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The Association of Charlson and Elixhauser Comorbidity Indices and Patient-Reported Outcomes in a Population Undergoing Shoulder Arthroplasty

The Association of Charlson and Elixhauser Comorbidity Indices and Patient-Reported Outcomes in a Population Undergoing Shoulder Arthroplasty

William A. Marmor, MD, UNITED STATES Brandon Schneider, MS, UNITED STATES Gabriella Ode, MD, UNITED STATES Lawrence V. Gulotta, MD, UNITED STATES Daphne Ling, PhD, MPH, TAIWAN

Hospital for Special Surgery, New York, NY, UNITED STATES

2021 Congress   ePoster Presentation     Not yet rated


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Sports Medicine

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Summary: Charlson and Elixhauser comorbidity indices can be used to determine worse patient outcomes following shoulder arthroplasty.


Shoulder arthroplasty (SA) procedures are increasingly common. The Charlson (17 comorbidities) and Elixhauser (30 comorbidities) indices are ICD-10 based measures used in large administrative databases to describe patient case mix in terms of secondary medical conditions. There is a paucity of data on the relationship between these indices and patient-reported outcome measures (PROMs) after shoulder arthroplasty.


Patients undergoing SA (anatomic, reverse, or hemiarthroplasty) from 2016-2018 were identified in our institution’s electronic medical records. Charlson (CCI) and Elixhauser comorbidities (ECI), listed as secondary diagnoses, were used to calculate comorbidity scores according to established algorithms. Patients were matched to our shoulder arthroplasty registry to obtain PROMs, including shoulder-specific (ASES and SAS) and general health scales (SF-12 MCS and PCS and PROMIS Pain Interference).

Linear regression models adjusting for age and sex evaluated associations between comorbidities and PROM scores. Minimal clinically important difference (MCID) values for each PROM were identified in the literature or calculated if not previously defined. Percentage of patients that did not reach 2-year MCID for each PROM was reported. Receiver operating characteristic (ROC) curves determined optimal cutoffs that maximized sensitivity and specificity to identify patients more likely to fail to meet MCID.


A total of 1817 SA procedures were identified. Mean/median age was 67 years (SD=10), and 52% were female. CCI ranged from 0 to 13, while ECI ranged from -13 to 26. Higher CCI and ECI were significantly associated with lower baseline SAS (p =<0.0001; p =0.01) and SF-12 PCS (p =<0.0001; p =0.004). Patients with higher CCI had lower baseline ASES (p =0.003) and SF-12 MCS at baseline (p =0.0002) and 2 years (p =0.02). No significant associations were found for PROMIS Pain Interference with either indices.

For shoulder specific PROMs, 10% of procedures failed to meet the ASES reported MCID (13.5 points) and 58% of patients failed to meet the SAS calculated MCID (2.7 points) for SA at 2 years. CCI of 4 or ECI of -7 produced a ROC area=57% on the ASES. CCI of 1 or ECI of -4 resulted in ROC areas of 63-64% on the SAS. On general health PROMs, 68% of patients failed to meet the SF-12 MCS MCID (5.7 points) and 36% of patients failed to meet the SF-12 PCS MCID (5.4 points). CCI of 4 or ECI of -4 resulted in ROC areas of 60-63% on the SF-12 MCS, while on the SF-12 PCS, a CCI of 3 gave a ROC area of 64%, and ECI of 1 gave a ROC area of 55%.


Higher Charlson and Elixhauser comorbidity scores were associated with lower baseline scores on most shoulder-specific and general health PROMs. The optimal cutoffs had moderate accuracy in predicting which patients would fail to meet MCID for different PROMs at 2 years. These cutoffs can be adjusted further depending on the tradeoff between sensitivity and specificity. Generally, the CCI performed better than the ECI in predicting worse outcomes. Comorbidity indices may be useful as a decision aid to provide appropriate expectations of outcomes for patients undergoing SA.

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