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Dmytriw AA, Chibbar R, Chen PPY, Traynor MD, Kim DW, Bruno FP, Cheung CC, Pareek A, Chou ACC, Graham J, Dibas M, Paranjape G, Reierson NL, Kamrowski S, Rozowsky J, Barrett A, Schmidt M, Shahani D, Cowie K, Davis AR, Abdelmegeed M, Touchette JC, Kallmes KM, Pederson JM, Keesari PR. Outcomes of acute respiratory distress syndrome in COVID-19 patients compared to the general population: a systematic review and meta-analysis. Expert Rev Respir Med 2021; 15:1347-1354. [PMID: 33882768 PMCID: PMC8108193 DOI: 10.1080/17476348.2021.1920927] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19) often leads to mortality. Outcomes of patients with COVID-19-related ARDS compared to ARDS unrelated to COVID-19 is not well characterized. AREAS COVERED We performed a systematic review of PubMed, Scopus, and MedRxiv 11/1/2019 to 3/1/2021, including studies comparing outcomes in COVID-19-related ARDS (COVID-19 group) and ARDS unrelated to COVID-19 (ARDS group). Outcomes investigated were duration of mechanical ventilation-free days, intensive care unit (ICU) length-of-stay (LOS), hospital LOS, and mortality. Random effects models were fit for each outcome measure. Effect sizes were reported as pooled median differences of medians (MDMs), mean differences (MDs), or odds ratios (ORs). EXPERT OPINION Ten studies with 2,281 patients met inclusion criteria (COVID-19: 861 [37.7%], ARDS: 1420 [62.3%]). There were no significant differences between the COVID-19 and ARDS groups for median number of mechanical ventilator-free days (MDM: -7.0 [95% CI: -14.8; 0.7], p = 0.075), ICU LOS (MD: 3.1 [95% CI: -5.9; 12.1], p = 0.501), hospital LOS (MD: 2.5 [95% CI: -5.6; 10.7], p = 0.542), or all-cause mortality (OR: 1.25 [95% CI: 0.78; 1.99], p = 0.361). Compared to the general ARDS population, results did not suggest worse outcomes in COVID-19-related ARDS.
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Affiliation(s)
- Adam A Dmytriw
- Neuroradiology & Neurointervention Service, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Richa Chibbar
- Department of Medicine, Lakeridge Health, Oshawa, Canada
| | - Petty Pin Yu Chen
- ASUS AICS Department, Ministry of Health Holdings Pte Ltd, Singapore
| | | | - Dong Wook Kim
- Department of Epidemiology and Case Management Cheongju, Korea Disease Control and Prevention Agency, Cheongju, South Korea
| | - Fernando P Bruno
- Department of Anatomy, Touro College of Osteopathic Medicine, Middletown, MN, USA.,Department of Public Health, Division of Epidemiology, School of Health Sciences and Practice, New York Medical College, Valhalla, NY, USA
| | | | - Anuj Pareek
- Department of Radiology, Stanford University, Stanford, CA, USA
| | | | - Jeffrey Graham
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Mahmoud Dibas
- Sulaiman Al Rajhi University, College of Medicine, Saudi Arabia
| | - Geeta Paranjape
- Research Department, Superior Medical Experts, St. Paul, MN, USA
| | | | | | - Jacob Rozowsky
- Research Department, Nested Knowledge, St. Paul, MN, USA
| | - Averi Barrett
- Research Department, Nested Knowledge, St. Paul, MN, USA
| | - Megan Schmidt
- Research Department, Nested Knowledge, St. Paul, MN, USA
| | - Disha Shahani
- Research Department, Nested Knowledge, St. Paul, MN, USA
| | - Kathryn Cowie
- Research Department, Nested Knowledge, St. Paul, MN, USA
| | - Amber R Davis
- Research Department, Superior Medical Experts, St. Paul, MN, USA
| | | | | | | | - John M Pederson
- Research Department, Superior Medical Experts, St. Paul, MN, USA
| | - Praneeth Reddy Keesari
- Department of Internal Medicine, Kamineni Academy of Medical Sciences and Research Centre, Hyderabad, India
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Wilson JM, Farley KX, Gottschalk MB, Daly CA, Wagner ER. Preoperative opioid use is an independent risk factor for complication, revision, and increased health care utilization following primary total shoulder arthroplasty. J Shoulder Elbow Surg 2021; 30:1025-1033. [PMID: 32853788 DOI: 10.1016/j.jse.2020.08.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 07/26/2020] [Accepted: 08/02/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The incidence of total shoulder arthroplasty (TSA) in increasing. Evidence in primary hip and knee arthroplasty suggest that preoperative opioid use is a risk factor for postoperative complication. This relationship in TSA is unknown. The purpose of this study was to investigate this relationship. METHODS The Truven Marketscan claims database was used to identify patients who underwent primary, unilateral TSA. Preoperative opioid use status was then used to divide patients into cohorts based on the average daily oral morphine equivalents (OMEs) received in the 6-month preoperative period. This included the following cohorts: opioid naïve and <1, 1-5, 5-10, and >10 average daily OMEs. In total, 29,454 patients with 90-day postoperative follow-up were included. Of these, 21,580 patients and 8959 patients had 1- and 3-year follow-up, respectively. Patient information and complication data were collected. Univariate and multivariate logistic regression were then performed to assess the association of preoperative opioid use with postoperative outcomes. A subgroup analysis was performed to examine revision surgery at 1 and 3 years postoperatively. RESULTS Forty-four percent of identified patients received preoperative opioids, but the preoperative opioid-naïve patient became more common over the study period. Multivariate analysis demonstrated that patients receiving >10 average daily OMEs (compared with opioid naïve) had higher odds of opioid overdose (odds ratio [OR] 4.17, 95% confidence interval [CI] 1.57-11.08, P = .004), wound complication (OR 2.04, 95% CI 1.44-2.89, P < .001), superficial surgical site infection (OR 2.33, 95% CI 1.63-3.34, P < .001), prosthetic joint infection (OR 3.41, 95% CI 2.50-4.67, P < .001), pneumonia (OR 1.95, 95% CI 1.39-2.75, P < .001), and thromboembolic event (OR 1.42, 95% CI 1.18-1.72, P < .001). The same group had higher health care utilization, including extended length of stay, nonhome discharge, readmission, and emergency department visits (P ≤ .001). Total perioperative adjusted costs were more than $7000 higher in the >10-OME group when compared to preoperative opioid-naïve patients. DISCUSSION Opioid use prior to TSA is common and is associated with increased complications, health care utilization, revision surgery, and costs. This risk is dose dependent, and efforts should be made at cessation prior to surgery.
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Affiliation(s)
- Jacob M Wilson
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA
| | - Kevin X Farley
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael B Gottschalk
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA
| | - Charles A Daly
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA
| | - Eric R Wagner
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA.
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103
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McCurdy MA, Burt CI, Schneider MB, Zhang T, Foster MJ, Aneizi A, Gilotra MN, Hasan SA, Henn III RF. Preoperative opioid use correlates with worse patient-reported outcomes two years after elective shoulder surgery. J Orthop 2021; 25:167-172. [PMID: 34025060 PMCID: PMC8131954 DOI: 10.1016/j.jor.2021.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/02/2021] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Prescription opioid consumption in the United States is a well-known public health problem, however, the deleterious effect of opioids may not be fully understood. The purpose of this study was to investigate the relationship between preoperative opioid use and patient-reported outcomes two years after shoulder surgery. We hypothesized preoperative opioid use would be predictive of worse two-year patient reported outcome scores. METHODS Patients undergoing shoulder surgery at an urban institution from June 2015 to July 2017 were prospectively enrolled into our orthopaedic registry. Preoperative opioid use and its association to patient outcome scores was retrospectively analyzed through bivariate analysis. Multivariate analysis was used to control for confounding variables and to determine independent predictors of two-year outcome scores. RESULTS Preoperative opioid use was associated with significantly worse scores on all two-year patient reported outcomes, and less improvement in PROMIS Physical Function and Numeric Pain Score (NPS) Body Pain two years postoperatively. Multivariate analysis showed preoperative opioid use to be an independent predictor of worse two-year scores in PROMIS Physical Function, PROMIS Pain Interference, PROMIS Social Satisfaction, American Shoulder and Elbow Surgeons Standardized Shoulder Form and NPS Operative Site. Preoperative opioid use was not an independent predictor of change in any outcome measure. CONCLUSION Preoperative opioid use was associated with worse scores on all two-year patient reported outcomes, and after controlling for confounders, preoperative opioid use was predictive of worse scores in several two-year outcome measures. To our knowledge, this is one of the few studies investigating the impact of preoperative opioid use on postoperative outcomes after shoulder surgery.
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Affiliation(s)
- Michael A. McCurdy
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Cameran I. Burt
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Matheus B. Schneider
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Tina Zhang
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael J. Foster
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ali Aneizi
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mohit N. Gilotra
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - S. Ashfaq Hasan
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - R. Frank Henn III
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
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Devano DMJ, Smith JR, Houck DA, McCarty EC, Seidl AJ, Wolcott ML, Frank RM, Bravman JT. Clinical Outcomes Associated With Preoperative Opioid Use in Various Shoulder Surgical Procedures: A Systematic Review. Orthop J Sports Med 2021; 9:2325967121997601. [PMID: 33997059 PMCID: PMC8072861 DOI: 10.1177/2325967121997601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 11/24/2020] [Indexed: 11/17/2022] Open
Abstract
Background: The impact of preoperative opioid use on outcomes after shoulder surgery is unknown. Purpose/Hypothesis: To examine the role of preoperative opioid use on outcomes in patients after shoulder surgery. We hypothesized that preoperative opioid use in shoulder surgery will result in increased postoperative pain and functional deficits when compared with nonuse. Study Design: Systematic review; Level of evidence, 3. Methods: A systematic review was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included were all English-language studies comparing clinical outcomes of shoulder surgery in patients who used opioids preoperatively (opioid group) as well as patients who did not (nonopioid group) with a minimum follow-up of 1 year. Outcomes included range of motion, American Shoulder and Elbow Surgeons score, Constant-Murley score, and visual analog scale for pain. Study quality was evaluated with the Modified Coleman Methodology Score and the MINORS score (Methodological Index for Non-randomized Studies). Results: Included were 5 studies (level 2, n = 1; level 3, n = 4): Two studies were on total shoulder arthroplasty, 2 on reverse total shoulder arthroplasty, 1 on both, and 1 on arthroscopic rotator cuff repair. There were 827 patients overall: 290 in the opioid group (age, 63.2 ± 4.0 years [mean ± SD]; follow-up, 38.9 ± 7.5 months) and 537 in the nonopioid group (age, 66.0 ± 4.7 years; follow-up, 39.5 ± 8.1 months). The opioid group demonstrated significantly worse pre- and postoperative visual analog scale and Constant-Murley score pain scores as compared with the nonopioid group. Mean American Shoulder and Elbow Surgeons scores were significantly lower in the opioid group at pre- and postoperative time points as compared with the nonopioid group (P < .05 for all). However, both groups experienced similar improvement in outcomes pre- to postoperatively. One study showed that the opioid group consumed significantly more opioids postoperatively than the nonopioid group and for a longer duration (P < .05). The overall mean Modified Coleman Methodology Score and MINORS score were 64.2 ± 14 and 15.8 ± 1.0, respectively. Conclusion: Opioid use prior to various shoulder surgical procedures negatively affected postoperative pain and functionality. Although the opioid group showed significantly worse scores postoperatively, the groups experienced similar improvements.
