Admission NarxCare Narcotics Scores are not Associated With Adverse Surgical Outcomes or Self-reported Patient Satisfaction Following Elective Spine Surgery

Implementation of Electronic Health Record Integration and Clinical Decision Support to Improve Emergency Department Prescription Drug Monitoring Program Use

STUDY OBJECTIVE(S)

To evaluate the implementation of 3 electronic health record (EHR)-based interventions to increase prescription drug monitoring program (PDMP) use in the emergency department (ED): EHR-PDMP integration, addition of a PDMP risk score, and addition of EHR-based clinical decision support alert to review the PDMP when prescribing an opioid.

METHODS

Three intervention stages were implemented using a prospective stepped-wedge design at 5 university-affiliated EDs split into 3 practice groups. The PDMP use and prescribing rates during the 3 stages were compared with baseline before EHR integration and a sustainability stage where the clinical decision support alert was removed, but EHR integration and risk score remained. Generalized linear mixed model with logit link function and a random intercept for clinicians was analyzed.

RESULTS

The ED provider PDMP review before opioid prescribing was low in all stages. The highest review rate occurred during interruptive clinical decision support alerts, 23.8% (interquartile range 10.6 to 37.5). Overall, opioid prescribing declined, and PDMP review was not associated with a decrease in opioid prescribing. PDMP review was associated with a reduction in the probability of prescribing an opioid as the number of prior opioid prescriptions increased (odds ratio: 0.92 [95% confidence interval: 0.91 to 0.94] for every additional prescription).

CONCLUSION

The EHR-PDMP integration did not increase PDMP use in the ED, but a PDMP risk score and a clinical decision support alert were associated with modest increases in the probability of PDMP review. When the PDMP is reviewed, ED clinicians are less likely to prescribe opioids to patients with a high number of prior opioid prescriptions.

Postoperative spine surgical site infections: high rate of failure of one-stage irrigation and debridement

BACKGROUND CONTEXT

Following spine surgery, postoperative surgical site infection (SSI) is a rare but potentially devastating complication. Previous studies have assessed risk factors for spine SSI and one aimed to develop risk stratification tool to assess management options, but this tool has not been externally validated or regularly used.

PURPOSE

The current study aimed to investigate the rate of SSI following elective spine surgery, surgical management pursued, and success of traditionally utilized one-stage of irrigation and debridement (I&D) with closure over drains.

STUDY DESIGN

Retrospective case-control study.

PATIENT SAMPLE

Adult, elective spine surgeries performed at a single academic institution between 2013 and 2021 were evaluated. Patients who developed SSI requiring surgical intervention were identified.

OUTCOME MEASURES

Those who underwent initial management with I&D and closure over drains were assessed for need of subsequent I&D (considered failure of initial infection management).

METHODS

Of spine surgeries meeting inclusion criteria, those with SSI were identified and management was characterized. For those who did and did not fail attempted one stage I&D with closure over drains, pre-operative and surgical variables from the index procedure as well as infection characteristics were assessed and compared with univariable and multivariable analyses.

RESULTS

Of 11,023 elective spine surgeries, SSI was identified for 76 (0.7%). For initial management, I&D with closure over drains was used for 66 (86.8%) while I&D and wound vacuum management was used 10 (13.2%). Failure of attempted one stage I&D (requiring subsequent I&D procedure) was identified for 18 (27% of those undergoing I&D and closure over drains). Of multiple patient, surgical, and infection characteristics, the only factor identified as independently predictive of one stage I&D failure was presence of bacteremia (odds ratio [OR] 38.3, p=0.0007). Within the sub-cohort of patients with bacteremia, failure of attempted one stage I&D was noted for 80%.

CONCLUSION

Less than one percent of a large cohort of patients undergoing spine surgery were found to develop SSIs. Of those undergoing attempted one stage I&D, most patient, surgical, and infection variables did not influence outcome of the intervention. However, those with bacteremia were at 38.3 times greater odds of failing attempted one-stage I&D. These results suggest considering delayed closure approaches in these cases.

Opioid and Sedative NarxCare Scores Greater Than 300 Are Associated With Adverse Outcomes After Nonemergent Spine Surgery

STUDY DESIGN

This was a prospectively captured cohort study.

OBJECTIVE

To explore associations between the preoperative opioid-specific NarxCare Scores (NCS) (NCS-opioids) as well as sedative-specific NCS (NCS-sedatives) as measures of patients' prescription drug use and (1) 90-day postoperative readmission; (2) ED visits; (3) reoperation; (4) prolonged (>2 d) hospital length of stay (LOS); and (5) nonhome discharge. In addition, we sought to evaluate the previously suggested 300+ threshold as a cutoff for moderate/high-risk designation.

