SCI rehabilitation population. This work suggests that alternative measures may
be needed to capture the complexity of this population.
Keywords
List of abbreviations:
CMS (Centers for Medicare and Medicaid Services), ICD-10-CM (International Classification of Diseases–10th Revision–Clinical Modifications), HRRP (Hospital Readmissions Reduction Program), IRF (inpatient rehabilitation facility), IRF-PAI (inpatient rehabilitation facility patient assessment instrument), ntSCI (nontraumatic spinal cord injury), SCI (spinal cord injury), tSCI (traumatic spinal cord injury), UDSMR (Uniform Data System for Medical Rehabilitation), UTI (urinary tract infection)To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Archives of Physical Medicine and RehabilitationAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- The pre-therapeutic classification of co-morbidity in chronic disease.J Chronic Dis. 1970; 23: 455-468
- Patient and hospital characteristics associated with inpatient severe sepsis mortality in California, 2005-2010.Crit Care Med. 2012; 40: 2960-2966
- Comprehensive geriatric assessment of risk factors associated with adverse outcomes and resource utilization in cancer patients undergoing abdominal surgery.J Surg Oncol. 2013; 108: 182-186
- Comorbidity and outcomes after surgery among women with breast cancer: analysis of nationwide in-patient sample database.Breast Cancer Res Treat. 2013; 139: 469-476
- Evaluation of the Charlson comorbidity index to predict early mortality in implantable cardioverter defibrillator patients.Ann Noninvasive Electrocardiol. 2013; 18: 379-388
- Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases.J Clin Epidemiol. 1992; 45: 613-619
- Comorbidity measures for use with administrative data.Med Care. 1998; 36: 8-27
- Assessing the ability of comorbidity indexes to capture comorbid disease in the inpatient rehabilitation burn injury population.Am J Phys Med Rehabil. 2015; 94: 373-384
- Validation of a combined comorbidity index.J Clin Epidemiol. 1994; 47: 1245-1251
- Functional status predicts acute care readmission in the traumatic spinal cord injury population.J Spinal Cord Med. 2019; 42: 20-31
- Comparing comorbidity indices to predict post-acute rehabilitation outcomes in older adults.Am J Phys Med Rehabil. 2016; 95: 889-898
- The inpatient rehabilitation facility-patient assessment instrument (IRF-PAI) training manual.(Available at:) (Accessed December 23, 2019)
- Inpatient rehabilitation facility prospective payment system for federal fiscal year 2019.(Availale at:) (Accessed December 23, 2019)
- A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.J Chronic Dis. 1987; 40: 373-383
- Further evidence concerning the use of a clinical comorbidity index with ICD-9-CM administrative data.J Clin Epidemiol. 1993; 46: 1085-1090
- Adapting a clinical comorbidity index for use with ICD-9-CM administrative data: differing perspectives.J Clin Epidemiol. 1993; 46: 1075-1079
- Etiology and incidence of rehospitalization after traumatic spinal cord injury: a multicenter analysis.Arch Phys Med Rehabil. 2004; 85: 1757-1763
- Rehospitalization in the first year of traumatic spinal cord injury after discharge from medical rehabilitation.Arch Phys Med Rehabil. 2013; 94: S87-S97
- Acute rehospitalizations during inpatient rehabilitation for spinal cord injury.Arch Phys Med Rehabil. 2013; 94: S98-S105
- Utilization of health services following spinal cord injury: a 6-year follow-up study.Spinal Cord. 2004; 42: 513-525
- Health-related outcomes of people with spinal cord injury--a 10 year longitudinal study.Spinal Cord. 2008; 46: 386-391
- Genitourinary complications are a leading and expensive cause of emergency department and inpatient encounters for persons with spinal cord injury.Arch Phys Med Rehabil. 2019; 100: 1614-1621
- Examining health-care utilization in the first year following spinal cord injury.J Spinal Cord Med. 2015; 38: 690-695
- Electrical stimulation for pressure sore prevention and wound healing.Assist Technol. 2000; 12: 50-66
- Use of behavioral contingencies to promote prevention of recurrent pressure ulcers.. 2003; 84: 796-802
- Dysphagia in individuals with tetraplegia: incidence and risk factors.J Spinal Cord Med. 2011; 34: 85-92
- Dysphagia and associated respiratory considerations in cervical spinal cord injury.Top Spinal Cord Inj Rehabil. 2012; 18: 291-299
- How to measure comorbidity. A critical review of available methods.J Clin Epidemiol. 2003; 56: 221-229
- Multimorbidity’s many challenges.BMJ. 2007; 334: 1016-1017
- Health care quality and multimorbidity.Med Care. 2007; 45: 477-479
- Defining comorbidity: implications for understanding health and health services.Ann Fam Med. 2009; 7: 357-363
- Association of the Hospital Readmissions Reduction Program with mortality among Medicare beneficiaries hospitalized for heart failure, acute myocardial infarction, and pneumonia.JAMA. 2018; 320: 2542-2552
- The Hospital Readmissions Reduction Program—time for a reboot.N Engl J Med. 2019; 380: 2289-2291
- Risk prediction models for hospital readmission: a systematic review.JAMA. 2011; 306: 1688-1698
- Utility of models to predict 28-day or 30-day unplanned hospital readmissions: an updated systematic review.BMJ Open. 2016; 6e011060
- Pay-for-performance: disappointing results or masked heterogeneity?.Med Care Res Rev. 2017; 74: 3-78
- Leadership by example: coordinating government roles in improving health.National Acadamies Press, Washington, D.C.2002 (Available at: https://books.google.com/books?hl=en&lr=&id=RxSdAgAAQBAJ&oi=fnd&pg=PT19&dq=Institute+of+Medicine.+Leadership+by+example:+coordinating+government+roles+in+improving+health+care+quality.+Washington,+DC:+National+Academies+Press,+October+2002.&ots=AjOxU88eVg. Accessed July 14, 2019)
- Paying for performance: Medicare should lead.Health Aff. 2003; 22: 8-10
- Pay for performance: the best worst choice.Qual Saf Health Care. 2004; 13: 323-324
- Achieving and sustaining improved quality: lessons from New York State and cardiac surgery.Health Aff. 2002; 21: 40-51
- Hospital performance reports: impact on quality, market share, and reputation.Health Aff. 2005; 24: 1150-1160
- Development of a risk-adjustment model for the inpatient rehabilitation facility discharge self-care functional status quality measure.Med Care. 2017; 55: 706-715
- Department of Health and Human Services Centers for Medicare & Medicaid Services 42 CFR Part 412 Medicare Program; inpatient rehabilitation facility prospective payment system for federal fiscal year 2017; final rule mstockstill on DSK3G9T082PROD with RULES3.(Available at:)http://www.cms.hhs.gov/Date accessed: December 23, 2019
Finalized item by item IRF PAI coding instructions, 2017, Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/IRFPAI. Accessed July 14, 2018.
Article info
Publication history
Published online: May 26, 2020
Footnotes
Supported by the National Institute on Disability, Independent Living, and Rehabilitation Research (grant no. 90SI5021).
Disclosures: Ross D. Zafonte received royalties from (1) Oakstone for an educational CD, Physical Medicine and Rehabilitation: A Comprehensive Review, and (2) Demos Publishing for serving as coeditor of the book Brain Injury Medicine. He serves on the Scientific Advisory Board of Myomo, Oxeia Biopharma, Biodirection, and EIMINDA. The other authors have nothing to disclose.
Identification
Copyright
Published by Elsevier Inc. on behalf of the American Congress of Rehabilitation Medicine
