Hospitalization Costs for Patients Undergoing Orthopedic Surgery Treated With Intravenous Acetaminophen (IV-APAP) Plus Other IV Analgesics or IV Opioid Monotherapy for Postoperative Pain

Evaluation of an Intravenous Acetaminophen Protocol in the Emergency Department

BACKGROUND

Acute pain is a leading reason for Emergency Department (ED) evaluation, accounting for nearly half of all ED visits. Therefore, providing effective non-opioid analgesics in the ED is critical. Oral acetaminophen (APAP) is commonly administered in the ED but is limited to patients tolerating oral intake. Intravenous (IV) APAP provides significant pain reduction parenterally. The purpose of this quality assessment project was to evaluate the frequency of opioid use in patients receiving IV APAP, the safety of IV APAP, and compliance with an ED IV APAP protocol.

METHODS

This study included all patients who received IV APAP in the ED of a tertiary care, level I trauma center, during a three-month period. The protocol required ED patients to be NPO (nil per os), 18 years or older, and administered with a single 1000 mg dose. The adverse reactions within 24 hours post-IV APAP, ED length of stay (LOS), and opioid administration within four hours post-IV APAP were assessed.

RESULTS

Ninety-four patients received IV APAP. All patients received a 1000 mg dose. One patient received more than one dose, but this patient had a 22-hour ED LOS. Two patients received oral medications within one hour of IV APAP (one received an antacid, and the other received carbamazepine and lamotrigine). An opioid was administered to 22 of the 94 (23.4%) patients during the four-hour protocol period. There were no reports of adverse reactions.

CONCLUSIONS

The results show excellent compliance with the protocol. IV APAP was safe and well-tolerated. Notably, most patients did not receive an opioid within four hours of IV APAP. IV APAP can be safely and effectively utilized as an analgesic and lessen ED opioid use.

Outcomes of hip fracture treatment with intravenous morphine and with other analgesics: postoperative analgesic medical expense, severity of pain and hospitalisation-a retrospective study

AIMS

This study compares the postoperative medical costs and outcomes of hip fracture patients treated with intravenous (IV) versus other analgesics (weak opioids, NSAIDs or acetaminophen).

METHODS

We performed a retrospective study at a tertiary hospital in Thailand, examining 1,531 patients who underwent hip fracture surgery between 2009 and 2020. We analyzed data on analgesic usage, costs, pain scores, and adverse effects.

RESULTS

In the study of 1531 patients, 63% of patients received as-needed analgesics, and 37% received preemptive prescriptions. In both groups, IV morphine was the predominant choice. The mean cost for the IV group was marginally higher than the other analgesics group ($2277 vs $2174). The other analgesics group had a significantly higher consumption of acetaminophen and selective NSAIDs (p = 0.004). Pain scores were similar across both groups, but the IV group had a significantly higher incidence of gastrointestinal side effects (24% vs 10.5%, p < 0.01).

CONCLUSION

The choice of IV or other analgesics in treating hip fractures affects analgesic usage, side effects, medical costs, and patient outcomes. Further studies across different regions are recommended.

The effect of hamstring donor-site block for functional outcomes and rehabilitation after anterior cruciate ligament reconstruction

Purpose

To determine the effect of local infiltration anesthesia (LIA) at the donor site combined with a femoral nerve block (FNB) on short-term postoperative pain, functional outcomes, and rehabilitation after arthroscopic hamstring tendon autograft anterior cruciate ligament reconstruction (ACLR).

Methods

This study was a single center, randomized controlled trial. Seventy-three subjects with ACL rupture were enrolled. Participants were randomly allocated to two groups, 47 in the experimental group (Group A) and 26 in the control group (Group B). All operations were performed under FNB. In Group A, 10 ml of 1% ropivacaine was injected precisely at the hamstring donor site. Patients in Group B were treated with the same amount of saline. Preoperatively and postoperatively, pain scores based on the numerical rating scale (NRS) and consumption of opioids were recorded. In addition, knee functions were assessed by the International Knee Documentation Committee Subjective Knee Form (IKDC), the Lysholm score, and the Knee injury and Osteoarthritis Outcome Score (KOOS) preoperatively and postoperatively at 1 and 3 months. In addition, we applied the KNEELAX3 arthrometer to evaluate the stability of the knee preoperatively and postoperatively so that subjective and objective knee conditions were obtained to help us assess knee recovery in a comprehensive manner.

Results

The hamstring donor-site block reduced pain within the first 12 postoperative hours. There were no significant differences between two groups in pain intensity preoperatively and equal to or greater than 24 hours postoperatively. Furthermore, there were no differences between the groups concerning knee functions preoperatively or in the short-term follow-up at 1 and 3 months.

Conclusion

LIA at the donor site can effectively improve the early postoperative pain of patients after ACLR and reduce the use of opioids without affecting the functional outcomes of the surgery.

Original Research: Combating the Opioid Epidemic Through Nurse Use of Multimodal Analgesia: An Integrative Literature Review

BACKGROUND

Opioid misuse and addiction have become a national crisis. New pain management guidelines call for the use of multimodal analgesia to manage acute pain. In hospital settings, a clinical decision aid that emphasizes multimodal analgesia may improve nurses' use of this opioid-sparing strategy.