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Affiliation(s)
- Dan Michael J Devano
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - John-Rudolph Smith
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Darby A Houck
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Eric C McCarty
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Adam J Seidl
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Michelle L Wolcott
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Rachel M Frank
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Jonathan T Bravman
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, School of Medicine, University of Colorado, Aurora, Colorado, USA
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105
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Cha Y, Jang SY, Yoo JI, Choi HG, Hwang JW, Choy W. Effect of Opioids on All-cause Mortality and Opioid Addiction in Total Hip Arthroplasty: a Korea Nationwide Cohort Study. J Korean Med Sci 2021; 36:e87. [PMID: 33821594 PMCID: PMC8021974 DOI: 10.3346/jkms.2021.36.e87] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/14/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The purpose of this study was to investigate the use of opioids before and after total hip arthroplasty (THA), to find out the effect of opioid use on mortality in patients with THA, and to analyze whether preoperative opioid use is a risk factor for sustained opioid use after surgery using Korean nationwide cohort data. METHODS This retrospective nationwide study identified subjects from the Korean National Health Insurance Service-Sample cohort (NHIS-Sample) compiled by the Korean NHIS. The index date (time zero) was defined as 90 days after an admission to a hospital to fulfill the eligibility criteria of the THA. RESULTS In the comparison of death risk according to current use and the defined daily dose of tramadol and strong opioids in each patient group according to past opioid use, there were no statistically significant differences in the adjusted hazard ratio for death compared to the current non-users in all groups (P > 0.05). Past tramadol and strong opioid use in current users increased the risk of the sustained use of tramadol and strong opioids 1.45-fold (adjusted rate ratio [aRR]; 95% confidence interval [CI], 1.12-1.87; P = 0.004) and 1.65-fold (aRR; 95% CI, 1.43-1.91; P < 0.001), respectively, compared to past non-users. CONCLUSION In THA patients, the use of opioids within 6 months before surgery and within 3 months after surgery does not affect postoperative mortality, but a past-use history of opioid is a risk factor for sustained opioid use. Even after THA, the use of strong opioids is observed to increase compared to before surgery.
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Affiliation(s)
- Yonghan Cha
- Department of Orthopaedic Surgery, Eulji University Hospital, Daejeon, Korea
| | - Suk Yong Jang
- Department of Preventive Medicine, Eulji University College of Medicine, Daejeon, Korea
| | - Jun Il Yoo
- Department of Orthopaedic Surgery, Gyeongsang National University Hospital, Jinju, Korea.
| | - Hyo Gil Choi
- Department of Orthopaedic Surgery, Eulji University Hospital, Daejeon, Korea
| | - Jeong Won Hwang
- Department of Orthopaedic Surgery, Eulji University Hospital, Daejeon, Korea
| | - Wonsik Choy
- Department of Orthopaedic Surgery, Eulji University Hospital, Daejeon, Korea
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Addressing National Opioid Prescribing Practices for Knee Osteoarthritis: An Analysis of an Estimated 41,389,332 Patients With Knee Arthritis. J Am Acad Orthop Surg 2021; 29:e337-e344. [PMID: 33591123 DOI: 10.5435/jaaos-d-20-00924] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/05/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Knee osteoarthritis (OA) is a chronic pathology that is treated across multiple specialties. Opioid prescribing practices for knee OA have not been described on a national level. The purpose of this study was to (1) investigate the trends in opioid prescriptions for knee OA, (2) characterize and identify predominant opioid based medications prescribed for knee OA, and (3) identify patient- and provider-related factors influencing opioid prescribing patterns in the treatment of knee OA in the outpatient setting. METHODS The National Ambulatory Medical Care Survey (NAMCS) was used to identify all patients in the United States who presented to an outpatient clinic for knee OA between 2007 and 2016. New opioid prescriptions were determined using a previously published algorithm. Generalized linear models were used to assess trends. RESULTS A total of 41,389,332 patients were included, of which 12.8% were prescribed an opioid-based medication. Opioid prescription rose from 2007/2008 to 2013/2014. Analysis of the opioid type demonstrated that the prescription of hydrocodone-based medication and "other" traditional opioids followed the aforementioned trends. However, tramadol prescription demonstrated a sustained increase throughout the years peaking at 2015/2016. Patient income in the lowest quartile, a worker's compensation status, and depression were independently associated with higher odds of opioid prescription for knee OA. CONCLUSIONS Opioid prescription for knee OA remains high. Decreases in traditional opioid prescription have been countered by increase in tramadol prescription. The risks and addictive potential of tramadol and patient and provider risk factors should be emphasized.
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107
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Brandenburger D, Ambrosino E. The impact of antenatal syphilis point of care testing on pregnancy outcomes: A systematic review. PLoS One 2021; 16:e0247649. [PMID: 33765040 PMCID: PMC7993761 DOI: 10.1371/journal.pone.0247649] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 02/10/2021] [Indexed: 12/26/2022] Open
Abstract
Background Mother-to-child transmission of syphilis remains a leading cause of neonatal death and stillbirth, disproportionally affecting women in low-resource settings where syphilis prevalence rates are high and testing rates low. Recently developed syphilis point-of-care tests (POCTs) are promising alternatives to conventional laboratory screening in low-resource settings as they do not require a laboratory setting, intensive technical training and yield results in 10–15 minutes thereby enabling both diagnosis and treatment in a single visit. Aim of this review was to provide clarity on the benefits of different POCTs and assess whether the implementation of syphilis POCTs is associated with decreased numbers of syphilis-related adverse pregnancy outcomes. Methods Following the PRISMA guidelines, three electronic databases (PubMed, Medline (Ovid), Cochrane) were systematically searched for intervention studies and cost-effectiveness analyses investigating the association between antenatal syphilis POCT and pregnancy outcomes such as congenital syphilis, low birth weight, prematurity, miscarriage, stillbirth as well as perinatal, fetal or infant death. Results Nine out of 278 initially identified articles were included, consisting of two clinical studies and seven modelling studies. Studies compared the effect on pregnancy outcomes of treponemal POCT, non-treponemal POCT and dual POCT to laboratory screening and no screening program. Based on the clinical studies, significantly higher testing and treatment rates, as well as a significant reduction (93%) in adverse pregnancy outcomes was reported for treponemal POCT compared to laboratory screening. Compared to no screening and laboratory screening, modelling studies assumed higher treatment rates for POCT and predicted the most prevented adverse pregnancy outcomes for treponemal POCT, followed by a dual treponemal and non-treponemal POCT strategy. Conclusion Implementation of treponemal POCT in low-resource settings increases syphilis testing and treatment rates and prevents the most syphilis-related adverse pregnancy outcomes compared to no screening, laboratory screening, non-treponemal POCT and dual POCT. Regarding the benefits of dual POCT, more research is needed. Overall, this review provides evidence on the contribution of treponemal POCT to healthier pregnancies and contributes greater clarity on the impact of diverse diagnostic methods available for the detection of syphilis.
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MESH Headings
- Abortion, Spontaneous/diagnosis
- Abortion, Spontaneous/economics
- Abortion, Spontaneous/prevention & control
- Cost-Benefit Analysis
- Developing Countries
- Female
- Humans
- Infant
- Infant Mortality/trends
- Infant, Low Birth Weight
- Infant, Newborn
- Infectious Disease Transmission, Vertical/prevention & control
- Infectious Disease Transmission, Vertical/statistics & numerical data
- Point-of-Care Testing/economics
- Pregnancy
- Pregnancy Complications, Infectious/diagnosis
- Pregnancy Complications, Infectious/economics
- Pregnancy Complications, Infectious/prevention & control
- Prenatal Diagnosis/economics
- Prenatal Diagnosis/methods
- Stillbirth
- Syphilis/diagnosis
- Syphilis/economics
- Syphilis/prevention & control
- Syphilis Serodiagnosis/economics
- Syphilis Serodiagnosis/methods
- Treponema pallidum/immunology
- Treponema pallidum/pathogenicity
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Affiliation(s)
- Dana Brandenburger
- Faculty of Health, Medicine & Life Sciences, University of Maastricht, Maastricht, The Netherlands
| | - Elena Ambrosino
- Department of Genetics and Cell Biology, Research School GROW (School for Oncology & Development), Institute for Public Health Genomics (IPHG), Faculty of Health, Medicine & Life Sciences, University of Maastricht, Maastricht, The Netherlands
- * E-mail:
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Buckingham P, Moulton JE, Subasinghe AK, Amos N, Mazza D. Acceptability of immediate postpartum and post-abortion long-acting reversible contraception provision to adolescents: A systematic review. Acta Obstet Gynecol Scand 2021; 100:629-640. [PMID: 33608901 DOI: 10.1111/aogs.14129] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 02/15/2021] [Accepted: 02/17/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Long-acting reversible contraception (LARC) methods are safe for adolescents and provide the greatest assurance against rapid repeated pregnancy when inserted during the immediate postpartum (IPP) and immediate post-abortion (IPA) period. Despite increasing enthusiasm for IPP/IPA LARC insertion, adolescents' preferences and experiences have seldom been examined. The objective of this review was to examine the attitudes of adolescents (aged 10-19 years) towards IPP/IPA LARC, their experiences and perceptions around having an LARC device fitted IPP/IPA and the factors involved in decision-making to use, not use or discontinue IPP/IPA LARC. MATERIAL AND METHODS In January 2021, we searched seven bibliographic databases for original research articles published in English, from the year 2000. Studies of any design focused on IPP/IPA LARC were eligible for inclusion. Three of the authors assessed articles for eligibility and extracted data relevant to the outcomes of the review. Joanna Briggs Institute Critical Appraisal Tools were used to assess methodological quality. Key themes emerging from the data were synthesized and reported narratively. RESULTS We identified 10 relevant articles, four of which were entirely adolescent-focused. Only three addressed IPA LARC. IPP availability was important for ensuring access to LARC postpartum. Attitudes towards LARC IPP were associated with adolescents' sociodemographic characteristics and positive perceptions related to the long duration of action. Determinants of discontinuation and nonuse included poor-quality contraceptive counseling, intolerable side effects and subsequent distress, misconceptions about LARC safety IPP and the influence of partners and community on autonomy. No factors involved in IPA LARC decision-making were available. Limited evidence demonstrated that adolescents may favor contraceptive implants over intrauterine devices, and in certain contexts may face greater barriers to IPA LARC access than adult women do. CONCLUSIONS Immediate insertion of LARC postpartum appears acceptable to adolescents who do not experience side effects and those with the opportunity to make autonomous contraception decisions. This important topic has been addressed in few studies involving an entirely adolescent population. Very limited evidence is available on IPA LARC. Further research on adolescents' lived experiences of IPP/IPA LARC access and use is necessary to inform the provision of person-centered care when assisting adolescents' contraceptive choice following pregnancy.
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Affiliation(s)
- Pip Buckingham
- National Health and Medical Research Council SPHERE Centre of Research Excellence in Sexual and Reproductive Health for Women in Primary Care, Monash University, Notting Hill, Victoria, Australia.,Department of General Practice, Monash University, Notting Hill, Victoria, Australia
| | - Jessica E Moulton
- National Health and Medical Research Council SPHERE Centre of Research Excellence in Sexual and Reproductive Health for Women in Primary Care, Monash University, Notting Hill, Victoria, Australia.,Department of General Practice, Monash University, Notting Hill, Victoria, Australia
| | - Asvini K Subasinghe
- National Health and Medical Research Council SPHERE Centre of Research Excellence in Sexual and Reproductive Health for Women in Primary Care, Monash University, Notting Hill, Victoria, Australia.,Department of General Practice, Monash University, Notting Hill, Victoria, Australia
| | - Natalie Amos
- National Health and Medical Research Council SPHERE Centre of Research Excellence in Sexual and Reproductive Health for Women in Primary Care, Monash University, Notting Hill, Victoria, Australia.,Department of General Practice, Monash University, Notting Hill, Victoria, Australia
| | - Danielle Mazza
- National Health and Medical Research Council SPHERE Centre of Research Excellence in Sexual and Reproductive Health for Women in Primary Care, Monash University, Notting Hill, Victoria, Australia.,Department of General Practice, Monash University, Notting Hill, Victoria, Australia
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Chen L, Wang Q, Li D, Chen C, Li Q, Kang P. Meta-analysis of retrospective studies suggests that the pre-operative opioid use is associated with an increased risk of adverse outcomes in total hip and or knee arthroplasty. INTERNATIONAL ORTHOPAEDICS 2021; 45:1923-1932. [PMID: 33594465 DOI: 10.1007/s00264-021-04968-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 02/02/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Opioid use is prevalent in the general population. This systematic review and meta-analysis sought to evaluate whether it affects patient-reported outcomes (PROs) following total hip or knee arthroplasty. METHODS The following databases were systematically searched on February 5, 2020: Medline, Embase (Ovid), Cochrane Library, and Web of Science. Studies were included if they compared patients who received opioids or not before total hip or knee arthroplasty. Outcomes of interest were rates of post-operative revision, peri-prosthetic infection, and readmission. RESULTS Ten retrospective studies were included for review. Pre-operative opioid use was identified as a risk factor for post-operative revision [odds ratio (OR) 1.58, 95% confidence interval (CI) 1.15-1.73, p<0.01], peri-prosthetic infection (OR 1.36, 95% CI 1.08-1.71, p=0.01), and readmission (OR 1.41, 95% CI 1.20-1.75, p<0.01). CONCLUSION The available evidence indicates that pre-operative opioid use increases the risk of adverse outcomes following total hip or knee arthroplasty. Orthopedic physicians should consider these risks when treating their patients.
