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Hadlandsmyth K, Lund BC, Gao Y, Strayer AL, Davila H, Hausmann LRM, Schmidt S, Shireman PK, Jacobs MA, Mader MJ, Tessler RA, Duncan CA, Hall DE, Sarrazin MV. Social Determinants of Long-Term Opioid Use Following Total Knee Arthroplasty. J Knee Surg 2024; 37:742-748. [PMID: 38599604 DOI: 10.1055/s-0044-1786021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
Total knee arthroplasty (TKA) risks persistent pain and long-term opioid use (LTO). The role of social determinants of health (SDoH) in LTO is not well established. We hypothesized that SDoH would be associated with postsurgical LTO after controlling for relevant demographic and clinical variables. This study utilized data from the Veterans Affairs Surgical Quality Improvement Program, VA Corporate Data Warehouse, and Centers for Medicare and Medicaid Services, including Veterans aged ≥ 65 who underwent elective TKA between 2013 and 2019 with no postsurgical complications or history of significant opioid use. LTO was defined as > 90 days of opioid use beginning within 90 days postsurgery. SDoH variables included the Area Deprivation Index, rurality, and housing instability in the last 12 months identified via medical record screener or International Classification of Diseases, Tenth Revision codes. Multivariable risk adjustment models controlled for demographic and clinical characteristics. Of the 9,064 Veterans, 97% were male, 84.2% white, mean age was 70.6 years, 46.3% rural, 11.2% living in highly deprived areas, and 0.9% with a history of homelessness/housing instability. Only 3.7% (n = 336) developed LTO following TKA. In a logistic regression model of only SDoH variables, housing instability (odds ratio [OR] = 2.38, 95% confidence interval [CI]: 1.09-5.22) and rurality conferred significant risk for LTO. After adjusting for demographic and clinical variables, LTO was only associated with increasing days of opioid supply in the year prior to surgery (OR = 1.52, 95% CI: 1.43-1.63 per 30 days) and the initial opioid fill (OR = 1.07; 95% CI: 1.06-1.08 per day). Our primary hypothesis was not supported; however, our findings do suggest that patients with housing instability may present unique challenges for postoperative pain management and be at higher risk for LTO.
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Affiliation(s)
- Katherine Hadlandsmyth
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
- Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Brian C Lund
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa
| | - Yubo Gao
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Andrea L Strayer
- College of Nursing, University of Iowa, Iowa City, Iowa
- Department of Veterans Affairs, Veterans Health Administration, Office of Academic Affiliations VA Quality Scholars Advanced Fellowship Program, Iowa City, Iowa
| | - Heather Davila
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Paula K Shireman
- Department of Primary Care and Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, Texas
| | - Michael A Jacobs
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Michael J Mader
- Research Service, South Texas Veterans Healthcare System, San Antonio, Texas
| | - Robert A Tessler
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Carly A Duncan
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Daniel E Hall
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Wolff Center at University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mary Vaughan Sarrazin
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
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Yoo M, Buys MJ, Nelson RE, Patel S, Bayless KM, Anderson Z, Hales JB, Brooke BS. Effect of Multidisciplinary Transitional Pain Service on Health Care Use and Costs Following Orthopedic Surgery. Fed Pract 2023; 40:418-425. [PMID: 38812900 PMCID: PMC11132101 DOI: 10.12788/fp.0438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
Background Opioid use disorder is a significant cause of morbidity, mortality, and health care costs. A transitional pain service (TPS) approach to perioperative pain management has been shown to reduce opioid use among patients undergoing orthopedic joint surgery. However, whether TPS also leads to lower health care use and costs is unknown. Methods We designed this study to estimate the effect of TPS implementation relative to standard care on health care use and associated costs of care following orthopedic surgery. We evaluated postoperative health care use and costs for patients who underwent orthopedic joint surgery at 6 US Department of Veterans Affairs medical centers (VAMCs) between 2018 and 2019 using difference-in-differences analysis. Patients enrolled in the TPS at the Salt Lake City VAMC were matched to control patients undergoing the same surgeries at 5 different VAMCs without a TPS. We stratified patients based on history of preoperative opioid use into chronic opioid use (COU) and nonopioid use (NOU) groups and analyzed them separately. Results For NOU patients, TPS was associated with a mean increase in the number of outpatient visits (6.9 visits; P < .001), no change in outpatient costs, and a mean decrease in inpatient costs (-$12,170; P = .02) during the 1-year follow-up period. TPS was not found to increase health care use or costs for COU patients. Conclusions Although TPS led to an increase in outpatient visits for NOU patients, there was no increase in outpatient costs and a decrease in inpatient costs after orthopedic surgery. Further, there was no added cost for managing COU patients with a TPS. These findings suggest that TPS can be implemented to reduce opioid use following joint surgery without increasing health care costs.
