The utility of three comorbidity indices in predicting post-operative complications in pediatric urology
Ruiyang Jiang, M.D, Steven Wolf, MS, J. Todd Purves, M.D, PhD, John S. Wiener, M.D, Jonathan C. Routh, M.D, MPH.
Duke University Medical Center, Durham, NC, USA.
Background: Validated surgical risk assessment scores such as the Charlson Comorbidity (CCI) and Van Walraven (VWI) predict mortality in adults; the Rhee Index does so for pediatric surgery patients. Given the low mortality risk associated with the majority of pediatric urologic surgeries, these indices have not been widely used in clinical practice. To evaluate their full scope of clinical utility, we compared these three comorbidity scores in predicting pediatric urologic post-operative complications.
Methods: We analyzed the 2013 Nationwide Readmissions Database (NRD). This database is constructed using inpatient data from 21 states to track readmission rates and causes. We identified children (<18 y) who underwent the following urological procedures: ureteroneocystostomy, ureteroureterostomy, radical/partial nephrectomy, pyeloplasty, appendicovesicostomy, enterocystoplasty, vesicostomy, and bladder neck sling. Comorbidity scores were classified using each of the three indices. Complications were identified based on the National Surgical Quality Improvement Program (NSQIP). We used weighted descriptive analysis to describe the patient cohort. Receiver operating characteristics (ROC) were constructed for each of the three indices to compare their performance in predicting post-operative complications.
Results obtained: We identified a total of 8,006 patients. Females accounted for 49.1% of the cohort; the median age was 3 years, and 51.1% were privately insured. 8.3% had at least one post-operative complication. The Rhee index had the best performance in predicting post-operative complications (AUC=0.67, 95%CI 0.63-0.71) compared to CCI (AUC=0.62, 95%CI 0.58-0.66) and VWI (AUC=0.61, 95% CI 0.58-0.65); p<0.05.
Conclusions: The Rhee index had a better predictability for post-operative complications in pediatric urology patients compared to Charlson or Van Walraven Index. Since the three indices were designed to predict mortality, they performed less well in predicting post-operative complications. Given the limitations of these indices in accurately predicting post-surgical complications, a new index needs to be developed for pediatric urology patients.
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