CONCLUSION: Our new multimorbidity definitions identified far more specific, higher-risk pools of patients than conventional definitions, potentially aiding clinical decision-making.
J Am Coll Surg. 2023 Mar 15:e000659. doi: 10.1097/XCS.0000000000000659. Online ahead of print.
ABSTRACT
BACKGROUND: Multimorbidity in surgery is common and associated with worse postoperative outcomes. However, conventional multimorbidity definitions (≥2 comorbidities) label the vast majority of older patients as multimorbid, limiting clinical usefulness. We sought to develop and validate better surgical specialty-specific multimorbidity definitions based on distinct comorbidity combinations.
STUDY DESIGN: We used Medicare claims for patients aged 66-90 undergoing inpatient general, orthopaedic, or vascular surgery. Using 2016-2017 data, we identified all comorbidity combinations associated with at least 2-fold (general/orthopaedic) or 1.5-fold (vascular) greater risk of 30-day mortality compared to the overall population undergoing the same procedure; we called these Qualifying Comorbidity Sets. We applied these to 2018-2019 data (general=230,410 patients, orthopaedic=778,131, vascular=146,570) to obtain 30-day mortality estimates. For further validation, we tested whether multimorbidity status was associated with differential outcomes for patients at better-resourced (based on nursing skill-mix, surgical volume, teaching status) versus all other hospitals using multivariate matching.
RESULTS: Compared to conventional multimorbidity definitions, the new definitions labeled far fewer patients as multimorbid: general=85.0% (conventional) versus 55.9% (new) (p<0.0001); orthopaedic=66.6% versus 40.2% (p<0.0001); vascular=96.2% versus 52.7% (p<0.0001). Thirty-day mortality was higher by the new definitions: general=3.96% (conventional) versus 5.64% (new) (p<0.0001); orthopaedic=1.13% versus 1.68% (p<0.0001); vascular=4.43% versus 7.00% (p<0.0001). Better-resourced hospitals offered significantly larger mortality benefits than all other hospitals for multimorbid versus non-multimorbid general and orthopaedic, but not vascular, patients (general surgery difference-in-differences=-0.94% [-1.36%,-0.52%], p<0.0001; orthopaedic=-0.20% [-0.34%,-0.05%], p=0.0087; vascular=-0.12% [-0.69%,0.45%], p=0.6795).
CONCLUSION: Our new multimorbidity definitions identified far more specific, higher-risk pools of patients than conventional definitions, potentially aiding clinical decision-making.
PMID:36919934 | DOI:10.1097/XCS.0000000000000659
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