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Affiliation(s)
- Liyile Chen
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Qiuru Wang
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Donghai Li
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Changjun Chen
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Qianhao Li
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Pengde Kang
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, People's Republic of China.
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Effects of Mind-Body Exercise on Brain Structure and Function: A Systematic Review on MRI Studies. Brain Sci 2021; 11:brainsci11020205. [PMID: 33562412 PMCID: PMC7915202 DOI: 10.3390/brainsci11020205] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/26/2021] [Accepted: 02/04/2021] [Indexed: 02/06/2023] Open
Abstract
Mind–body exercise has been proposed to confer both physical and mental health benefits. However, there is no clear consensus on the neural mechanisms underlying the improvements in health. Herein, we conducted a systematic review to reveal which brain region or network is regulated by mind–body exercise. PubMed, Web of Science, PsycINFO, SPORTDiscus, and China National Knowledge Infrastructure databases were systematically searched to identify cross-sectional and intervention studies using magnetic resonance imaging (MRI) to explore the effect of mind–body exercise on brain structure and function, from their inception to June 2020. The risk of bias for cross-sectional studies was assessed using the Joanna Briggs Institute (JBI) checklist, whereas that of interventional studies was analyzed using the Physiotherapy Evidence Database (PEDro) scale. A total of 15 studies met the inclusion criteria. Our analysis revealed that mind–body exercise modulated brain structure, brain neural activity, and functional connectivity, mainly in the prefrontal cortex, hippocampus/medial temporal lobe, lateral temporal lobe, insula, and the cingulate cortex, as well as the cognitive control and default mode networks, which might underlie the beneficial effects of such exercises on health. However, due to the heterogeneity of included studies, more randomized controlled trials with rigorous designs, similar measured outcomes, and whole-brain analyses are warranted.
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van Vuuren J, Thomas B, Agarwal G, MacDermott S, Kinsman L, O'Meara P, Spelten E. Reshaping healthcare delivery for elderly patients: the role of community paramedicine; a systematic review. BMC Health Serv Res 2021; 21:29. [PMID: 33407406 PMCID: PMC7789625 DOI: 10.1186/s12913-020-06037-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 12/21/2020] [Indexed: 12/19/2022] Open
Abstract
Background Healthcare systems are overloaded and changing. In response to growing demands on the healthcare systems, new models of healthcare delivery are emerging. Community paramedicine is a novel approach in which paramedics use their knowledge and skills beyond emergency health response to contribute to preventative and rehabilitative health. In our systematic review, we aimed to identify evidence of the community paramedicine role in care delivery for elderly patients, with an additional focus on palliative care, and the possible impact of this role on the wider healthcare system. Methods A systematic review of peer-reviewed literature from MEDLINE, Embase, CINAHL, and Web of Sciences was undertaken to identify relevant full-text articles in English published until October 3, 2019. Additional inclusion criteria were studies focussing on extended care paramedics or community paramedics caring for elderly patients. Case studies were excluded. All papers were screened by at least two authors and underwent a quality assessment, using the Joanna Briggs Institute appraisal checklists for cross sectional, qualitative, cohort, and randomised controlled trial studies to assess the methodological quality of the articles. A process of narrative synthesis was used to summarise the data. Results Ten studies, across 13 articles, provided clear evidence that Community Paramedic programs had a positive impact on the health of patients and on the wider healthcare system. The role of a Community Paramedic was often a combination of four aspects: assessment, referral, education and communication. Limited evidence was available on the involvement of Community Paramedics in palliative and end-of-life care and in care delivery in residential aged care facilities. Observed challenges were a lack of additional training, and the need for proper integration and understanding of their role in the healthcare system. Conclusions The use of community paramedics in care delivery could be beneficial to both patients’ health and the wider healthcare system. They already play a promising role in improving the care of our elderly population. With consistent adherence to the training curriculum and effective integration within the wider healthcare system, community paramedics have the potential to take on specialised roles in residential aged care facilities and palliative and end-of-life care. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-020-06037-0.
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Affiliation(s)
- Julia van Vuuren
- Department of Community Health, Rural Health School, La Trobe University, Melbourne, Australia.
| | - Brodie Thomas
- Department of Community Health, Rural Health School, La Trobe University, Melbourne, Australia
| | - Gina Agarwal
- Department of Family Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Sean MacDermott
- Department of Community Health, Rural Health School, La Trobe University, Melbourne, Australia
| | - Leigh Kinsman
- University of Newcastle and Mid-North Coast Local Health District, Port Macquarie Base Hospital, Port Macquarie, Australia
| | - Peter O'Meara
- Department of Paramedicine, Monash University, Peninsula Campus, Melbourne, Australia
| | - Evelien Spelten
- Department of Community Health, Rural Health School, La Trobe University, Melbourne, Australia
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112
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Gould D, Dowsey MM, Spelman T, Jo O, Kabir W, Trieu J, Bailey J, Bunzli S, Choong P. Patient-Related Risk Factors for Unplanned 30-Day Hospital Readmission Following Primary and Revision Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:E134. [PMID: 33401763 PMCID: PMC7795505 DOI: 10.3390/jcm10010134] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/27/2020] [Accepted: 12/28/2020] [Indexed: 01/10/2023] Open
Abstract
Total knee arthroplasty (TKA) is a highly effective procedure for advanced osteoarthritis of the knee. Thirty-day hospital readmission is an adverse outcome related to complications, which can be mitigated by identifying associated risk factors. We aimed to identify patient-related characteristics associated with unplanned 30-day readmission following TKA, and to determine the effect size of the association between these risk factors and unplanned 30-day readmission. We searched MEDLINE and EMBASE from inception to 8 September 2020 for English language articles. Reference lists of included articles were searched for additional literature. Patients of interest were TKA recipients (primary and revision) compared for 30-day readmission to any institution, due to any cause, based on patient risk factors; case series were excluded. Two reviewers independently extracted data and carried out critical appraisal. In-hospital complications during the index admission were the strongest risk factors for 30-day readmission in both primary and revision TKA patients, suggesting discharge planning to include closer post-discharge monitoring to prevent avoidable readmission may be warranted. Further research could determine whether closer monitoring post-discharge would prevent unplanned but avoidable readmissions. Increased comorbidity burden correlated with increased risk, as did specific comorbidities. Body mass index was not strongly correlated with readmission risk. Demographic risk factors included low socioeconomic status, but the impact of age on readmission risk was less clear. These risk factors can also be included in predictive models for 30-day readmission in TKA patients to identify high-risk patients as part of risk reduction programs.
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Affiliation(s)
- Daniel Gould
- Department of Surgery, University of Melbourne, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia; (M.M.D.); (T.S.); (O.J.); (W.K.); (J.T.); (S.B.); (P.C.)
| | - Michelle M Dowsey
- Department of Surgery, University of Melbourne, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia; (M.M.D.); (T.S.); (O.J.); (W.K.); (J.T.); (S.B.); (P.C.)
- Department of Othopaedics, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia
| | - Tim Spelman
- Department of Surgery, University of Melbourne, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia; (M.M.D.); (T.S.); (O.J.); (W.K.); (J.T.); (S.B.); (P.C.)
| | - Olivia Jo
- Department of Surgery, University of Melbourne, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia; (M.M.D.); (T.S.); (O.J.); (W.K.); (J.T.); (S.B.); (P.C.)
| | - Wassif Kabir
- Department of Surgery, University of Melbourne, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia; (M.M.D.); (T.S.); (O.J.); (W.K.); (J.T.); (S.B.); (P.C.)
| | - Jason Trieu
- Department of Surgery, University of Melbourne, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia; (M.M.D.); (T.S.); (O.J.); (W.K.); (J.T.); (S.B.); (P.C.)
| | - James Bailey
- School of Computing and Information Systems, University of Melbourne, 3052 Melbourne, Australia;
| | - Samantha Bunzli
- Department of Surgery, University of Melbourne, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia; (M.M.D.); (T.S.); (O.J.); (W.K.); (J.T.); (S.B.); (P.C.)
| | - Peter Choong
- Department of Surgery, University of Melbourne, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia; (M.M.D.); (T.S.); (O.J.); (W.K.); (J.T.); (S.B.); (P.C.)
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Preoperative Analgesia, Complications, and Resource Utilization After Total Hip Arthroplasty: Tramadol Is Associated With Less Risk Than Other Preoperative Opioid Medications. J Arthroplasty 2021; 36:180-186. [PMID: 32788062 DOI: 10.1016/j.arth.2020.07.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/05/2020] [Accepted: 07/14/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Preoperative opioid use is known to be detrimental to outcomes after total hip arthroplasty (THA). This is concerning as multiple societies recommend tramadol for the management of arthritis. The purpose of this study was to determine if tramadol is associated with postoperative complications, increased resource utilization, and revision when compared with patients receiving nontramadol opioids (NTOs) and those who are opioid naive (ON). METHODS This is a retrospective cohort study using the Truven MarketScan databases (Truven Health, Ann Arbor, MI). Adult patients undergoing primary THA were identified and divided into 4 cohorts based on preoperative opioid medications (ie, ON, tramadol-only [TO], or NTOs; ±tramadol). Demographics, comorbidities, and 90-day complications were collected and compared between cohorts. Revision rates were compared at 3 years. Univariate and multivariate analyses were performed. Finally, preoperative prescription patterns were trended during the study period. RESULTS About 198,357 patients, including 18,694 TO and 106,768 ON, were identified. Compared with ON, TO patients had similar rates of complications and revision surgery (P > .05) but had slightly higher emergency department visits (odds ratio [OR], 1.06; 95% confidence interval [95% CI], 1.01-1.12; P = .027), readmissions (OR, 1.16; 95% CI, 1.09-1.22; P < .001), and nonhome discharges (OR, 1.07; 95% CI, 1.02-1.12; P = .010). TO patients had significantly lower odds of incurring most examined complications, including revision surgery, when compared with NTO (P < .05). From 2009 to 2018, the proportion of patients prescribed preoperative opioids decreased. CONCLUSION Preoperative TO is associated with less postoperative risk than NTO use and is similar to opioid naivety. Fortunately, the number of patients receiving preoperative NTOs appears to be decreasing. Our results support tramadol as an appropriate pre-THA analgesic.