PURPOSE

This integrative review was conducted to provide nurses with evidence-based information on the opioid-sparing benefits of multimodal analgesia.

METHODS

A literature search was conducted using several electronic databases and Google Scholar. These initial searches yielded 136 articles of interest. Twenty-eight were selected for retrieval and in-depth appraisal; of these, 13 met all inclusion criteria.

RESULTS

Of the 13 reviewed studies, six were randomized controlled trials, six were retrospective cohort or population-based studies, and one was a qualitative study. Overall, the findings provided strong evidence that multimodal analgesia is effective in managing acute pain in surgical patients while reducing opioid requirements. Several studies also found that multimodal analgesia was associated with shorter hospital lengths of stay.

CONCLUSIONS

With the appropriate tools and education, nurses can make the transition from traditional opioids to multimodal analgesia strategies. In so doing, they can have a significant positive impact on the opioid epidemic. Hospital leaders must address nursing practice regarding the use of opioids alone versus multimodal analgesia for the management of acute pain. Clinical decision tools such as the Michigan Opioid Safety Score may help nurses adopt new acute pain management guidelines. Further research regarding nursing practice and the opioid epidemic is needed.

Defining the Opioid Requirement in Anterior Cruciate Ligament Reconstruction

Introduction:

The amount and duration of opioids necessary after anterior cruciate ligament reconstruction (ACLR) are inadequately defined. This study sought to prospectively (1) define the amount and duration of opioid consumption, (2) investigate the relationship between preoperative pain expectation and postoperative satisfaction with pain management, and (3) identify risk factors for increased opioid use after ACLR.

Methods:

One hundred eight patients undergoing primary ACLR with hamstring graft were prospectively analyzed for preoperative pain expectation, using visual analog scale (VAS) rating, and postoperative satisfaction with pain management. Univariate and multivariate analyses were done to identify patient characteristics associated with satisfaction and/or amount and duration of opioid use.

Results:

Mean duration and cumulative intake of opioid consumption after ACLR were 5.3 days and 15.3 tablets, respectively. Patients expected moderate postoperative pain: mean preoperative VAS = 68.9. The preoperative VAS rating was associated with a significantly greater amount (P = 0.0265) and longer duration (P = 0.0212) of opioid consumption. Baseline opioid users took opioids for twice as long postoperatively (10.0 versus 5.0 days; P = 0.0149) and consumed twice as many tablets (29.3 versus 14.8 tablets; P = 0.0280) compared with opioid-naive patients.

Discussion:

This study demonstrated on average 15.3 opioid tablets over 5.3 days provided satisfactory pain management after ACLR. Risk factors for increased opioid consumption included preoperative opioid use.

Economic Impact of Preoperative Meloxicam IV Administration in Total Knee Arthroplasty: A Randomized Trial Sub-Study

We evaluated the economic impact associated with preoperative meloxicam IV 30 mg vs placebo administration among adult total knee arthroplasty (TKA) recipients enrolled in Phase IIIB NCT03434275 trial. Data on total hospital costs and length of stay (LOS) obtained from the trial were compared between meloxicam IV 30 mg and placebo groups. Patients in the meloxicam IV 30 mg vs placebo group (n = 93 vs 88) incurred an adjusted $2,266 (95% CI: -$1,035, $5,116; p = 0.1689) lower total hospital costs and an adjusted 8.6% (95% confidence interval [CI]: -2.0%, 18.1%; p = 0.1082) shorter LOS. While statistically non-significant, based on 95% CIs, the results from this sub-study may suggest a favorable impact associated with meloxicam IV 30 mg on hospital costs and LOS.

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations

OBJECTIVE

Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families.

PURPOSE

The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed.This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients.

ACTION STATEMENTS

The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method.The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.

Effect of Opioids on All-cause Mortality and Sustained Opioid Use in Elderly Patients with Hip Fracture: a Korea Nationwide Cohort Study

BACKGROUND

The purpose of our study was to assess the use of opioids before and after hip fracture in elderly patients in order to determine the effect of opioid use on all-cause mortality, and to analyze how the history of opioid use before fracture increases the risk of sustained use following hip fracture using a Korea nationwide cohort.

METHODS

Our study identified hip fracture patients from the Korean National Health Insurance Service-Senior cohort. The index date was defined as 90-days after admission to the acute care hospital that fulfilled the eligibility criteria of elderly hip fracture. Patients were classified into past user, current user, and sustained user according to the use of opioid at each period based on the time of admission and index date. The opioids were classified into strong opioids and tramadol. A generalized estimating equation model with a Poisson distribution and logarithmic link function was performed to estimate the adjusted rate ratios (aRRs) and 95% confidence intervals (CIs) to assess the association between past use and sustained use. A multivariable-adjusted Cox proportional hazard model was used to investigate the effects of strong opioid and tramadol use on all-cause mortality.

RESULTS

A total of 12,927 patients were included in our study. There were 7,384 (57.12%) opioid past-users, 11,467 (88.71%) opioid current-users, and 7,172 (55.48%) sustained users. In comparison of the death risk according to current use or the defined daily dose of the opioids or past opioid use, there were no significant differences in the adjusted hazard ratio for death in all groups, compared to the current non-users (P > 0.05). Among survivors 1 year after hip fracture, opioid past-use increased the risk of opioid sustained use by 1.52-fold (aRR; 95% CI, 1.45-1.8; P < 0.001).

