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The CARDE-B Scoring System Predicts 30-Day Mortality After Revision Total Joint Arthroplasty
Micheal Raad1, Raj Amin1, Varun Puvanesarajah1
1Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
Insights
The CARDE-B score identifies patients at high risk for 30-day mortality after revision total joint arthroplasty (TJA). This validated tool helps surgeons and patients make informed decisions about revision TJA risks.
Area of Science:
- Orthopedic surgery
- Surgical outcomes research
- Patient risk stratification
Background:
- Revision total joint arthroplasty (TJA) carries a significant risk of perioperative complications.
- Identifying patients at high risk for mortality after revision TJA is crucial for shared decision-making.
- The CARDE-B score was developed to address this need for a high-fidelity risk assessment tool.
Purpose of the Study:
- To develop and validate the CARDE-B score for predicting 30-day mortality after revision TJA.
- To compare the predictive accuracy of the CARDE-B score against existing risk assessment tools.
- To provide a simple, effective tool for risk stratification in patients undergoing revision TJA.
Main Methods:
- Analysis of 13,118 revision TJA cases from the National Surgical Quality Improvement Program (NSQIP) database.
- Development of the CARDE-B score based on logistic regression, assigning 1 point for each of six criteria (congestive heart failure, low albumin, renal failure on dialysis, dependence, age >65, low BMI).
- External validation using the Nationwide Inpatient Sample (NIS) database (19,153 patients).
Main Results:
- The CARDE-B score demonstrated good predictive accuracy (AUC=0.85) for 30-day mortality after revision TJA.
- The score was significantly more accurate than the ASA physical status classification (AUC=0.77) and mFI-5 (AUC=0.67).
- External validation in the NIS dataset showed an AUC of 0.75, with good overall model fit (Hosmer-Lemeshow p=0.34).
Conclusions:
- The CARDE-B score is a simple, validated tool for predicting 30-day mortality risk in patients undergoing revision TJA.
- It offers a valuable risk-stratification method to aid surgeons and patients in complex decision-making.
- The score's accuracy surpasses that of commonly used risk assessment tools.
Background:
There exists a substantial risk of having a perioperative complication after revision total joint arthroplasty (TJA). The complex shared decision-making between surgeon and patient would benefit from a high-fidelity tool to identify patients at risk for mortality after revision TJA. Therefore, we developed the CARDE-B score. CARDE-B is an acronym for congestive heart failure, albumin or malnutrition (<3.5 mg/dL), renal failure on dialysis, dependence for daily living, elderly (>65 years of age), and body mass index <25 kg/m2. We developed and validated the CARDE-B score to determine the risk of death within 30 days of a revision TJA.
Methods:
A total of 13,118 revision TJAs (40% hip and 60% knee) from the National Surgical Quality Improvement Program (NSQIP) database were analyzed. A simple 1-point scoring system, CARDE-B, was created for predicting 30-day mortality after revision TJA, based on a logistic regression model. The CARDE-B scoring system assigns 1 point to each criterion in the acronym: congestive heart failure, albumin (<3.5 mg/dL), renal failure on dialysis, dependence for daily living, elderly (>65 years of age), and body mass index of <25 kg/m2. The CARDE-B scoring system was compared with 2 commonly utilized scores: American Society of Anesthesiologists (ASA) physical status classification and the 5-factor modified frailty index (mFI-5). The area under the curve (AUC) was used to assess the accuracy of each model. The Hosmer-Lemeshow test was used to assess goodness of fit. Finally, the Nationwide Inpatient Sample (NIS) was used for external validation of the CARDE-B score in 19,153 patients who underwent revision TJA in 2017.
Results:
Eighty-eight patients (0.7%) did not survive 30 days after revision TJA. The AUC for the logistic regression model was 0.88 in both the derivation and internal validation samples using NSQIP. The predicted probability of 30-day mortality after revision TJA increased stepwise from <0.01% for a CARDE-B score of 0 points to 39% for a CARDE-B score of 5 points. The AUC for the CARDE-B score predicting 30-day mortality after revision TJA was 0.85. This was more accurate (p < 0.001) than the ASA physical status classification (AUC, 0.77) and the mFI-5 (AUC, 0.67). The AUC for the CARDE-B score in the NIS external validation set was 0.75. The Hosmer-Lemeshow p value for goodness of fit was 0.34, indicating goodness of fit in the external validation sample.
Conclusions:
The CARDE-B score is a simple system that predicts the risk of death within 30 days of a revision TJA, offering surgeons and patients a valuable and validated risk-stratification tool.
Level Of Evidence:
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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