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Wilson JM, Schwartz AM, Farley KX, Erens GA, Bradbury TL, Guild GN. The impact of preoperative tramadol-only use on outcomes following total knee arthroplasty - Is tramadol different than traditional opioids? Knee 2021; 28:131-138. [PMID: 33359945 DOI: 10.1016/j.knee.2020.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 10/06/2020] [Accepted: 11/05/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Opioid use prior to total knee arthroplasty (TKA) is known to have detrimental influence on postoperative outcomes. Whether or not the same is true for tramadol is currently unclear. The aim of this study was to clarify the relationship between preoperative tramadol and postoperative complications. METHODS The Truven Marketscan® Databases were used to conduct this retrospective cohort study. Patients undergoing primary TKA were identified and divided into cohorts based on preoperative medication status (i.e. opioid naïve, tramadol-only, or non-tramadol opioids). Patient demographics, comorbidities, and 90-day outcomes were collected and compared between cohorts. Revision rates were analyzed at 1- and 3-years postoperatively. Univariate and multivariate analysis was performed. RESULTS 336,316 patients were included and 23,097 (6.9%) were preoperative tramadol-only users. Tramadol-only patients (v. opioid naïve) had increased odds of 90-day readmission (OR-1.07, 95%CI 1.02-1.12, p = 0.004), wound complication (OR-1.13, 95%CI 1.01-1.27, p = 0.34), and 3-year revision rates (OR-1.35, 95%CI 1.19-1.53, p < 0.001). However, when compared to the preoperative opioid cohorts, tramadol-only patients had decreased odds of nearly all outcomes. Over the study period, the number of patients receiving preoperative opioids decreased while the proportion of patients prescribed tramadol-only increased. CONCLUSIONS While tramadol-only use has lower risk than traditional opioids, tramadol-only use preceding TKA is associated with increased rates of readmission, wound complication and revision surgery. This is important information for prescribers who may be using tramadol to treat symptomatic knee arthrosis prior to arthroplasty referral and for thought leaders producing clinical practice guidelines. LEVEL OF EVIDENCE Level III, Prognostic.
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Affiliation(s)
- Jacob M Wilson
- Investigation Performed at Emory University, Atlanta, GA, United States.
| | - Andrew M Schwartz
- Investigation Performed at Emory University, Atlanta, GA, United States.
| | - Kevin X Farley
- Investigation Performed at Emory University, Atlanta, GA, United States.
| | - Greg A Erens
- Investigation Performed at Emory University, Atlanta, GA, United States.
| | - Thomas L Bradbury
- Investigation Performed at Emory University, Atlanta, GA, United States.
| | - George N Guild
- Investigation Performed at Emory University, Atlanta, GA, United States.
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Lee CW, Lo YT, Devi S, Seo Y, Simon A, Zborovancik K, Alsheikh MY, Lamba N, Smith TR, Mekary RA, Aglio LS. Gender Differences in Preoperative Opioid Use in Spine Surgery Patients: A Systematic Review and Meta-analysis. PAIN MEDICINE 2020; 21:3292-3300. [PMID: 32989460 DOI: 10.1093/pm/pnaa266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Opioids are frequently used in spine surgeries despite their adverse effects, including physical dependence and addiction. Gender difference is an important consideration for personalized treatment. There is no review assessing the prevalence of opioid use between men and women before spine surgeries. DESIGN We compared the prevalence of preoperative opioid use between men and women. SETTING Spine surgery. SUBJECTS Comparison between men and women. METHODS PubMed, Embase, and Cochrane were searched from inception to November 9, 2018. Clinical characteristics and prevalence of preoperative opioid use were collected. Where feasible, data were pooled from nonoverlapping studies using random-effects models. RESULTS Four studies with nonoverlapping populations were included in the meta-analysis (one prospective, three retrospective cohorts). The prevalence of preoperative opioid use was 0.64 (95% CI = 0.40-0.83). Comparing men with women, no statistically significant difference in preoperative opioid use was detected (relative risk [RR] = 0.99, 95% CI = 0.96-1.02). Surgery location (cervical, lumbar) and study duration (more than five years or five years or less) did not modify this association. All involved open spine surgery. Only one secondary analysis provided data on both pre- and postoperative opioid use stratified by gender, which showed a borderline significantly higher prevalence of postoperative use in women than men. CONCLUSIONS The prevalence of opioid use before spine surgery was similar between men and women, irrespective of surgery location or study duration. More studies characterizing the pattern of opioid use between genders are still needed.
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Affiliation(s)
- Chung-Wang Lee
- School of Pharmacy, MCPHS University, Boston, Massachusetts
| | - Yu Tung Lo
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sharmila Devi
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yookyung Seo
- School of Pharmacy, MCPHS University, Boston, Massachusetts
| | - Angela Simon
- School of Pharmacy, MCPHS University, Boston, Massachusetts
| | | | - Mona Y Alsheikh
- Clinical Pharmacy Department, School of Pharmacy, Taif University, Taif, Saudi Arabia
| | - Nayan Lamba
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Harvard Radiation Oncology Program, Boston, Massachusetts, USA
| | - Timothy R Smith
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rania A Mekary
- School of Pharmacy, MCPHS University, Boston, Massachusetts.,Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Linda S Aglio
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Juliana NCA, Suiters MJM, Al-Nasiry S, Morré SA, Peters RPH, Ambrosino E. The Association Between Vaginal Microbiota Dysbiosis, Bacterial Vaginosis, and Aerobic Vaginitis, and Adverse Pregnancy Outcomes of Women Living in Sub-Saharan Africa: A Systematic Review. Front Public Health 2020; 8:567885. [PMID: 33363078 PMCID: PMC7758254 DOI: 10.3389/fpubh.2020.567885] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023] Open
Abstract
Background: Previous studies have described the association between dysbiosis of the vaginal microbiota (VMB) and related dysbiotic conditions, such as bacterial vaginosis (BV) and aerobic vaginitis (AV), and various adverse pregnancy outcomes. There is limited overview of this association from countries in sub-Saharan Africa (SSA), which bear a disproportionally high burden of both vaginal dysbiotic conditions and adverse pregnancy outcomes. This systematic review assesses the evidence on the association between VMB dysbiosis, BV, and AV, and late adverse pregnancy outcomes in women living in SSA. Methods: The Preferred Reporting Items for Systematic Review and Meta-Analysis Statement (PRISMA) guidelines were followed. Three databases [PubMed, Embase (Ovid), and Cochrane] were used to retrieve observational and intervention studies conducted in SSA that associated VMB dysbiosis, BV, or AV and preterm birth/labor/delivery, preterm rupture of membranes (PROM), low birthweight, small for gestational age, intrauterine growth restriction, intrauterine infection, intrauterine (fetal) death, stillbirth, perinatal death, or perinatal mortality. Results: Twelve studies out of 693 search records from five SSA countries were included. One study identified a positive association between VMB dysbiosis and low birthweight. Despite considerable differences in study design and outcome reporting, studies reported an association between BV and preterm birth (7/9), low birthweight (2/6), PROM (2/4), intrauterine infections (1/1), and small for gestational age (1/1). None of the retrieved studies found an association between BV and pregnancy loss (5/5) or intrauterine growth retardation (1/1). At least two studies support the association between BV and PROM, low birthweight, and preterm birth in Nigerian pregnant women. No reports were identified investigating the association between AV and late adverse pregnancy outcomes in SSA. Conclusion: Two of the included studies from SSA support the association between BV and PROM. The remaining studies show discrepancies in supporting an association between BV and preterm birth or low birthweight. None of the studies found an association between BV and pregnancy loss. As for the role of VMB dysbiosis, BV, and AV during pregnancy among SSA women, additional research is needed. These results provide useful evidence for prevention efforts to decrease vaginal dysbiosis and its contribution to adverse pregnancy outcomes in SSA.
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Affiliation(s)
- Naomi C A Juliana
- Department of Genetics and Cell Biology, Faculty of Health, Medicine and Life Sciences, Research School GROW (School for Oncology & Developmental Biology), Institute for Public Health Genomics, Maastricht University, Maastricht, Netherlands
| | - Meghan J M Suiters
- Department of Genetics and Cell Biology, Faculty of Health, Medicine and Life Sciences, Research School GROW (School for Oncology & Developmental Biology), Institute for Public Health Genomics, Maastricht University, Maastricht, Netherlands
| | - Salwan Al-Nasiry
- Department of Obstetrics and Gynecology, GROW School of Oncology and Developmental Biology, Maastricht University Medical Center (MUMC), Maastricht, Netherlands
| | - Servaas A Morré
- Department of Genetics and Cell Biology, Faculty of Health, Medicine and Life Sciences, Research School GROW (School for Oncology & Developmental Biology), Institute for Public Health Genomics, Maastricht University, Maastricht, Netherlands.,Laboratory of Immunogenetics, Department of Medical Microbiology and Infection Control, Amsterdam UMC, Amsterdam, Netherlands
| | - Remco P H Peters
- Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa.,Department of Medical Microbiology, School for Public Health and Primary Care (CAPRHI), Maastricht University, Maastricht, Netherlands.,Research Unit, Foundation for Professional Development, East London, South Africa
| | - Elena Ambrosino
- Department of Genetics and Cell Biology, Faculty of Health, Medicine and Life Sciences, Research School GROW (School for Oncology & Developmental Biology), Institute for Public Health Genomics, Maastricht University, Maastricht, Netherlands
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Triantafyllopoulos GK, Fiasconaro M, Wilson LA, Liu J, Poeran J, Memtsoudis SG, Poultsides LA. Bilateral Total Knee Arthroplasty and In-Hospital Opioid Dispension: A Population-Based Study. J Arthroplasty 2020; 35:3581-3586. [PMID: 32665155 DOI: 10.1016/j.arth.2020.06.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 06/11/2020] [Accepted: 06/15/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND There is paucity of data regarding opioid dispension in patients undergoing bilateral total knee arthroplasty (BTKA). Our aim is to compare in-hospital opioid dispension between BTKA and unilateral TKA (UTKA) and to identify other factors associated with opioid dispension in the BTKA and UTKA cohorts. METHODS Patients receiving elective TKA from 2006 to 2016 were retrospectively extracted from the Premier Healthcare Database. The effect of interest was bilateral TKA. Our primary outcome was in-hospital opioid dispension in oral morphine equivalents. Univariable statistics between study variables and TKA type were obtained. A multilevel logistic regression model was run for the outcome of high opioid dispension. RESULTS A total of 1,029,120 patients were included. Among these, 14,469 (1.4%) underwent a BTKA. Within the 10-year period studied, there was a decrease in opioid dispension in both groups. Logistic regression analysis showed that patients treated with BTKA had 1.68 times higher odds for high opioid dispension compared to UTKA patients (odds ratio = 1.68; 95.5% confidence interval = 1.62, 1.75; P < .0001). White race, longer length of stay, Charlson/Deyo index, type of insurance, rural location, general anesthesia, peripheral nerve block use, and patient-controlled analgesia were also associated with high opioid dispension. Conversely, a more recent year of surgery, female gender, older age, and administration of nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors were associated with lower odds for high opioid dispension. CONCLUSION BTKA patients have increased odds for higher in-hospital opioid dispension compared to UTKA recipients. Utilization and prescribing habits should be examined to determine the optimal approach to opioid prescription in BTKA patients compared to UTKA.