CONCLUSION

Current use and past use of opioid did not increase all-cause mortality after hip fracture in elderly patients over 65 years of age. Past use of opioid before hip fracture increased risk of sustained use of opioid compared to the current opioid used without past use.

Postoperative around-the-clock administration of intravenous acetaminophen for pain control following robot-assisted radical prostatectomy

The objective of this study was to examine the impact of around-the-clock (ATC) administration of intravenous (IV) acetaminophen following robot-assisted radical prostatectomy (RARP). Intravenous infusion of acetaminophen was started on the day of the operation at 1000 mg/dose every 6 h, and the infusion was continued on a fixed schedule until postoperative day 2 a.m. In a retrospective observational study, we compared 127 patients who were administered IV acetaminophen on a fixed schedule (ATC group) with 485 patients who were administered analgesic drugs only as needed (PRN group). We investigated postoperative pain intensity and additional analgesic consumption on postoperative day 0, 1, 2, 3, and 5 between the two groups. Postoperative pain scores were significantly lower in the ATC group than in the PRN group at 1 and 2 days, and this period matched the duration of ATC administration of IV acetaminophen. Postoperative frequency of rescue analgesia was significantly lower in the ATC group than in the PRN group at postoperative 0, 1, and 2 days. ATC administration of IV acetaminophen has the potential to be a very versatile and valuable additional dose to achieve appropriate postoperative analgesia in patients with RARP.

Opioid-free multimodal analgesia pathway to decrease opioid utilization after cesarean delivery

AIM

To evaluate an opioid-free multimodal analgesic pathway (MAP) to decrease opioid utilization after cesarean delivery (CD) compared to historic data of our institution prior to using MAP for pain management (pre-MAP).

METHODS

The MAP was implemented in three phases from September 2018 to August 2019. Patients received 1000 mg intravenous (IV) acetaminophen with 30 mg IV ketorolac at 0 (arrival time at recovery room), 6, 12 and 18 h of postoperative course. On the 2nd and the 3rd postoperative days, patients were monitored for pain every 6 h by Numeric Pain Intensity Scale (0 = no pain to 10 = severe pain) and administered 600 mg oral ibuprofen for a pain score between 0 and 4, 600 mg oral ibuprofen and/or 650 mg oral acetaminophen for a pain score between 5-6, 1000 mg IV acetaminophen and/or 30 mg of IV or intramuscular ketorolac for a pain score between 7 and 10. Five milligrams of oral oxycodone was reserved for rescue if all protocol options were exhausted. Patients were discharged with 600 mg oral ibuprofen without opioid prescription. Likert surveys measuring patient satisfaction of pain control were administered during phase 3.

RESULTS

Inpatient and outpatient opioid consumption rates were significantly decreased from 45%, 18% to 23.8%, 8.5% after MAP implementation (P-value <0.001). More than 90% of patients reported that their pain was well controlled and willing to request the same regimen for a future CD.

CONCLUSION

MAP Implementation after CD significantly reduced inpatient and outpatient opioid consumption compared to pre-MAP results while maintaining high patients' satisfaction with pain control.

Preoperative Intravenous Versus Oral Acetaminophen in Outpatient Surgery: A Double-Blinded, Randomized Control Trial

PURPOSE

Preoperative acetaminophen is recognized as an effective part of the multimodal approach to perioperative pain management. The present study, conducted between April 12, 2018 and February 14, 2019, examined whether there are differences in patient-reported pain, postoperative opioid consumption, negative opioid effects, length of postanesthesia care unit stay, and patient satisfaction with pain control between patients who receive intravenous (IV) acetaminophen and patients who receive oral acetaminophen.

DESIGN

This double-blinded, randomized controlled trial was conducted among 120 patients undergoing outpatient surgery.

METHODS

Patients were randomized to receive preoperatively either intravenous (IV) acetaminophen (and oral placebo) or oral acetaminophen (and IV placebo). Results were analyzed using SPSS statistical software; statistical analyses consisted of Mann-Whitney U test, independent samples t test, and χ² test. In all analyses, a P value less than .05 was considered significant.

FINDINGS

There were no significant differences in any outcome measures based on the route of acetaminophen administration.

CONCLUSIONS

The findings of the present study support the practice of administering oral acetaminophen, as opposed to IV acetaminophen, preoperatively as part of the multimodal approach to manage postoperative pain in patients able to tolerate preoperative oral medications.

Effectiveness of Multimodal Pain Therapy on Reducing Opioid Use in Surgical Geriatric Hip Fracture Patients

BACKGROUND

There is a need for appropriate pain control in the geriatric hip fracture population to prevent diminished function, increased mortality, and opioid dependence. Multimodal pain therapy is one method for reducing pain postoperatively while also decreasing opioid use in the geriatric hip fracture patient. This study aimed to determine whether multimodal pain therapy could decrease opioid use without increasing pain scores in surgical geriatric hip fracture patients.

METHODS

This was a before-and-after cohort study. The hospital implemented multimodal pain control order sets with a standardized pain regimen and performed retrospective chart review pre- and postorder set implementation for analysis.