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Affiliation(s)
- Minkyoung Yoo
- University of Utah School of Medicine, Salt Lake City
| | - Michael J. Buys
- Informatics Decision Enhancement and Surveillance (IDEAS) Center, Veterans Affairs Salt Lake City Healthcare System, Utah
| | - Richard E. Nelson
- University of Utah School of Medicine, Salt Lake City
- Informatics Decision Enhancement and Surveillance (IDEAS) Center, Veterans Affairs Salt Lake City Healthcare System, Utah
| | | | | | - Zachary Anderson
- Informatics Decision Enhancement and Surveillance (IDEAS) Center, Veterans Affairs Salt Lake City Healthcare System, Utah
| | | | - Benjamin S. Brooke
- University of Utah School of Medicine, Salt Lake City
- Informatics Decision Enhancement and Surveillance (IDEAS) Center, Veterans Affairs Salt Lake City Healthcare System, Utah
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Hadlandsmyth K, Mosher HJ, Bayman EO, Mares JG, Odom AS, Lund BC. Opioid Prescribing Patterns for Acute Pain. Eur J Pain 2022; 26:1523-1531. [PMID: 35607721 DOI: 10.1002/ejp.1980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 05/16/2022] [Accepted: 05/20/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE The current study aimed to identify patients presenting with acute pain who may be at risk for a complicated trajectory, via identifying clusters of early opioid prescribing patterns. METHODS National Veterans Affairs administrative data were utilized to build a cohort of outpatients with acute pain presentations and no more than minimal opioid use in the prior year. Latent Class Analyses (LCA) identified clusters of early opioid prescribing patterns. Risk of progression to long-term opioid use was contrasted between LCA clusters using log-binomial regression, adjusting for confounding variables. RESULTS The 2018 cohort included N = 191,283. Among the 27,890 who received an initial opioid prescription, LCA classes were identified using: first supply day, total days dispensed across 30 days, opioid type, dose, and number of prescriptions across the first 30 days. In the three-class model: class 1 indicated an immediate, low-dose, brief supply; class 2 included delayed, low-dose and longer duration prescriptions; and class 3 included delayed high-dose, and moderate duration. Adjusted relative risk ratios for progression to long-term opioid use in the following year were 3.33 (95% CI: 2.71-4.10) for class 1 (absolute risk 1.1%); 7.76 (95% CI: 6.69-8.99) for class 2 (3.1%); and 6.81 (95% CI: 5.72 - 8.12) for class 3 (2.4%); compared to patients who did not receive an acute opioid prescription (0.3%). CONCLUSIONS These clusters of acute opioid prescribing could facilitate identification of patients who may benefit from enhanced pain care earlier in the pain trajectory and decrease future reliance on long-term opioid therapy.
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Affiliation(s)
- Katherine Hadlandsmyth
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.,Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, IA, USA.,University of Iowa, Carver College of Medicine, Department of Anesthesia, Iowa City, IA, USA
| | - Hilary J Mosher
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.,Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, IA, USA.,University of Iowa, Carver College of Medicine, Department of Internal Medicine, Iowa City, USA
| | - Emine O Bayman
- University of Iowa, Carver College of Medicine, Department of Anesthesia, Iowa City, IA, USA.,University of Iowa, College of Public Health, Department of Biostatistics, Iowa City, IA, USA
| | - Jasmine G Mares
- University of Iowa, Carver College of Medicine, Department of Anesthesia, Iowa City, IA, USA
| | - Annie S Odom
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
| | - Brian C Lund
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.,Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, IA, USA
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Hadlandsmyth K, Mosher HJ, Vander Weg MW, O'Shea AM, McCoy KD, Lund BC. Utility of accumulated opioid supply days and individual patient factors in predicting probability of transitioning to long-term opioid use: An observational study in the Veterans Health Administration. Pharmacol Res Perspect 2020; 8:e00571. [PMID: 32126163 PMCID: PMC7053662 DOI: 10.1002/prp2.571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 02/06/2020] [Indexed: 12/31/2022] Open
Abstract
Initial supply days dispensed to new users is strongly predictive of future long‐term opioid use (LTO). The objective was to examine whether a model integrating additional clinical variables conferred meaningful improvement in predicting LTO, beyond a simple approach using only accumulated supply. Three cohorts were created using Veteran's Health Administration data based on accumulated supply days during the 90 days following opioid initiation: (a) <30 days, (b) ≥30 days, (c) ≥60 days. A base, unadjusted probability of subsequent LTO (days 91‐365) was calculated for each cohort, along with an associated risk range based on midpoint values between cohorts. Within each cohort, log‐binomial regression modeled the probability of subsequent LTO, using demographic, diagnostic, and medication characteristics. Each patient's LTO probability was determined using their individual characteristic values and model parameter estimates, where values falling outside the cohort's risk range were considered a clinically meaningful change in predictive value. Base probabilities for subsequent LTO and associated risk ranges by cohort were as follows: (a) 3.92% (0%‐10.75%), (b) 17.59% (10.76%‐28.05%), (c) 38.53% (28.06%‐47.55%). The proportion of patients whose individual probability fell outside their cohort's risk range was as follows: 1.5%, 4.6%, and 9.2% for cohorts 1, 2, and 3, respectively. The strong relationship between accumulated supply days and future LTO offers an opportunity to leverage electronic healthcare records for decision support in preventing the initiation of inappropriate LTO through early intervention. More complex models are unlikely to meaningfully guide decision making beyond the single variable of accumulated supply days.
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Affiliation(s)
- Katherine Hadlandsmyth
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, USA.,Veterans Rural Health Resource Center, Iowa City VA Healthcare System, Iowa City, IA, USA.,Department of Anesthesia, Carver College of Medicine, University of Iowa Iowa City, Iowa City, IA, USA
| | - Hilary J Mosher
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, USA.,Veterans Rural Health Resource Center, Iowa City VA Healthcare System, Iowa City, IA, USA.,Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Mark W Vander Weg
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, USA.,Veterans Rural Health Resource Center, Iowa City VA Healthcare System, Iowa City, IA, USA.,Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Amy M O'Shea
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, USA.,Veterans Rural Health Resource Center, Iowa City VA Healthcare System, Iowa City, IA, USA.,Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Kimberly D McCoy
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, USA.,Veterans Rural Health Resource Center, Iowa City VA Healthcare System, Iowa City, IA, USA
| | - Brian C Lund
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, USA.,Veterans Rural Health Resource Center, Iowa City VA Healthcare System, Iowa City, IA, USA
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