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Affiliation(s)
- Georgios K Triantafyllopoulos
- Department of Orthopaedic Surgery, Division of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY
| | - Megan Fiasconaro
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY
| | - Lauren A Wilson
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY
| | - Jashvant Poeran
- Departments of Orthopedics and Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY
| | - Lazaros A Poultsides
- Academic Orthopaedic Department, Papageorgiou General Hospital, Aristotle University Medical School, Thessaloniki, Greece; Centre of Orthopaedics and Regenerative Medicine (C.O.RE.), Centre of Interdisciplinary Research and Innovation (C.I.R.I.), Aristotle University, Thessaloniki, Greece
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Sreerama D, Surana M, Moolchandani K, Chaturvedula L, Keepanasseril A, Keepanasseril A, Pillai AA, Nair NS. Percutaneous balloon mitral valvotomy during pregnancy: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2020; 100:666-675. [PMID: 33070306 DOI: 10.1111/aogs.14029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 10/08/2020] [Accepted: 10/13/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The objective of this study was to systematically review the maternal and fetal outcomes in pregnant women who underwent percutaneous balloon mitral valvuloplasty (PBMV) during pregnancy. MATERIAL AND METHODS A search was conducted on MEDLINE and Embase databases to identify studies published between 2000 and 2018 that reported on maternal and fetal outcomes following PBMV performed in pregnancy. Randomized controlled trials, cohort studies, case-control studies, cross-sectional studies and case series with four or more pregnancies in which PBMV was performed during pregnancy were included. Reference lists from relevant articles were also hand-searched for relevant citations. A successful procedure was defined as one where there was a reported improvement in the valve area or reduction in the mitral valve gradient. A random effects model was used to derive pooled estimates of various outcomes and the final estimates were reported as percentages with a 95% confidence interval (95% CI). RESULTS Twenty-one observational studies reporting 745 pregnancies were included in the review, all of them having reported outcomes without a comparison group. Most of the studies fell into the low-risk category as determined using the Joanna Briggs Institute (JBI) critical appraisal checklist for case series. Most of the studies (86%) were reported from low- to middle-income countries and PBMV was mostly performed during the second trimester of pregnancy. Forty-three procedures (5.7%) were unsuccessful, nearly half (n = 19) of them reported among women with the severe subvalve disease (Wilkins subvalve score 3 or more). There were 11 maternal deaths among those with suboptimal valve anatomy (severe subvalve disease or Wilkin score >8). Mitral regurgitation was the most common cardiac complication (12.7%; 95% CI 7.3%-19.1%), followed by restenosis (2.4%; 95% CI 0.02%-7.2%). Pooled incidence of cesarean section was 12.1% (95% CI 3.6%-23.8%), preterm delivery 3.9% (95% CI 0.6%-9.0%), stillbirth 0.9% (95%CI 0.2%-2.2%) and low birthweight 5.4% (95% CI 0.2%-14.7%). CONCLUSIONS PBMV may be an effective and safe procedure for optimizing outcomes in pregnant women with mitral stenosis in the absence of severe subvalve disease.
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Affiliation(s)
- Damini Sreerama
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
| | - Mahak Surana
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
| | - Kailash Moolchandani
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
| | - Latha Chaturvedula
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
| | - Arun Keepanasseril
- School of Dentistry, Amrita Institute of Medical Sciences, Kochi, India.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Anish Keepanasseril
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
| | - Ajith A Pillai
- Department of Cardiology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
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Werner BC, Kew ME, Brockmeier SF, Gowd AK, Romeo AA, Agarwalla A. Postoperative opioid usage is greater following hemiarthroplasty compared to reverse total shoulder arthroplasty for proximal humerus fractures. SEMINARS IN ARTHROPLASTY: JSES 2020. [DOI: 10.1053/j.sart.2020.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Hannon CP, Fillingham YA, Nam D, Courtney PM, Curtin BM, Vigdorchik J, Mullen K, Casambre F, Riley C, Hamilton WG, Della Valle CJ. The Efficacy and Safety of Opioids in Total Joint Arthroplasty: Systematic Review and Direct Meta-Analysis. J Arthroplasty 2020; 35:2759-2771.e13. [PMID: 32571589 DOI: 10.1016/j.arth.2020.05.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/18/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Opioids are frequently used to treat pain after total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of opioids in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management. METHODS The MEDLINE, EMBASE, and Cochrane Central Register of controlled trials were searched for studies published before November 2018 on opioids in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of opioids. RESULTS Preoperative opioid use leads to increased opioid consumption and complications after TJA along with a higher risk of chronic opioid use and inferior patient-reported outcomes. Scheduled opioids administered preemptively, intraoperatively, or postoperatively reduce the need for additional opioids for breakthrough pain. Prescribing fewer opioid pills after discharge is associated with equivalent functional outcomes and decreased opioid consumption. Tramadol reduces postoperative opioid consumption but increases the risk of postoperative nausea, vomiting, dry mouth, and dizziness. CONCLUSION Moderate evidence supports the use of opioids in TJA to reduce postoperative pain and opioid consumption. Opioids should be used cautiously as they may increase the risk of complications, such as respiratory depression and sedation, especially if combined with other central nervous system depressants or used in the elderly.
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Affiliation(s)
- Charles P Hannon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Yale A Fillingham
- Department of Orthopaedic Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Denis Nam
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - P Maxwell Courtney
- Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | | | - Jonathan Vigdorchik
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Kyle Mullen
- Department of Research, Quality, and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Francisco Casambre
- Department of Research, Quality, and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Connor Riley
- Department of Research, Quality, and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | | | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Rhon DI, Snodgrass SJ, Cleland JA, Cook CE. The Risk of Prior Opioid Exposure on Future Opioid Use and Comorbidities in Individuals With Non-Acute Musculoskeletal Knee Pain. J Prim Care Community Health 2020; 11:2150132720957438. [PMID: 32909510 PMCID: PMC7493235 DOI: 10.1177/2150132720957438] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objectives Due to their potentially deleterious effects, minimizing the use of opioids for musculoskeletal pain is a priority for healthcare systems. The objective of this study was to examine the risk of future opioid prescription use based on prior opioid use within a non-surgical cohort with musculoskeletal knee pain. We also examined the risk of pre-existing comorbidities on future opioid use, and the risk of prior opioid use on future comorbidities (sleep, mental health, cardiometabolic disorders). Methods Data came from the Military Health System Data Repository for 80 290 consecutive beneficiaries with an initial episode of care for patellofemoral pain from January 1, 2010 through December 31, 2011. Risk was calculated using 2 × 2 tables based on pre- and post-opioid utilization and comorbid diagnosis. Risk ratios, relative and absolute risk increases, and numbers needed to harm were calculated, all with 95% confidence intervals. Results Prior opioid use resulted in a risk ratio of 18.0 (95 CI 17.1, 19.0) and an absolute risk increase of 61.6% for future opioid use (numbers needed to harm = 2). The presence of all comorbidities (except cardiometabolic syndrome) were associated with a significant relative risk for future opioid use (RR range 1.2-1.5), but the absolute risk increase was trivial (range 0.7%-2.2%). The relative risk for a chronic pain diagnosis, traumatic brain injury/concussion, insomnia, depression, and PTSD were all significantly higher in those with prior opioid use (1.3-1.6), but absolute risk increase was minimal (1.1%-6.5%). Discussion Prior opioid use was a strong risk factor for future opioid use in non-surgical patients with knee pain. These findings show that history of prior opioid use is important when assessing the risk of future opioid use, whereas prior comorbidities may not be as important. Opioid history assessment should be standard practice for all patients with patellofemoral pain in whom an opioid prescription is considered.
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Affiliation(s)
- Daniel I Rhon
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,University of Newcastle, Callaghan, NSW, Australia
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Non-Orthopedic Encounters Increase Opioid Exposure in Joint Osteoarthritis: A Single-Institution Analysis. J Arthroplasty 2020; 35:2386-2391. [PMID: 32444234 DOI: 10.1016/j.arth.2020.04.076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 04/16/2020] [Accepted: 04/21/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND There has been little-to-no evidence to support the use of opioid analgesia as a treatment modality for osteoarthritis (OA). Chronic opioid use has been associated with peri-operative and post-operative complications with joint reconstruction. The purpose of this study is to compare opioid-prescribing habits for OA between orthopedic and non-orthopedic physicians to identify encounters that increase opioid exposure. METHODS A retrospective chart review was performed on opioid-naive adult patients with outpatient opioid prescriptions for OA at a single academic institution between 2013 and 2018. Patients with prior surgery or opioid prescriptions were excluded. Independent t-tests and analysis of variance were used to compare prescription characteristics among providers. RESULTS A total of 9625 opioid prescriptions were identified. Non-orthopedic providers account for 92% of prescriptions vs 8% by orthopedic surgeons. The greatest number of prescriptions is written by Internal Medicine (37.1%) and Family Medicine physicians (36.0%). Non-orthopedic physicians prescribe a greater number of prescriptions per patient, dosages, and refills (P < .001 for all). Non-orthopedic encounters are associated with increased risk for prescription dosages ≥50 MME/d (odds ratio 5.81, 95% confidence interval 4.35-7.81, P < .001) and 90 MME/d (odds ratio 18.2, 95% confidence interval 4.43-35.70, P < .001). CONCLUSION The majority of opioid prescriptions for OA are written by non-orthopedic providers, with higher prescription rates, dosages, and more refills than orthopedic surgeons. OA is a common condition that will benefit from multi-disciplinary awareness to minimize unnecessary opioid exposure and reduce potential complications with joint arthroplasty.
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The influence of prior opioid use on healthcare utilization and recurrence rates for non-surgical patients seeking initial care for patellofemoral pain. Clin Rheumatol 2020; 40:1047-1054. [PMID: 32803567 DOI: 10.1007/s10067-020-05307-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 07/17/2020] [Accepted: 07/21/2020] [Indexed: 01/06/2023]
Abstract
INTRODUCTION/OBJECTIVES Prior opioid use can influence outcomes for patients with musculoskeletal disorders. The purpose of this study was to compare downstream medical utilization-based outcomes (costs, visits, recurrent episodes) after an initial diagnosis of patellofemoral pain based on pre-injury utilization of opioids. METHOD A total of 85,7880 consecutive patients were followed for a full 12 months before and 24 months after an initial diagnosis of patellofemoral pain (January 2009 to December 2013). Data were sourced from the Military Health System Data Repository, a single-payer closed government system. Opioid prescription fills were identified, and medical visits and costs were calculated for all knee-related medical care, to include recurrence rates in the 2-year surveillance period. RESULTS A relatively small number of individuals filled an opioid prescription in the year prior (n = 1746; 2.0%); however, these individuals had almost twice the mean costs of knee-related medical care ($1557 versus %802) and medical visits (8.4 versus 4.0). Patients with prior opioid use were more likely to have at least 1 recurrent episode of knee pain (relative risk 1.58, 95% CI 1.51, 1.65) with a higher mean number of episodes of knee pain (1.5 vs 1.8). The use of opioids with higher risk of misuse or dependency (Schedule II or III) resulted in greater medical costs (for any reason) and recurrent episodes of knee pain compared to the use of opioids in a lower risk category (Schedule IV). CONCLUSIONS Prior opioid utilization was associated with a greater number of recurrent episodes of knee pain and higher downstream medical costs compared with individuals without prior opioid use. For individuals with prior opioid utilization, opioids with higher risk of misuse or dependency (Schedule II or III) resulted in greater medical costs (for any reason) and recurrent episodes compared to the use of lower-risk opioids (Schedule IV). Key Points • Patients with prior opioid use had much greater knee-related medical costs compared to patients without prior opioid use. • Patients with prior opioid use were more likely to have additional episodes of knee pain in the following 2 years compared to patients without prior opioid use. • Prior opioid use has predicted higher costs and poor outcomes after surgery, but this is the first study to confirm similar findings in non-surgical patients.
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Wilson JM, Farley KX, Bradbury TL, Erens GA, Guild GN. Preoperative opioid use is a risk factor for complication and increased healthcare utilization following revision total knee arthroplasty. Knee 2020; 27:1121-1127. [PMID: 32711872 DOI: 10.1016/j.knee.2020.05.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 05/12/2020] [Accepted: 05/23/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Prior literature suggests that opioid use prior to primary arthroplasty procedures results in increased risk for complication. Despite this, it is unknown whether preoperative opioid use increases risk following revision TKA. The purpose of this study was to examine this relationship. METHODS The Truven Marketscan® database was used to conduct this retrospective cohort study. Patients undergoing revision TKA for aseptic indication were identified. Opioid prescriptions were collected for one-year preoperatively. Patients were divided into cohorts based on the number of prescriptions received preoperatively. Patients who had an "opioid holiday" (six months opioid naïve period after prior use) were also analyzed. Univariate and multivariate analysis was performed to assess the relationship between preoperative opioids and postoperative complications. RESULTS In the year preceding surgery, 84% of patients received an opioid prescription. Compared to opioid naïve patients, continuous preoperative use was associated with higher odds of every examined complication (p ≤ .008). This included PJI (OR 1.77, 95% CI 1.34-2.35, p < .001), VTE (OR 1.56, 95% CI 1.26-1.93, p < .001), opioid overdose (OR 5.03, 95% CI 1.64-15.42, p = .005), and revision surgery (OR 1.80, 95%CI 1.50-2.16, p < .001). Similarly, health care utilization was higher in this group including the following: extended length of stay, non-home discharge, 90-day readmission, and emergency room visits (p ≤ .01). The opioid holiday appeared to confer risk reduction. CONCLUSIONS Preoperative opioid use preceding revision TKA is common and is associated with complications following surgery. An opioid holiday appears to provide risk reduction and suggests that opioid use may be a modifiable risk factor.