RESULTS

A total of 248 patients were enrolled in the study: 131 in the preorder set group and 117 in the postorder set group. The mean postoperative oral morphine equivalent (OME) was significantly lower in the postorder set group than in the preorder set group (45.1 mg vs. 63.4 mg, respectively, p = .03). Compared with the preorder set group, total OME and postoperative OME were decreased by 22.6% (95% confidence interval [CI] -44.9, -3.8), 1-tailed p < .01, and 53.6% (95% CI -103.4, -16.1), 1-tailed p <.01 respectively, in the postorder set group. There was not a statistically significant difference in mean pain scores at 6, 24, and 48 hr postoperatively (p = .53, .10, and .99), respectively.

CONCLUSION

Implementing a multimodal approach to pain management may help reduce opioid use and may be a critical maneuver in averting the national opioid epidemic.

Evolving the management of acute perioperative pain towards opioid free protocols: a narrative review

Objective: Identification of pain as the fifth vital sign has resulted in over-prescription and overuse of opioids in the US, with addiction reaching epidemic proportions. In Europe, and more recently in the US, a shift has occurred with the global adoption of multimodal analgesia (MMA), which seeks to minimize perioperative opioid use. Improved functional outcomes and reduced healthcare utilization costs have been demonstrated with MMA, but wide scale use of opioids in pain management protocols continues. As a next step in the pain management evolution, opioid-free analgesia (OFA) MMA strategies have emerged as feasible in many surgical settings.Methods: Articles were limited to clinical studies and meta-analyses focusing on comparisons between opioid-intensive and opioid-free/opioid-sparing strategies published in English.Results: In this review, elimination or substantial reduction in opioid use with OFA strategies for perioperative acute pain are discussed, with an emphasis on improved pain control and patient satisfaction. Improved functional outcomes and patient recovery, as well as reduced healthcare utilization costs, are also discussed, along with challenges facing the implementation of such strategies.Conclusions: Effective MMA strategies have paved the way for OFA approaches to postoperative pain management, with goals to reduce opioid prescriptions, improve patient recovery, and reduce overall healthcare resource utilization and costs. However, institution-wide deployment and adoption of OFA is still in early stages and will require personalization and better management of patient expectations.

Is Insurance Status Associated with the Likelihood of Operative Treatment of Clavicle Fractures?

BACKGROUND

Most closed clavicle fractures are treated nonoperatively. Research during the past decade has reported differences in the treatment of clavicle fractures based on insurance status in the US and may highlight unmet needs in a vulnerable population, particularly because new data show that surgery may lead to improved outcomes in select populations. Large-scale, national data are needed to better inform this debate.

QUESTIONS/PURPOSES

(1) Does the likelihood of operative fixation of closed clavicle fractures vary among patients with different types of insurance? (2) What demographic and socioeconomic factors are associated with the likelihood of clavicle fracture surgery? (3) Has the proportion of operative fixation of clavicle fractures changed over time?

METHODS

A retrospective analysis of the Nationwide Inpatient Sample 2001-2013 database was performed. This database is the largest publicly available all-payer inpatient database in the US that provides pertinent socioeconomic data on a nationwide scale. Data were queried for patients with closed clavicle fractures using International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes, and surgery was determined using ICD-9 procedural codes. A total of 252,109 patients were included in the final analysis after 158,619 patients were excluded because of missing demographic or insurance data, ambiguous fracture location, or age younger than 19 years. Of the 252,109 included patients, 21,638 (9%) underwent surgical fixation of clavicle fractures. A chi-square analysis was performed to determine variables to be included in a multivariable analysis. A binary logistic regression analysis was used to examine demographic and other important variables, with a significance level of p < 0.01. Poisson's regression and a t-test were used to analyze trends over time. Results were recorded as odds ratios (OR) and incidence rate ratios.

RESULTS

After controlling for demographic and potentially relevant variables, such as the median income and fracture location, we found that patients with Medicare, Medicaid, and no insurance had a lower likelihood of undergoing operative fixation of clavicle fractures than did those with private insurance. Patients without insurance were the least likely to undergo surgery (OR, 0.63; 95% CI, 0.60-0.66; p < 0.001), followed by those with Medicare (OR, 0.73; 95% CI, 0.70-0.78; p < 0.001) and those with Medicaid (OR, 0.74; 95% CI, 0.69-0.78; p < 0.001). Women, black, and Hispanic patients were also less likely to undergo surgery than men and white patients (OR, 0.95; p = 0.003; OR = 0.67; p < 0.001; and OR = 0.82; p < 0.001, respectively) There was an increase in the overall proportion of patients undergoing surgery, from 5% in 2001 to 11% in 2013 (incidence rate ratio, 2.99; p < 0.001).

CONCLUSIONS

We believe that the greater use of surgery among adult patients with clavicle fractures who have private insurance than among those with nonprivate or no insurance-as well as among men and white patients compared with women and patients of color-may be a manifestation of important health care disparities in the inpatient population. This may be owing to variable access to care or a difference in the likelihood that a surgeon will offer surgery based on a patient's insurance status. Because operative fixation of closed clavicle fractures increases in the adult population, future research should elucidate conscious and subconscious motivations of patients and surgeons to better inform the discussion of health care disparities in orthopaedics.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Effectiveness of intravenous acetaminophen for postoperative pain management in shoulder arthroplasties: A population-based study

Background

Intravenous acetaminophen (IV APAP) is an option in multimodal postoperative analgesia. Prior trials focus on hip and knee arthroplasties, whereas large-scale data on utilization and effectiveness in shoulder arthroplasties are lacking.

