Prevalence of Prescription Opioids for Nonoperative Treatment of Rotator Cuff Disease Is High

Rotator Cuff Tendinopathy Diagnosis, Nonsurgical Medical Care, and Rehabilitation: A Clinical Practice Guideline

This evidence-based clinical practice guideline (CPG) aims to guide clinicians with recommendations covering the assessment, treatment, and prognosis of adults with shoulder pain with suspected rotator cuff (RC) tendinopathy, the nonsurgical medical care and rehabilitation of adults with RC tendinopathy, as well as the return to function and sport for elite and recreational athletes. This CPG includes recommendations for managing RC tendinopathy with or without calcifications and partial-thickness RC tears. J Orthop Sports Phys Ther 2025;55(4):235-274. Epub 30 January 2025. doi:10.2519/jospt.2025.13182.

Real-world clinical and economic impacts of delayed rotator cuff repair surgery in Japan: analysis of a large claims database

Background

In patients with rotator cuff tears (RCTs), there is a lack of evidence regarding the impact of the timeliness of rotator cuff repair (RCR) surgery on treatment outcomes and overall healthcare burden. This study aimed to understand the impact of early vs. delayed RCR on real-world healthcare costs and resource use (HCRU) in Japan.

Methods

This study utilized JMDC health insurance claims data from January 2012 to February 2021. Patients aged ≥18 years were included if they had ≥1 inpatient or ≥2 nondiagnostic outpatient claims (≥1 month apart) for RCT (diagnosis codes S460/S468), had RCR (procedure codes K080-X) within 12 months postindex, and had 12 months post-RCR continuous enrollment. Index month was defined upon the first RCT claim, and surgery month was defined upon the first RCR. Patients were categorized as having had early (≤1 month postindex) or delayed (2-12 months postindex) RCR. RCT-related HCRU were reported for the 12-month postindex or postsurgery periods.

Results

Of 1243 RCR patients, 68.9% were male and the mean (standard deviation [SD]) age was 55.3 (8.9) years. Of 46.3% patients with an initial diagnosis of tendinosis, their RCT was diagnosed for only a mean (SD) of 5.7 (4.0) months later. The mean (SD) time from index to first RCR was 2.4 (2.3) months; 518 (41.7%) patients had early RCR. The mean total RCT-related healthcare costs were higher for patients with delayed vs. early RCR (P < .05 for both postindex and surgery). The mean (SD) postsurgery inpatient costs were higher for delayed vs. early RCR (¥1,260,066 vs. ¥1,119,381; P < .05), possibly partly driven by longer hospital stays among delayed RCR patients. Patients with delayed RCR had a higher mean number of physical therapy visits compared with early RCR, especially postsurgery (42.6 vs. 38.4; P < .05); physical therapy costs were significantly higher for delayed RCR patients, compared with early RCR, for both postindex or postsurgery periods (P < .05). During the postindex period, higher proportions of delayed vs. early RCR patients received opioids (22.1% vs. 16.2%; P < .05), nonopioid pain medications (77.7% vs. 69.5%; P < .05), cortisone injections (47.2% vs. 33.8%; P < .05), and oral cortisone (4.8% vs. 1.4%; P < .05). The mean outpatient pharmacy prescription costs were significantly higher for delayed vs. early RCR for both the postindex and postsurgery periods (both P < .05).

Conclusions

Long delays in the diagnosis or treatment of RCT in Japan may lead to higher burdens of healthcare. Patients with delayed RCR may require more prescription medications and/or PT before and after surgery. Improving the timeliness of RCT treatment could therefore reduce overall HCRU.

Nonoperative Treatment of Rotator Cuff Tears

Rotator cuff tears are common with prevalence increasing with age. Diagnosis by physical examination may require a cluster of tests. Although radiographs can be helpful, MRI, MRI arthrography, and ultrasound represent the most used imaging technique to identify rotator cuff tears. Although surgery is sometimes necessary, a large portion of patients may respond to conservative treatment including physical therapy and injections. Physical therapy should include restoring the range of motion, addressing any pectoralis minor or posterior capsule stiffness, and restoring motor control/strength to the scapula and rotator cuff. Other conservative treatments may include nonsteroidal anti-inflammatory drugs, corticosteroid injects, and platelet-rich plasma.

Impact of an opioid prescribing alert system on patients with posttraumatic stress disorder

BACKGROUND AND OBJECTIVES

Posttraumatic stress disorder (PTSD) is associated with higher rates of chronic pain and increased risk of developing Opioid use disorder. This paper evaluates the impact of PRIMUM, an electronic health record-embedded (EHR) clinical decision support intervention on opioid prescribing patterns for patients with diagnosis of PTSD.

METHODS

Inpatient, emergency department (ED), urgent care, and outpatient encounters with ICD-10 codes F43.1 (PTSD), F43.10 (PTSD, unspecified), F43.11 (PTSD, acute), and F43.12 (PTSD, chronic) at Atrium Health between 1/1/2016 and 12/29/2018 were included in the study.

RESULTS

A total of 3121 patients with a diagnosis of PTSD were seen in 37,443 encounters during the study period. Ten percent (n = 3761) of the encounters resulted in prescriptions for opioids and PRIMUM alerts were triggered in 1488 of these encounters. These alerts resulted in "decision influenced" for 17% of patients (n = 255) or no prescriptions for opioids or benzodiazepines for 5.8% (n = 86). The majority of the prescriptions were below 50 Morphine milligram equivalents (MME)/day, but there were 570 (15.5%) prescriptions for doses of 50-90 MME and 721 (19.6%) prescriptions for >90 MME/day.

DISCUSSION AND CONCLUSION

The PRIMUM alert system helps improve patient safety. PRIMUM affected clinician decisions 17% of the time, and the effect was greater in patients with opioid overdose history and those presenting for early refills.

SCIENTIFIC SIGNIFICANCE

The effectiveness of clinical support interventions for opioid prescribing for patients with PTSD has not been documented previously. Our findings provide novel evidence that the EHR can be used to improve patient safety among patients with PTSD in the context of substance use.