Scores derived from comorbidities can help with risk adjustment of quality and safety data. The Charlson and Elixhauser comorbidity measures are well-known risk adjustment models, yet the optimal score for orthopaedic patients remains unclear.

Study Design. Analysis of the National Hospital Discharge Survey database from 1990 to 2007. Objective. To evaluate the influence of preoperative depression, anxiety, schizophrenia, or dementia on in-hospital (1) adverse events, (2) mortality, and (3) nonroutine discharge in patients undergoing major spine surgery. Summary of Background Data. Psychiatric comorbidity is a known risk factor for impaired health-related quality of life and poor long-term outcomes after spine surgery, yet little is known about its impact in the perioperative spine surgery setting. Methods. Using the National Hospital Discharge Survey database, all patients undergoing either spinal fusion or laminectomy between 1990 and 2007 were identified and separated into groups with and without psychiatric disorders. Multivariable regression analysis was performed for each of the outcome variables. Results. Between 1990 and 2007, a total estimated number of 5,382,343 spinal fusions and laminectomies were performed. The prevalence of diagnosed depression, anxiety, and schizophrenia among the study population increased significantly over time. Depression, anxiety, schizophrenia, and dementia were associated with higher rates of nonroutine discharge. Depression, schizophrenia, and dementia were associated with higher rates of adverse events. Dementia was the only psychiatric disorder associated with a higher risk of in-hospital mortality. Conclusion. Patients with preoperative psychiatric disorders undergoing major spine surgery are at increased risk for perioperative adverse events and posthospitalization care, but its effect in perioperative mortality is more limited. Presurgical psychological screening of candidates undergoing spine surgery might ultimately lead to the enhancement of perioperative outcomes in this growing segment of the US population. Level of Evidence: N/A

The Charlson Comorbidity Index (CCI) and its modifications are comorbidity-based measures that predict mortality. It was developed for patients without trauma and inconsistently predicted mortality and adverse events in several previous studies of patients with trauma. We therefore (1) determined whether the three different CCIs were predictors for in-hospital deaths in patients with hip fractures, (2) verified if the CCI mortality prediction had changed with time, (3) evaluated other predictors of in-hospital death in patients with hip fractures, and (4) determined if the CCI has predicted in-hospital adverse events. We retrospectively reviewed a nationwide probability sample survey, the National Hospital Discharge Survey. More than 6 million adult patients with hip fractures and their associated comorbidities were scored by the original 1987 CCI, the 1994 age-adjusted CCI, and the 2011 updated, reweighted CCI. The three mortality indices’ predictive values and predictors of in-hospital adverse events were compared. For patients with hip fractures, all three CCI variations predicted in-hospital mortality. The receiver operating curves (ROC) of the models were less than 0.68, but they improved when we used statistical models that included age, sex, concomitant injuries, and other comorbidities not contained in the CCI models (ROC > 0.74). The age-adjusted CCI accuracy was slightly better than the other two CCIs. Adverse events during hospital stays were associated with a higher CCI, pertrochanteric fracture (versus transcervical), abdominal, chest, or head trauma, atrial fibrillation, multiple fractures, female sex, and longer hospital stays; however, the accuracy of this model was poor (ROC = 0.65). While all three CCI variations predicted in-hospital mortality in patients with hip fractures, other factors may be of value in patients with trauma.

Bone graft and bone graft substitutes are used to provide structural support and enhance bone healing. Autogenous, allogeneic, and artificial bone grafts each have advantages and drawbacks. The development of allografts, synthetic bone grafts, and new operative techniques may have influenced the use of bone grafts in recent years. The goal of this study was to analyze the use of bone grafts and bone graft substitutes in the United States during a 16-year period. Using data from the National Hospital Discharge Survey, the authors analyzed the use of autogenous and artificial bone grafts in almost 2 million patients in the United States between 1992 and 2007 using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes in 4 periods (1992–1995, 1996–1999, 2000–2003, and 2004–2007). Among an estimated almost 2 million bone graft procedures (83% autogenous, 17% artificial), the use of both types of grafts decreased. The main diagnoses for which bone grafts were used did not change; however, cervical spine diseases and lower-limb fractures decreased more remarkably. Although sex (52% male in the early 1990s to 47% in 2000–2003) and discharge status (more discharges to a short-term or long-term-care facility) significantly changed, age increased from 47 to 53 years and inpatient days decreased significantly from 6 to 5 days during the study period. The use of bone grafts and bone graft substitutes is decreasing in the United States, with a slight shift from autogenous to substitute grafts.