Methods

Data on 67,494 (452 hospitals) partial/total shoulder arthroplasties were extracted from the Premier claims database (2011-2016). Patients were categorized by receipt and dosage of IV APAP. Multilevel models measured associations between IV APAP and opioid utilization (in oral morphine equivalents), length/cost of stay and opioid-related complications. Effect estimates (adjusted % change) with 95% confidence intervals (CIs) are reported.

Results

IV APAP was used in 17.7% (n = 11,949) of patients with an increasing utilization trend. Most patients received only one dose on the day of surgery (69.5%; n = 8308). When adjusting for relevant covariates, IV APAP was not associated with meaningful effects on outcomes. Specifically, its use (versus no use) was not associated with decreased (but rather somewhat increased) opioid utilization: + 5.4% (CI 3.6-7.1%; P < 0.05).

Conclusion

In this first large-scale study that assesses IV APAP in shoulder arthroplasties, IV APAP use was not associated with decreased opioid utilization or the length/cost of stay. These results do not support routine use of IV APAP in this cohort, especially given its high cost.

The translational potential for this article

Multimodal pain control to assist in reducing the opioid pain medications are seen as a route to improved postoperative patient outcomes, better pain control and expedited hospital discharge. Acetaminophen plays a significant role in these protocols in many institutions, but it is not established if this expensive IV formulation is superior to the oral formulation. This study evaluates the use and effectiveness of IV acetaminophen following shoulder arthroplasty at a large number of institutions.

Health Care Burden Associated with Outpatient Opioid Use Following Inpatient or Outpatient Surgery

BACKGROUND

The treatment of postsurgical pain with prescription opioids has been associated with persistent opioid use and increased health care utilization and costs.

OBJECTIVE

To compare the health care burden between opioid-naive adult patients who were prescribed opioids after a major surgery and opioidnaive adult patients who were not prescribed opioids.

METHODS

Administrative claims data from the IBM Watson Health MarketScan Research Databases for 2010-2016 were used. Opioid-naive adult patients who underwent major inpatient or outpatient surgery and who had at least 1 year of continuous enrollment before and after the index surgery date were eligible for inclusion. Cohorts were defined based on an opioid pharmacy claim between 7 days before index surgery and 1 year after index surgery (opioid use during surgery and inpatient use were not available). To ensure an opioid-naive population, patients with opioid claims between 365 and 8 days before surgery were excluded. Acute medical outcomes, opioid utilization, health care utilization, and costs were measured during the post-index period (index surgery hospitalization and day of index outpatient surgery not included). Predicted costs were estimated from multivariable log-linked gamma-generalized linear models.

RESULTS

The final sample consisted of 1,174,905 opioid-naive patients with an inpatient surgery (73% commercial, 20% Medicare, 7% Medicaid) and 2,930,216 opioid-naive patients with an outpatient surgery (74% commercial, 23% Medicare, and 3% Medicaid). Opioid use after discharge was common among all 3 payer types but was less common among Medicare patients (63% inpatient/43% outpatient) than patients with commercial (80% inpatient/75% outpatient) or Medicaid insurance (86% inpatient/81% outpatient). Across all 3 payers, opioid users were younger, were more likely to be female, and had a higher preoperative comorbidity burden than nonopioid users. In unadjusted analyses, opioid users tended to have more hospitalizations, emergency department visits, and pharmacy claims. Adjusted predicted 1-year post-period total health care costs were significantly higher (P< 0.001) for opioid users than nonopioid users for commercial insurance (inpatient: $22,209 vs. $14,439; outpatient: $13,897 vs. $8,825), Medicare (inpatient: $31,721 vs. $26,761; outpatient: $24,529 vs. $15,225), and Medicaid (inpatient: $13,512 vs. $9,204; outpatient: $11,975 vs. $8,212).

CONCLUSIONS

Filling an outpatient opioid prescription (vs. no opioid prescription) in the 1 year after inpatient or outpatient surgery was associated with increased health care utilization and costs across all payers.

DISCLOSURES

Funding for this study was provided by Heron Therapeutics, which participated in analysis and interpretation of data, drafting, reviewing, and approving the publication. All authors contributed to the development of the publication and maintained control over the final content. Brummett is a paid consultant for Heron Therapeutics and Recro Pharma and reports receipt of research funding from MDHHS (Sub K Michigan Open), NIDA (Centralized Pain Opioid Non-Responsiveness R01 DA038261-05), NIH0DHHS-US-16 PAF 07628 (R01 NR017096-05), NIH-DHHS (P50 AR070600-05 CORT), NIH-DHHS-US (K23 DA038718-04), NIH-DHHS-US-16-PAF06270 (R01 HD088712-05), NIH-DHHS-US-17-PAF02680 (R01 DA042859-05), and UM Michigan Genomics Initiative and holding a patent for peripheral perineural dexmedetomidine. Oderda is a paid consultant for Heron Therapeutics. Pawasauskas is a paid consultant to Heron Therapeutics and Mallinckrodt Pharmaceuticals. England and Evans-Shields are employees of Heron Therapeutics. Kong, Lew, Zimmerman, and Henriques are employees of IBM Watson Health, which was compensated by Heron Therapeutics for conducting this research. Portions of this work were presented as a poster at the AMCP Managed Care and Specialty Pharmacy Annual Meeting 2019; March 25-28, 2019; San Diego, CA.

Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury

PURPOSE

We aimed to produce comprehensive guidelines and recommendations that can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury.

METHODS

A panel of 15 members with expertise in orthopaedic trauma, pain management, or both was convened to review the literature and develop recommendations on acute musculoskeletal pain management. The methods described by the Grading of Recommendations Assessment, Development, and Evaluation Working Group were applied to each recommendation. The guideline was submitted to the Orthopaedic Trauma Association (OTA) for review and was approved on October 16, 2018.

RESULTS

We present evidence-based best practice recommendations and pain medication recommendations with the hope that they can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. Recommendations are presented regarding pain management, cognitive strategies, physical strategies, strategies for patients on long term opioids at presentation, and system implementation strategies. We recommend the use of multimodal analgesia, prescribing the lowest effective immediate-release opioid for the shortest period possible, and considering regional anesthesia. We also recommend connecting patients to psychosocial interventions as indicated and considering anxiety reduction strategies such as aromatherapy. Finally, we also recommend physical strategies including ice, elevation, and transcutaneous electrical stimulation. Prescribing for patients on long term opioids at presentation should be limited to one prescriber. Both pain and sedation should be assessed regularly for inpatients with short, validated tools. Finally, the group supports querying the relevant regional and state prescription drug monitoring program, development of clinical decision support, opioid education efforts for prescribers and patients, and implementing a department or organization pain medication prescribing strategy or policy.

CONCLUSIONS

Balancing comfort and patient safety following acute musculoskeletal injury is possible when utilizing a true multimodal approach including cognitive, physical, and pharmaceutical strategies. In this guideline, we attempt to provide practical, evidence-based guidance for clinicians in both the operative and non-operative settings to address acute pain from musculoskeletal injury. We also organized and graded the evidence to both support recommendations and identify gap areas for future research.

Reduced length of stay and hospitalization costs among inpatient hysterectomy patients with postoperative pain management including IV versus oral acetaminophen

OBJECTIVE

To compare the outcomes of hysterectomy patients who received standard pain management including IV acetaminophen (IV APAP) versus oral APAP.

METHODS

We performed a retrospective analysis of the Premier Database (January 2012 to September 2015) comparing hysterectomy patients who received postoperative pain management including IV APAP to those who received oral APAP starting on the day of surgery and continuing up to the third post-operative day, with no exclusions based on additional pain management. We compared the groups on length of stay (LOS), hospitalization costs, and average daily morphine equivalent dose (MED). The quarterly rate of IV APAP use for all hospitalizations by hospital was used as an instrumental variable in two-stage least squares regressions also adjusting for patient demographics, clinical risk factors, and hospital characteristics.

RESULTS

We identified 22,828 hysterectomy patients including 14,811 (65%) who had received IV APAP. Study subjects averaged 50 and 52 years of age, respectively in the IV APAP and oral APAP cohorts and were predominantly non-Hispanic Caucasians (≥60% in both cohorts). Instrumental variable models found IV APAP associated with 0.8 days shorter hospitalization (95% CI: -0.92 to -0.68, p<0.0001) and $2,449 lower hospitalization costs (95% CI: -$2,902 to -$1,996, p<0.0001). Average daily MED trended lower without statistical significance (-1.41 mg, 95% CI: -3.43 mg to 0.61 mg, p = 0.17).

CONCLUSIONS

Compared to oral APAP, managing post-hysterectomy pain with IV APAP is associated with shorter LOS and lower total hospitalization costs.

Hospitalization costs and resource allocation in cholecystectomy with use of intravenous versus oral acetaminophen

OBJECTIVE

To evaluate intravenous (IV) acetaminophen (APAP) vs oral APAP use as adjunctive analgesics in cholecystectomy patients by comparing associated hospital length of stay (LOS), hospital costs, opioid use, and rates of nausea/vomiting, respiratory depression, and bowel obstruction.

METHODS

We conducted a retrospective analysis of the Premier Database (January 2012 to September 2015) including cholecystectomy patients who received either IV APAP or oral APAP. Differences in LOS, hospitalization costs, mean daily morphine equivalent dose (MED), and potential opioid-related adverse events were estimated. Multivariable logistic regression was performed for the binary outcomes and instrumental variable regressions, using the quarterly rate of IV APAP use for all hospitalizations by hospital as the instrument in two-stage least squares regressions for continuous outcomes. Models were adjusted for patient demographics, clinical risk factors, and hospital characteristics.

RESULTS

Among 61,017 cholecystectomy patients, 31,133 (51%) received IV APAP. Subjects averaged 51 and 57 years of age, respectively, in the IV and oral APAP cohorts. In the adjusted models, IV APAP was associated with 0.42 days shorter LOS (95% CI = -0.58 to -0.27; p < .0001), $1,045 lower hospitalization costs (95% CI = -$1,521 to -$569; p < .0001), 2 mg lower average daily MED (95% CI = -3 mg to -0.9 mg; p = .0005), and lower rates of respiratory depression (odds ratio [OR] = 0.89, 95% CI = 0.82-0.97; p = .006), and nausea and vomiting (OR = 0.86, 95% CI = 0.86-0.86; p < .0001).