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Affiliation(s)
- Jacob M Wilson
- Department of Orthopaedic Surgery, 59 S Executive Park NW, Atlanta, GA 30329, United States of America.
| | - Kevin X Farley
- Department of Orthopaedic Surgery, 59 S Executive Park NW, Atlanta, GA 30329, United States of America.
| | - Thomas L Bradbury
- Department of Orthopaedic Surgery, 59 S Executive Park NW, Atlanta, GA 30329, United States of America.
| | - Greg A Erens
- Department of Orthopaedic Surgery, 59 S Executive Park NW, Atlanta, GA 30329, United States of America.
| | - George N Guild
- Department of Orthopaedic Surgery, 59 S Executive Park NW, Atlanta, GA 30329, United States of America.
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Sodhi N, Anis HK, Acuña AJ, Vakharia RM, Gold PA, Garbarino LJ, Mahmood BM, Ehiorobo JO, Grossman EL, Higuera CA, Roche MW, Mont MA. Opioid Use Disorder Is Associated with an Increased Risk of Infection after Total Joint Arthroplasty: A Large Database Study. Clin Orthop Relat Res 2020; 478:1752-1759. [PMID: 32662956 PMCID: PMC7371033 DOI: 10.1097/corr.0000000000001390] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 06/09/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recent studies have shown that patients with opioid use disorder have impaired immunity. However, few studies with large patient populations have evaluated the risks of surgical site infection (SSI) and prosthetic joint infection (PJI) with opioid use disorder after total joint arthroplasty (TJA), and there is a lack of evidence for revision TJA in particular. QUESTIONS/PURPOSES Are patients with opioid use disorder who undergo (1) primary THA, (2) primary TKA, (3) revision THA, or (4) revision TKA at a higher risk of experiencing SSIs 90 days after surgery or PJIs 2 years after surgery than those who do not have opioid use disorder? METHODS All primary and revision TJAs performed between 2005 and 2014 were identified from the Medicare Analytical Files of the PearlDiver Supercomputer using ICD-9 codes. This database is one of the largest nationwide databases; it comprehensively and longitudinally tracks patients based on all insurance claims rather than particular hospital visits, and has a low error rate (estimated at 1.3%). Boolean command operators were used to form a study group of patients with a history of opioid use disorder before surgery. ICD-9 diagnosis codes 304.00 to 304.02 and 305.50 to 305.52 were used to identify patients with opioid use disorder. Study group patients were matched 1:1 to control participants without opioid use disorder undergoing TJA, according to age, sex, and comorbidity burden (Elixhauser comorbidity index [ECI]). The ECI is comprised of 31 different comorbidities and can be used for large administrative databases. The query yielded a study population of 54,332 patients: 14,944 undergoing primary THA (opioid use disorder: n = 7472), 23,680 undergoing primary TKA (opioid use disorder: n = 11,840), 8116 undergoing revision THA (opioid use disorder: n = 4058), and 7592 undergoing revision TKA (opioid use disorder: n = 3796). The primary outcomes analyzed were SSI at 90 days and PJI at 2 years postoperatively, which were identified with ICD-9 codes. Logistic regression analyses were performed to calculate the risk that an infection would develop in a patient with opioid use disorder compared with the matched control patients without opioid use disorder. RESULTS Patients with opioid use disorder undergoing primary THA had an increased risk of SSI at 90 days (OR 1.85 [95% CI 1.51 to 2.25]; p < 0.001) and PJI at 2 years (OR 1.66 [95% CI 1.42 to 1.93]; p < 0.001). Compared with matched controls, opioid use disorder patients undergoing primary TKA had an increased risk of SSI at 90 days (OR 1.72 [95% CI 1.46 to 2.02]; p < 0.001) and PJI at 2 years (OR 1.31 [95% CI 1.16 to 1.47]; p < 0.001). Similarly, for revision THAs, there was an increase in 90-day SSIs (OR 1.89 [95% CI 1.53 to 2.32]; p < 0.001) and 2-year PJIs (OR 4.24 [95% CI 3.67 to 4.89]; p < 0.001). The same held for revision TKAs for 90-day SSIs (OR 1.88 [95% CI 1.53 to 2.29]; p < 0.001) and 2-year PJIs (OR 4.94 [95% CI 4.24 to 5.76]; p < 0.001). CONCLUSIONS After accounting for age, sex, and comorbidity burden, these results revealed that patients with opioid use disorder undergoing TJA were at increased risk of having SSIs and PJIs. Based on these findings, healthcare systems and/or administrators should recognize the increased associated PJI and SSI risks in patients with opioid use disorder and enact clinical policies that reflect these associated risks. Additionally, these findings should encourage surgeons to pursue multidisciplinary approaches to help patients reduce their opioid consumption before their arthroplasty procedure. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Nipun Sodhi
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Lenox Hill Hospital, New York, NY, USA
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Long Island Jewish Medical Center, New York, NY, USA
| | - Hiba K Anis
- H. K. Anis, A. J. Acuña, B. M. Mahmood, C. A. Higuera, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Alexander J Acuña
- H. K. Anis, A. J. Acuña, B. M. Mahmood, C. A. Higuera, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Rushabh M Vakharia
- R. M. Vakharia, M. W. Roche, Holy Cross Hospital, Fort Lauderdale, FL, USA
| | - Peter A Gold
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Lenox Hill Hospital, New York, NY, USA
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Long Island Jewish Medical Center, New York, NY, USA
| | - Luke J Garbarino
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Lenox Hill Hospital, New York, NY, USA
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Long Island Jewish Medical Center, New York, NY, USA
| | - Bilal M Mahmood
- H. K. Anis, A. J. Acuña, B. M. Mahmood, C. A. Higuera, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Joseph O Ehiorobo
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Lenox Hill Hospital, New York, NY, USA
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Long Island Jewish Medical Center, New York, NY, USA
| | - Eric L Grossman
- E. L. Grossman, Rothman Orthopaedic Institute, New York, NY, USA
| | - Carlos A Higuera
- H. K. Anis, A. J. Acuña, B. M. Mahmood, C. A. Higuera, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Martin W Roche
- R. M. Vakharia, M. W. Roche, Holy Cross Hospital, Fort Lauderdale, FL, USA
| | - Michael A Mont
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Lenox Hill Hospital, New York, NY, USA
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Long Island Jewish Medical Center, New York, NY, USA
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Are medical comorbidities contributing to the use of opioid analgesics in patients with knee osteoarthritis? Osteoarthritis Cartilage 2020; 28:1030-1037. [PMID: 32387761 DOI: 10.1016/j.joca.2020.04.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 04/24/2020] [Accepted: 04/27/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Although opioid analgesics are not generally recommended for treatment of knee osteoarthritis (OA), they are frequently used. We sought to determine the association between medical comorbidities and self-reported opioid analgesic use in these patients. METHODS This cross-sectional study recruited patients referred to two provincial hip and knee clinics in Alberta, Canada for consideration of total knee arthroplasty. Standardized questionnaires assessed demographic (age, gender, income, education, social support, smoking status) and clinical (pain, function, total number of troublesome joints) characteristics, comorbid medical conditions, and non-surgical OA management participants had ever used or were currently using. Multivariable Poisson regression with robust estimate of the standard errors assessed the association between comorbid medical conditions and current opioid use, controlling for potential confounders. RESULTS 2,127 patients were included: mean age 65.4 (SD 9.1) years and 59.2% female. Currently used treatments for knee OA were: 57.6% exercise and/or physiotherapy, 61.1% NSAIDs, and 29.8% opioid analgesics. In multivariable regression, controlling for potential confounders, comorbid hypertension (RR 1.18, 95% CI 1.02-1.37), gastrointestinal disease (RR 1.31, 95% CI 1.07-1.60), depressed mood (RR 1.25, 95% CI 1.05-1.48) and a higher number of troublesome joints (RR 1.04 per joint, 95% CI 1.00-1.09) were associated with opioid use, with no association found with having ever used recommended non-opioid pharmacological or non-pharmacological treatments. CONCLUSIONS In a large cohort of patients with knee OA, of 12 comorbidities assessed, comorbid hypertension, gastrointestinal disease, and depressed mood were associated with current use of opioid analgesics, in addition to total burden of troublesome joints. Improved guidance on the management of painful OA in the setting of common comorbidities is warranted.
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Pedersen C, Troensegaard H, Laigaard J, Koyuncu S, Schrøder HM, Overgaard S, Mathiesen O, Karlsen APH. Differences in patient characteristics and external validity of randomized clinical trials on pain management following total hip and knee arthroplasty: a systematic review. Reg Anesth Pain Med 2020; 45:709-715. [DOI: 10.1136/rapm-2020-101459] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/24/2020] [Accepted: 05/28/2020] [Indexed: 12/24/2022]
Abstract
BackgroundThe external validity of randomized controlled trials (RCTs) is critical for the relevance of trial results in a clinical setting. We aimed to assess the external validity of RCTs investigating postoperative pain treatment after total hip and knee arthroplasty (THA and TKA) by comparing patient characteristics in these trials with a clinical cohort. Further, we assessed the use of exclusion criteria of the included RCTs.MethodsWe searched PubMed, Embase, and Cochrane Central Register of Controlled Trials for relevant RCTs up to June 2019. Data on patient characteristics from this research population were compared with an unselected clinical cohort from the Danish Hip and Knee Arthroplasty Registries in the period 2005–2019. Trends in patient characteristics and the use of exclusion criteria were assessed with control charts.ResultsIn total, 550 RCTs with 48 962 participants were included in the research cohort. The clinical cohort included 101 439 THA patients and 90 505 TKA patients. Patient characteristics (age, body mass index (BMI), American Society of Anesthesiologists (ASA) score and sex distribution) in the research cohort resembled those of the clinical cohort. Age, BMI and ASA scores did not change over time in the research cohort. In the clinical cohort, age increased among both THA and TKA patients, and BMI and ASA scores increased among TKA patients. Most commonly used exclusion criteria in the RCTs were high ASA score (62%), older age (45%), obesity (32%) and chronic opioid use (41%). Exclusion of chronic opioid users and individuals with obesity increased over time.ConclusionPatient characteristics in research trials investigating postoperative pain management after THA and TKA currently resemble those of a clinical cohort. However, individuals in the clinical cohort are getting older, and TKA patients more obese with increasing ASA scores. Concomitantly, RCTs increase the tendency to exclude patients with older age, obesity, chronic pain and/or opioid use. This trending discrepancy can hinder the generalizability of future research results, and therefore increased focus on pragmatic trials resembling real-world conditions are needed.PROSPERO registration numberCRD42019125691
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Gandhi K, Wei W, Huang A, Wang L, Iyer R, Katz NP. A Real-World Study Using Claims Data to Evaluate Possible Failure of Opioid Treatment Regimens Among Patients with Hip and/or Knee Osteoarthritis in the US. CLINICOECONOMICS AND OUTCOMES RESEARCH 2020; 12:285-297. [PMID: 32606845 PMCID: PMC7293383 DOI: 10.2147/ceor.s244329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 04/10/2020] [Indexed: 01/02/2023] Open
Abstract
Background Although opioids may be used in the management of pain in patients with osteoarthritis (OA), there is a dearth of real-world data characterizing opioid regimen failure in these patients. Objective Using claims data, this study explored measures that may be potentially indicative of opioid treatment failure and the association of such potential failure with health care resource utilization (HRU) and costs. Patients and Methods Using a national employer-sponsored insurance claims database covering the years 2011–2016, this retrospective longitudinal study identified adults with hip/knee osteoarthritis who filled ≥1 opioid prescription (index event) and had continuous health plan enrollment 6 months pre- and ≥12 months post-index. Index opioid regimen intensity was defined in the 3-month post-index period by frequency, average daily dose, and duration of action. Possible index opioid regimen failure was defined as an increase in opioid regimen intensity, addition of a non-opioid pain medication, joint surgery, or opioid-abuse-related events. One-year follow-up HRU and costs were compared between those with possible treatment failure and those without. Results Among 271,512 OA patients (61.5% knee; 11.1% hip; 27.4% both), 34.9% met the definition of possible index opioid regimen failure within a year: increased regimen intensity (16.1%), joint surgery (14.0%), addition of non-opioid pain medication (11.4%), and opioid-abuse-related events (1.9%). Rates of possible failure generally increased with higher index regimen intensity. Compared with those who did not fail, those who potentially failed their index treatment regimen had significantly higher HRU (P<0.001), and all-cause ($36,699 vs $15,114) and osteoarthritis-related costs ($17,298 vs $1,967) (both P<0.0001). Conclusion Among OA patients treated with opioids, approximately one-third may fail their index opioid regimen within a year and incur significantly higher HRU and costs than those without. Further research is needed to validate these findings with clinical outcomes.
