Meyers Primary Care Institute
Comorbidity; Epidemiologic Measurements
Health Services Research | Primary Care
BACKGROUND: Comorbidity indices summarize complex medical histories into concise ordinal scales, facilitating stratification and regression in epidemiologic analyses. Low subject prevalence in the highest strata of a comorbidity index often prompts combination of upper categories into a single stratum ('collapsing').
OBJECTIVE: We use data from a breast cancer cohort to illustrate potential inferential errors resulting from collapsing a comorbidity index.
METHODS: Starting from a full index (0, 1, 2, 3, and >/=4 comorbidities), we sequentially collapsed upper categories to yield three collapsed categorizations. The full and collapsed categorizations were applied to analyses of (1) the association between comorbidity and all-cause mortality, wherein comorbidity was the exposure; (2) the association between older age and all-cause mortality, wherein comorbidity was a candidate confounder or effect modifier.
RESULTS: Collapsing the index attenuated the association between comorbidity and mortality (risk ratio, full versus dichotomized categorization: 4.6 vs 2.1), reduced the apparent magnitude of confounding by comorbidity of the age/mortality association (relative risk due to confounding, full versus dichotomized categorization: 1.14 vs 1.09), and obscured modification of the association between age and mortality on both the absolute and relative scales.
CONCLUSIONS: Collapsing categories of a comorbidity index can alter inferences concerning comorbidity as an exposure, confounder and effect modifier.
DOI of Published Version
Clin Epidemiol. 2009 Aug 9;1:93-100. Link to article on publisher's website
Ahern, Thomas P.; Bosco, Jaclyn L. F.; Silliman, Rebecca A.; Yood, Marianne Ulcickas; Field, Terry S.; Wei, Feifei; and Lash, Timothy L., "Potential misinterpretations caused by collapsing upper categories of comorbidity indices: An illustration from a cohort of older breast cancer survivors" (2009). Meyers Primary Care Institute Publications and Presentations. 449.