CONCLUSIONS

In patients having cholecystectomy, the addition of IV APAP to perioperative pain management is associated with shorter LOS, lower costs, reduced opioid use, and less frequent nausea/vomiting and respiratory depression compared to oral APAP. These findings should be confirmed in a prospective study comparing IV and oral APAP.

Improved Outcomes Associated With the Use of Intravenous Acetaminophen for Management of Acute Post-Surgical Pain in Cesarean Sections and Hysterectomies

Background

Post-surgical pain impacts many patient outcomes. Effective pain management increasingly relies on multimodal analgesia regimens in which acetaminophen (APAP) is a key component. The aim of our study was to examine the impact of oral APAP versus intravenous (IV) APAP as a component of post-surgical pain management after Cesarean sections and hysterectomies.

Methods

A retrospective analysis of the Cerner HealthFacts® database (from January, 2011 to December, 2015) was conducted to compare outcomes of Cesarean section and hysterectomy surgery patients who received oral APAP to those who received IV APAP post-surgically. Length of stay (LOS), daily morphine milligram equivalent (MME) consumption, the presence of potential opioid-related adverse events (ORADEs), and total pharmacy costs were assessed. Adjusted results were derived using inverse probability weighted regression adjustment (IPW-RA) estimators based on covariates that included demographics, comorbidities, patient clinical characteristics, and hospital characteristics.

Results

The study identified 29,124 Cesarean section patients (24,612 oral APAP; 4,512 IV APAP) and 9,767 hysterectomy surgery patients (5,586 oral APAP; 4,181 IV APAP). Compared to the oral APAP group, the IV APAP group had reductions in adjusted LOS (Cesarean section: -11.7% days (P < 0.001), hysterectomy: -11.8% days (P = 0.005)), lowered adjusted daily MME consumption from day 0 to day 3 (Cesarean section: -1.6 mg (P < 0.001), hysterectomy: -1.7 mg (P = 0.014)), and reduced risk of ORADEs for Cesarean sections (relative risk of 0.45, P < 0.001). Total pharmacy costs were not significantly different between the two APAP groups.

Conclusions

Post-surgical pain managed with IV APAP in patients undergoing Cesarean section or hysterectomy was associated with shorter LOS, reduced risk of ORADEs, and lower opioid consumption compared to patients managed with oral APAP, without adversely impacting total pharmacy costs.

Comparative Analysis of Inpatient Costs for Obstetrics and Gynecology Surgery Patients Treated With IV Acetaminophen and IV Opioids Versus IV Opioid-only Analgesia for Postoperative Pain

BACKGROUND

Recovery from obstetrics and gynecology (OB/GYN) surgery, including hysterectomy and cesarean section delivery, aims to restore function while minimizing hospital length of stay (LOS) and medical expenditures.

OBJECTIVE

Our analyses compare OB/GYN surgery patients who received combination intravenous (IV) acetaminophen and IV opioid analgesia with those who received IV opioid-only analgesia and estimate differences in LOS, hospitalization costs, and opioid consumption.

METHODS

We performed a retrospective analysis of the Premier Database between January 2009 and June 2015, comparing OB/GYN surgery patients who received postoperative pain management with combination IV acetaminophen and IV opioids with those who received only IV opioids starting on the day of surgery and continuing up to the second postoperative day. We performed instrumental variable 2-stage least-squares regressions controlling for patient and hospital covariates to compare the LOS, hospitalization costs, and daily opioid doses (morphine equivalent dose) of IV acetaminophen recipients with that of opioid-only analgesia patients.

RESULTS

We identified 225 142 OB/GYN surgery patients who were eligible for our study of whom 89 568 (40%) had been managed with IV acetaminophen and opioids. Participants averaged 36 years of age and were predominantly non-Hispanic Caucasians (60%). Multivariable regression models estimated statistically significant differences in hospitalization cost and opioid use with IV acetaminophen associated with $484.4 lower total hospitalization costs (95% CI = -$760.4 to -$208.4; P = 0.0006) and 8.2 mg lower daily opioid use (95% CI = -10.0 to -6.4), whereas the difference in LOS was not significant, at -0.09 days (95% CI = -0.19 to 0.01; P = 0.07).

CONCLUSION

Compared with IV opioid-only analgesia, managing post-OB/GYN surgery pain with the addition of IV acetaminophen is associated with decreased hospitalization costs and reduced opioid use.

Comparative analysis of length of stay, hospitalization costs, opioid use, and discharge status among spine surgery patients with postoperative pain management including intravenous versus oral acetaminophen

BACKGROUND

Recovery from spine surgery is oriented toward restoring functional health outcomes while reducing resource use. Optimal pain management is a key to reaching these objectives. We compared outcomes of spine surgery patients who received standard pain management including intravenous (IV) acetaminophen (APAP) vs. oral APAP.