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Affiliation(s)
| | - Wenhui Wei
- Regeneron Pharmaceuticals, Tarrytown, NY, USA
| | | | - Li Wang
- STATinMED Research, Dallas, TX, USA
| | - Ravi Iyer
- Teva Pharmaceutical Industries, Frazer, PA, USA
| | - Nathaniel P Katz
- Analgesic Solutions, Wayland, MA, USA.,Tufts University School of Medicine, Boston, MA, USA
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Associations between pre-surgical daily opioid use and short-term outcomes following knee or hip arthroplasty: a prospective, exploratory cohort study. BMC Musculoskelet Disord 2020; 21:398. [PMID: 32571280 PMCID: PMC7310486 DOI: 10.1186/s12891-020-03413-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/09/2020] [Indexed: 11/10/2022] Open
Abstract
Background Retrospective studies have found that daily opioid use pre-arthroplasty predicts worse longer-term service, clinical and patient-reported outcomes. Prospective studies are needed to confirm these observations. This prospective, exploratory study aimed to determine: the proportion of total knee or hip arthroplasty (TKA, THA) patients who use opioids regularly (daily) pre-surgery; if opioid use pre-surgery is associated with acute and sub-acute outcomes to 12-weeks post-surgery. Methods Consecutive patients undergoing primary TKA or THA were prospectively enrolled pre-surgery and followed-up by telephone to 12-weeks post-surgery. Acute-care (oral morphine equivalent dosage (OMED), length of stay, discharge to inpatient rehabilitation, complications) and 12-week outcomes (Oxford Knee or Hip Score, Euroqol ‘today’ health score, current use of opioids, and complications including readmissions) were monitored. Unadjusted and adjusted Odds Ratios (ORs) (95% Confidence Interval, CI), Rate Ratios and β coefficients (standard error) were calculated. Results Five Hundred Twenty-One patients were included (TKA n = 381). 15.7% (95%CI 12.6 to 18.9) used opioids regularly pre-surgery. 86.8% (452/521) were available for follow-up at 12-weeks. In unadjusted analyses, pre-surgical opioid use was significantly associated with higher average acute daily OMED [β 0.40 (0.07), p < 0.001], presence of an acute complication [OR 1.75 (1.02 to 3.00)], and ongoing use of opioids at 12-weeks [OR 5.06 (2.86 to 8.93)]. After adjusting for covariates, opioid use pre-surgery remained significantly associated with average acute daily OMED [β 0.40 (0.07), p < 0.001] and ongoing use at 12-weeks [OR 5.38 (2.89 to 9.99)]. Conclusion People who take daily opioids pre-surgery have significantly greater odds for greater opioid consumption acutely and ongoing use post-surgery. Adequately powered prospective studies are required to confirm whether pre-surgical opioid use is or is not associated with poorer joint and quality of life scores or a complication in the short-term.
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Shadbolt C, Gould D, Camacho X, Knight J, Rele S, Thuraisingam S, Zhang Y, Dowsey MM, Choong PF. Preoperative opioid use and complications following total joint replacement: a protocol for a systematic review and meta-analysis. BMJ Open 2020; 10:e035377. [PMID: 32554741 PMCID: PMC7304809 DOI: 10.1136/bmjopen-2019-035377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 04/03/2020] [Accepted: 05/06/2020] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Mounting evidence now indicates that preoperative opioid use is associated with an array of complications following total joint replacement (TJR). However, evidence of these risks remains fragmented. A comprehensive and well-integrated understanding of this body of evidence is necessary to appropriately inform treatment decisions, the allocation of limited healthcare resources, and the direction of future clinical research. The proposed systematic review and meta-analysis aims to identify and synthesise the available evidence of an association between opioid use prior to TJR and postoperative complications, categorised by complication type. METHODS AND ANALYSIS We will search MEDLINE, EMBASE, CINAHL, PsycINFO, and Web of Science from inception to April 2020. Observational and experimental studies that compare preoperative opioid users who have undergone elective TJR to opioid naïve TJR patients will be included. The primary outcomes will be postoperative complications, which will be categorised as either mortality, morbidity, or joint-related complications. The secondary outcomes will be persistent postoperative opioid use, readmission, and length of stay. Individual study quality will be assessed using the relevant NIH-NHLBI study quality assessment tools. Findings will be reported in narrative and tabular form, and, where possible, odds ratios (dichotomous outcomes) or standardised mean differences (continuous outcomes) will be reported with 95% confidence intervals. Where appropriate, random effect meta-analyses will be conducted for each outcome, and heterogeneity will be quantified using the I2 statistic and Cochran's Q test. This study will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analyses Of Observational Studies in Epidemiology (MOOSE) guidelines. ETHICS AND DISSEMINATION Ethics approval will not be required as no primary or private data are being collected. Findings will be disseminated through peer-reviewed publication and presentation at academic conferences. PROSPERO REGISTRATION NUMBER CRD42020153047.
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Affiliation(s)
- Cade Shadbolt
- Department of Surgery, The University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Daniel Gould
- Department of Surgery, The University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Ximena Camacho
- Centre for Digital Transformation of Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Josh Knight
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Siddharth Rele
- Department of Surgery, The University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia
- Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Sharmala Thuraisingam
- Department of Surgery, The University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
| | - Yuting Zhang
- Melbourne Institute: Applied Economic & Social Research, Faculty of Business & Economics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Michelle M Dowsey
- Department of Surgery, The University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia
- Department of Orthopaedics, St Vincent's Hospital, Melbourne, Fitzroy, Victoria, Australia
| | - Peter Fm Choong
- Department of Surgery, The University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia
- Department of Orthopaedics, St Vincent's Hospital, Melbourne, Fitzroy, Victoria, Australia
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132
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Sodhi N, Anis HK, Acuña AJ, Vakharia RM, Piuzzi NS, Higuera CA, Roche MW, Mont MA. The Effects of Opioid Use on Thromboembolic Complications, Readmission Rates, and 90-Day Episode of Care Costs After Total Hip Arthroplasty. J Arthroplasty 2020; 35:S237-S240. [PMID: 32197965 DOI: 10.1016/j.arth.2020.02.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 02/04/2020] [Accepted: 02/07/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study was to investigate whether opioid use disorder (OUD) patients are at greater odds than non-opioid use disorder (NUD) patients in developing (1) thromboembolic complications; (2) readmission rates; and (3) costs of care. METHODS All patients with a 90-day history of OUD before total hip arthroplasty (THA) were identified from a national database. Patients were matched 1:5 to controls by age, gender, Elixhauser Comorbidity Index scores, and high-risk medical comorbidities, yielding 38,821 patients with (n = 6398) and without (n = 31,883) OUD. Multivariate logistic regression analyses were performed to compare the risks of developing venous thromboembolism (deep vein thrombosis and/or pulmonary embolism) 90 days after the index procedure, 90-day readmission rates, and total global 90-day episode of care costs. RESULTS Patients with a history of OUD were found to be at greater risk for 90-day venous thromboembolisms (2.38 vs. 1.07%; OR: 2.25, 95% CI: 1.86-2.73, P < .0001) compared with matched NUD patients. Specifically, OUD patients were at greater risk for both deep vein thromboses (2.13 vs. 0.87%; OR: 2.46, 95% CI: 2.00-3.03, P < .001) and pulmonary embolism (0.61 vs. 0.27%; OR: 2.24, 95% CI: 1.53-3.27, P < .0001). In addition, patients with OUD were at an increased risk for 90-day readmission (28.68 vs. 22.62%; OR: 1.37, 95% CI: 1.29-1.46, P < .0001) compared with controls. Primary THA patients with OUD incurred a 14.72% higher cost of care ($20,610.65 vs. $17,964.58) compared with NUD patients. CONCLUSION These findings demonstrate that primary THA patients with a history of OUD are at greater risks for thromboembolic complications, readmissions, and higher costs of care in the 90-day postoperative period.
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Affiliation(s)
- Nipun Sodhi
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center, Northwell Health, New York, NY
| | - Hiba K Anis
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | | | - Rushabh M Vakharia
- Department of Orthopaedic Surgery, Holy Cross Hospital, Ft. Lauderdale, FL
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | | | - Martin W Roche
- Department of Orthopaedic Surgery, Holy Cross Hospital, Ft. Lauderdale, FL
| | - Michael A Mont
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
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133
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Schommer J, Allen S, Scholz N, Reams M, Bohn D. Evaluation of Quality Improvement Methods for Altering Opioid Prescribing Behavior in Hand Surgery. J Bone Joint Surg Am 2020; 102:804-810. [PMID: 32379121 DOI: 10.2106/jbjs.19.01052] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The opioid epidemic in the United States continues to be problematic as morbidity and mortality rates increase yearly. Orthopaedic surgeons are the third highest prescribing group among physicians. Studies show that orthopaedic surgeons tend to overprescribe opioids, but published data on patient opioid utilization, pain management satisfaction, and national clinical practice guidelines on opioid prescribing are scarce or lacking. Furthermore, little information is available on influences on physician prescribing behavior and whether changes in prescribing habits are lasting. METHODS Using recently published opioid utilization and prescribing guidelines for hand surgery, we created an opioid prescribing quality improvement program with the aim of reducing postoperative opioid prescribing without negatively impacting patient pain satisfaction. The main aspect of the program was the implementation and modification of an opioid prescribing order set, but the program also included surgeon education-executed in 2 intervention steps-about how their prescribing behavior compared with that of their peers. Three phases of data representing 3 months each were collected prior to, between, and after the interventions. RESULTS Two thousand and sixty-seven hand surgery cases were reviewed (629 in Phase 1, 655 in Phase 2, and 783 in Phase 3). The average number of morphine milligram equivalents (MMEs) was reduced from 142.0 in Phase 1 to 69.9 in Phase 2 (51% reduction) to 61.3 in Phase 3 (57% reduction compared with Phase 1). Significant reductions in MMEs occurred across the procedural categories as well as the hand surgeons. Patient pain satisfaction was similar before and after implementation of the first intervention (p = 0.96). CONCLUSIONS Quality improvement methods were effective in altering prescribing behavior by physicians in the long term, and our approach may be effective if applied more widely. Similar studies on quality improvement methods and prescribing behavior, patient opioid utilization, and patient satisfaction with pain management are needed in other orthopaedic subspecialties. CLINICAL RELEVANCE Evidence-based guidelines, a quality improvement process, and unblinded information on prescribing behavior compared with that of peers may result in long-lasting reductions in surgeons' opioid prescribing practices.