METHODS

We performed a retrospective analysis of the Premier database (January 2012 to September 2015) comparing spine surgery patients who received pain management with IV APAP to those who received oral APAP, with no exclusions based on additional pain management. We performed multivariable logistic regression for the discharge and all cause 30-day readmission to the same hospital outcomes and instrumental variable regressions using the quarterly rate of IV APAP use for all hospitalizations by hospital as the instrument in two-stage least squares regressions for length of stay (LOS), hospitalization costs, and average daily morphine equivalent dose (MED) outcomes. Models adjusted for age, gender, race, admission type, 3M All Patient Refined Diagnosis Related Group severity of illness and risk of mortality, hospital size, and indicators for whether the hospital was an academic center and whether it was urban or rural.

RESULTS

We identified 112,586 spine surgery patients with 51,835 (46%) having received IV APAP. Subjects averaged 57 and 59 years of age respectively in the IV APAP and oral APAP cohorts and were predominantly non-Hispanic Caucasians and female. In our adjusted models, IV APAP was associated with 0.68 days shorter LOS (95% CI: -0.76 to -0.59, p < .0001), $1175 lower hospitalization costs (95% CI: -$1611 to -$739, p < .0001), 13 mg lower average daily MED (95% CI: -14 mg to -12 mg, p < .0001), 34% lower risk of discharge to a skilled nursing facility (95% CI: 0.63 to 0.69, p < .0001), and 13% less risk of 30-day readmission (95% CI: 0.73 to 1.03).

CONCLUSIONS

Compared to oral APAP, managing post-spine-surgery pain with IV APAP is associated with less resource use, lower costs, lower doses of opioids, and improved discharge status.

The efficiency and safety of fascia iliaca block for pain control after total joint arthroplasty: A meta-analysis

BACKGROUND

This meta-analysis aimed to perform a meta-analysis including randomized controlled trials (RCTs) to assess the efficiency and safety of fascia iliaca block (FIB) for pain control in patients undergoing total joint arthroplasty (TJA).

METHODS

A systematic search was performed in Medline (1966-2017.03), PubMed (1966-2017.03), Embase (1980-2017.03), ScienceDirect (1985-2017.03) and the Cochrane Library. Study evaluated the efficiency and safety of FIB in TJA was selected. Meta-analysis was performed using Stata 11.0 software.

RESULTS

Five randomized controlled trials (RCTs) including 270 patients met the inclusion criteria. The present meta-analysis indicated that there were significant differences between groups in terms of visual analog scale (VAS) score at 12 hours (SMD = -0.544, 95% CI: -0.806 to -0.281, P = .000) and 24 hours (SMD = -0.519, 95% CI: -0.764 to -0.273, P = .000), morphine equivalent consumption at 12 hours (SMD = -0.895, 95% CI: -1.164 to -0.626, P = .000) and 24 hours (SMD = -0.548, 95% CI:-0.793 to -0.303, P = .000). In addition, fewer adverse side effect was identified in FIB groups (RD = -0.139, 95% CI: -0.243 to -0.034, P = .009).

CONCLUSION

The application of fascia iliaca block could significantly reduce VAS scores and morphine consumption at 12 and 24 hours following total knee and hip arthroplasty. In addition, there were fewer adverse effects in FIB groups. Due to the limited quality of the evidence currently available, higher quality RCTs are required.

Estimating the Effect of Intravenous Acetaminophen for Postoperative Pain Management on Length of Stay and Inpatient Hospital Costs

Introduction

The provision of safe, effective, cost-efficient perioperative inpatient acute pain management is an important concern among clinicians and administrators within healthcare institutions. Overreliance on opioid monotherapy in this setting continues to present health risks for patients and increase healthcare costs resulting from preventable adverse events. The goal of this study was to model length of stay (LOS), potential opioid-related complications, and costs for patients reducing opioid use and adding intravenous acetaminophen (IV APAP) for management of postoperative pain.

Methods

Data for this study were de-identified inpatient encounters from The Advisory Board Company across 297 hospitals from 2012–2014, containing 2,238,433 encounters (IV APAP used in 12.1%). Encounters for adults ≥18 years of age admitted for cardiovascular, colorectal, general, obstetrics and gynecology, orthopedics, or spine surgery were included. The effects of reducing opioids and adding IV APAP were estimated using hierarchical statistical models. Costs were estimated by multiplying modeled reductions in LOS or complication rates by observed average volumes for medium-sized facilities, and by average cost per day or per complication (LOS: US$2383/day; complications: derived from observed charges).

Results

Across all surgery types, LOS showed an average reduction of 18.5% (10.7–32.0%) for the modeled scenario of reducing opioids by one level (high to medium, medium to low, or low to none) and adding IV APAP, with an associated total LOS-related cost savings of $4.5 M. Modeled opioid-related complication rates showed similar improvements, averaging a reduction of 28.7% (5.4–44.0%) with associated cost savings of $0.2 M. In aggregate, costs decreased by an estimated $4.7 M for a medium-sized hospital. The study design demonstrates associations only and cannot establish causal relationships. The cost impact of LOS is modeled based on observed data.

Conclusions

This investigation indicates that reducing opioid use and including IV APAP for postoperative pain management has the potential to decrease LOS, opioid-related complication rates, and costs from a hospital perspective.

Funding

Mallinckrodt Pharmaceuticals.