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Affiliation(s)
- Jillian Schommer
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Scott Allen
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Natalie Scholz
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Megan Reams
- TRIA Orthopaedic Center, Bloomington, Minnesota
| | - Deborah Bohn
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota
- TRIA Orthopaedic Center, Bloomington, Minnesota
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134
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Rahman TM, Fleifel D, Padela MT, Anoushiravani A, Rizvi SA, El-Othmani MM, Sayeed Z. Interventions for Obesity and Nutritional Status in Arthroplasty Patients. JBJS Rev 2020; 8:e0161. [PMID: 32224637 DOI: 10.2106/jbjs.rvw.19.00161] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Nutritional risk in patients undergoing total joint arthroplasty has been well-studied with regard to diagnostic criteria; however, therapeutic management of abnormal body mass index (BMI) values and serum markers remains to be studied in patients undergoing joint replacement surgery. Patients with a BMI value of >40 kg/m2 are at increased risk for postoperative complications; weight loss programs and bariatric surgery are therapeutic modalities that can be used in the prehabilitation and long-term rehabilitation of patients undergoing total joint arthroplasty. Management of patients with abnormal nutritional status should be multidisciplinary and allow for the incorporation of dietitians and nutritionists in therapeutic planning. Hypoalbuminemia correction can be completed intravenously or orally; however, arthroplasty studies remain lacking with regard to the preferred modalities of correction.
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Affiliation(s)
- Tahsin M Rahman
- Wayne State University School of Medicine, Detroit, Michigan
| | - Dominik Fleifel
- Wayne State University School of Medicine, Detroit, Michigan
| | - Muhammad T Padela
- Department of Orthopaedic Surgery, Detroit Medical Center, Detroit, Michigan
| | | | | | | | - Zain Sayeed
- Department of Orthopaedic Surgery, Detroit Medical Center, Detroit, Michigan
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135
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Shadbolt C, Abbott JH, Camacho X, Clarke P, Lohmander LS, Spelman T, Sun EC, Thorlund JB, Zhang Y, Dowsey MM, Choong PFM. The Surgeon's Role in the Opioid Crisis: A Narrative Review and Call to Action. Front Surg 2020; 7:4. [PMID: 32133370 PMCID: PMC7041404 DOI: 10.3389/fsurg.2020.00004] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 01/29/2020] [Indexed: 12/27/2022] Open
Abstract
Over the past two decades, there has been a sharp rise in the use of prescription opioids. In several countries, most notably the United States, opioid-related harm has been deemed a public health crisis. As surgeons are among the most prolific prescribers of opioids, growing attention is now being paid to the role that opioids play in surgical care. While opioids may sometimes be necessary to provide patients with adequate relief from acute pain after major surgery, the impact of opioids on the quality and safety of surgical care calls for greater scrutiny. This narrative review summarizes the available evidence on rates of persistent postsurgical opioid use and highlights the need to target known risk factors for persistent postoperative use before patients present for surgery. We draw attention to the mounting evidence that preoperative opioid exposure places patients at risk of persistent postoperative use, while also contributing to an increased risk of several other adverse clinical outcomes. By discussing the prevalence of excess opioid prescribing following surgery and highlighting significant variations in prescribing practices between countries, we note that there is a pressing need to optimize postoperative prescribing practices. Guided by the available evidence, we call for specific actions to be taken to address important research gaps and alleviate the harms associated with opioid use among surgical patients.
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Affiliation(s)
- Cade Shadbolt
- Department of Surgery, St. Vincent's Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - J Haxby Abbott
- Centre for Musculoskeletal Outcomes Research, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Ximena Camacho
- Melbourne School of Population and Global Health, The University of Melbourne, Carlton, VIC, Australia
| | - Philip Clarke
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, VIC, Australia.,Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund, Sweden
| | - Tim Spelman
- Department of Surgery, St. Vincent's Hospital, The University of Melbourne, Melbourne, VIC, Australia.,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Rigshospitalet, Copenhagen, Denmark
| | - Eric C Sun
- Department of Anaesthesiology, Perioperative and Pain Medicine and Department of Health Research and Policy, Stanford University, Stanford, CA, United States
| | - Jonas B Thorlund
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Yuting Zhang
- Melbourne Institute of Applied Economic and Social Research, Faculty of Business and Economics, University of Melbourne, Carlton, VIC, Australia
| | - Michelle M Dowsey
- Department of Surgery, St. Vincent's Hospital, The University of Melbourne, Melbourne, VIC, Australia.,Department of Orthopaedics, St. Vincent's Hospital, Melbourne, VIC, Australia
| | - Peter F M Choong
- Department of Surgery, St. Vincent's Hospital, The University of Melbourne, Melbourne, VIC, Australia.,Department of Orthopaedics, St. Vincent's Hospital, Melbourne, VIC, Australia
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Shibuya M, Nanri Y, Kamiya K, Fukushima K, Uchiyama K, Takahira N, Takaso M, Fukuda M, Matsunaga A. The maximal gait speed is a simple and useful prognostic indicator for functional recovery after total hip arthroplasty. BMC Musculoskelet Disord 2020; 21:84. [PMID: 32033550 PMCID: PMC7007664 DOI: 10.1186/s12891-020-3093-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 01/24/2020] [Indexed: 01/14/2023] Open
Abstract
PURPOSE The present study aimed to compare the capabilities of preoperative usual and maximal gait speeds in predicting functional recovery in patients who have undergone total hip arthroplasty (THA). METHODS Primary and unilateral THAs were performed in 317 patients, and the proportion of patients who achieved unassisted walking (functional recovery) 5 days postoperatively was recorded as an outcome measure. Preoperative functional assessment included hip pain, leg muscle strength, range of motion (ROM), and gait speed evaluations. The capabilities of preoperative usual and maximal gait speeds in predicting functional recovery were compared based on the areas under the curves (AUCs) of receiver operating characteristic (ROC) curves. Further, ROC curves were constructed using two models: 1. a model of gait speed only and 2. a clinical model including age, sex, leg muscle strength, and ROM. RESULTS On the AUCs for predictive ability of functional recovery, maximal gait speed was greater than usual gait speed (0.66 and 0.70, respectively). The AUC for maximal gait speed was as large as that of the clinical model (0.70 and 0.70, respectively). CONCLUSION Our results suggest that maximal gait speed is a simple and useful prognostic indicator of functional recovery in patients who have undergone THA.
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Affiliation(s)
- Manaka Shibuya
- Department of Rehabilitation, Kitasato University Hospital, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0375, Japan.,Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan
| | - Yuta Nanri
- Department of Rehabilitation, Kitasato University Hospital, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0375, Japan
| | - Kentaro Kamiya
- Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan. .,Department of Rehabilitation, School of Allied Health Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan.
| | - Kensuke Fukushima
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Katsufumi Uchiyama
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Naonobu Takahira
- Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan.,Department of Rehabilitation, School of Allied Health Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan.,Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Masashi Takaso
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Michinari Fukuda
- Department of Rehabilitation, Kitasato University Hospital, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0375, Japan.,Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan.,Department of Rehabilitation, School of Allied Health Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan
| | - Atsuhiko Matsunaga
- Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan.,Department of Rehabilitation, School of Allied Health Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan
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The Impact of Preoperative Opioid Use Disorder on Complications and Costs following Primary Total Hip and Knee Arthroplasty. Adv Orthop 2019; 2019:9319480. [PMID: 31929911 PMCID: PMC6939449 DOI: 10.1155/2019/9319480] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 11/29/2019] [Indexed: 02/06/2023] Open
Abstract
Introduction Multiple studies have demonstrated that patients taking opioids in the preoperative period are at elevated risk for complications following total hip (THA) and knee (TKA) arthroplasty. However, the incidence and impact of opioid use disorder (OUD) among these patients—both clinically and fiscally—remain unknown. The purpose of this study was to investigate this relationship. Methods The Nationwide Readmission Database (NRD) was used to identify patients undergoing THA and TKA from 2011 to 2015. Coarsened exact matching was used to statistically match the OUD and non-OUD cohorts. Further analysis was then conducted on matched cohorts with multivariate analysis. The incidence of OUD was also determined, and the costs associated with this comorbidity were calculated. Results The incidence of OUD in arthroplasty patients increased 80% over the study period. OUD patients had higher odds of prosthetic joint infection (OR 1.55, 95% CI 1.23–1.94), wound complication (OR 1.40, 95% CI 1.12–1.76), prosthetic complication (OR 1.37, 95% CI 1.10–1.70), and revision surgery (OR 1.47, 95% CI 1.19–1.81). OUD patients also had longer length of stays (TKA: +0.67 days; THA: +1.09 days), higher readmission (OR 1.60, 95% CI 1.43–1.79), and increased 90-day costs (TKA: +$3,602 [95% CI $3,138–4,065]; THA: +4,527 [95% CI $3,593–4,920). Conclusion Opioid use disorder is becoming a more common comorbidity among THA and TKA patients. This is concerning as it represents a significant risk factor for postoperative complication. It additionally confers increased perioperative costs. Patients with OUD should be counseled on their elevated risk, and future work will be needed to determine if this is a modifiable risk factor.
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Goplen CM, Randall JR, Kang SH, Vakilian F, Jones CA, Voaklander DC, Beaupre LA. The Influence of Allowable Refill Gaps on Detecting Long-Term Opioid Therapy: An Analysis of Population-Based Administrative Dispensing Data Among Patients with Knee Arthritis Awaiting Total Knee Arthroplasty. J Manag Care Spec Pharm 2019; 25:1064-1072. [PMID: 31556825 PMCID: PMC10401997 DOI: 10.18553/jmcp.2019.25.10.1064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND It is challenging to detect long-term opioid therapy (LTOT) using administrative data, as refill gaps can disrupt opioid utilization episodes. Previous studies have used various methods to define LTOT and allowable refill gaps with little supporting evidence. OBJECTIVE To describe the effect of allowable refill gaps on detecting LTOT among a cohort of patients with arthritis awaiting total knee arthroplasty (TKA) using 3 different methods. METHODS A retrospective analysis of multicenter population-based data between January 1, 2012, and December 31, 2016, identified patients prescribed opioids before TKA in Alberta, Canada. We described 3 methods to detect LTOT based on a (1) fixed number of days between prescriptions; (2) fraction of the preceding prescription length; and (3) combination method that selected whichever refill gap was greatest. We then compared the number of patients classified as long-term opioid users by varying the number of days between prescriptions from 1-90 days (fixed method) or 0.04-3.2 times the duration (fraction method) for each method and refill gap. RESULTS Of the 14,252 patients included in our cohort, 4,393 patients (31%) had an opioid prescription within 180 days before TKA. Detection of LTOT varied from 4.4% to 14.6% (fixed method), 4.2% to 13.2% (fraction method), and 4.5% to 15.1% (mixed method) as refill gaps varied from minimum to maximum. As refills gaps increased, the dose and duration of opioids in the utilization episode decreased for all 3 methods. CONCLUSIONS The allowable refill gap between opioid prescriptions can influence the estimated rate of LTOT when using administrative pharmaceutical dispensing data. Definitional parameters should be carefully considered when using administrative data to define consistent opioid use. DISCLOSURES This work was supported by the Department of Surgery's Clinical Research Grant at the University of Alberta (RES0039945). The authors have no potential conflicts of interest.
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Affiliation(s)
| | - Jason R. Randall
- School of Public Health, University of Alberta, Edmonton, Canada
| | - Sung Hyun Kang
- Alberta Bone and Joint Institute, Calgary, Alberta, Canada
| | - Fatemeh Vakilian
- School of Public Health, University of Alberta, Edmonton, Canada
| | | | | | - Lauren A. Beaupre
- Department of Surgery and Department of Physical Therapy, University of Alberta, Edmonton, Canada
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139
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Perioperative use of opioids: Current controversies and concerns. Best Pract Res Clin Anaesthesiol 2019; 33:341-351. [DOI: 10.1016/j.bpa.2019.07.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 07/09/2019] [Indexed: 02/02/2023]
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