BACKGROUND

The association between preoperative opioids and sedative use and healthcare utilization after nonemergent spine surgery is not well quantified. The NCS is a weighted scalar measure of opioids and sedatives that accounts for the number of prescribing providers, dispensing pharmacies, milligram equivalence doses, and overlapping prescription days.

METHODS

A total of 4680 nonemergent spine surgery cases were included. Preoperative NCS-opioids/sedatives were captured. Bivariate and multivariable regression models were constructed to analyze associations between NCS-opioids/sedatives ranges and outcomes while accounting for baseline differences. Spline regression and propensity score matching (PSM) analyses were also implemented.

RESULTS

For NCS-opioid, multivariable regression demonstrated higher odds of prolonged LOS starting in the 400 to 499 NCS-opioids category [odds ratio (OR): 1.44; 95% confidence interval (CI): 1.05-1.97; P =0.026] going into the 500+ category (OR: 1.94; 95% CI: 1.29-2.93; P =0.002]. The 500+ categories exhibited higher odds of 90-day readmission (OR: 1.77; 95% CI: 1.01-3.09; P =0.045). PSM comparison demonstrated that patients within the 300+ category had higher incidence of prolonged LOS [n=455 (44%) vs . n=537 (52%); P <0.001], 90-day readmission [n=118 (11%) vs . n=155 (15%); P =0.019] and 90-day reoperation [n=51 (4.9%) vs . n=74 (7.2%); P =0.042]. For NCS-sedative; there was higher odds of prolonged LOS (OR: 1.73; 95% CI: 1.14-2.63; P =0.010) and nonhome discharge(OR: 2.09; 95%CI: 1.22-3.63; P =0.008) within the 400 to 499 NCS-sedatives category. PSM comparison demonstrated significantly higher rates of prolonged LOS within the 300+ NCS-sedative cohort ( vs . scores <300), [n=277 (44%) vs. 319 (50%); P =0.021].

CONCLUSION

Spine surgery continues to advance toward patient-specific care. Higher NCS-opioids/sedatives values may predict up to a twofold increase in postoperative healthcare utilization. High values should prompt an interdisciplinary approach to mitigate deleterious prescription drug use.

Patient characteristics and outcomes among bariatric surgery patients with high narcotic overdose scores

BACKGROUND

Obesity-related chronic pain can increase the risk of narcotic abuse in bariatric surgery patients. However, assessment of overdose risk has not been evaluated to date.

METHODS

A NARxCHECK® overdose score ("Narx score") was obtained preoperatively on all patients undergoing bariatric surgery (n = 306) between 2018 and 2020 at a single-center academic bariatric surgery program. The 3-digit score ranges from 000 to 999 and is based on patient risk factors found within the Prescription Drug Monitoring Program. A Narx score ≥ 200 indicates tenfold increased risk of narcotic overdose. Patient characteristics, comorbidities, and emergency room (ER) visits were compared between patients in the upper (≥ 200) and lower (000) terciles of Narx scores. Morphine milligram equivalent (MME) prescribed at discharge and refills was also evaluated.

RESULTS

Patients in the upper tercile represented 32% (n = 99) of the study population, and compared to the lower tercile (n = 101, 33%), were more likely to have depression (63.6% vs 38.6%, p = 0.0004), anxiety (47.5% vs 30.7%, p = 0.0150), and bipolar disorder (6.1% vs 0.0%, p = 0.0120). Median MME prescribed at discharge was the same between both groups (75); however, high-risk patients were more likely to be prescribed more than 10 tablets of a secondary opioid (83.3% vs 0.0%, p = 0.0111), which was prescribed by another provider in 67% of cases. ER visits among patients who did not have a complication or require a readmission was also higher among high-risk patients (7.8% vs 0.0%, p = 0.0043). There were no deaths or incidents of mental health-related ER visits in either group.

CONCLUSION

Patients with a Narx score ≥ 200 were more likely to have mental health disorders and have potentially avoidable ER visits in the setting of standardized opioid prescribing practices. Narx scores can help reduce ER visits by identifying at-risk patients who may benefit from additional clinic or telehealth follow-up.

Admission NarxCare Narcotic Scores Are Associated With Increased Odds of Readmission and Prolonged Length of Hospital Stay After Primary Elective Total Knee Arthroplasty

INTRODUCTION

The association of preoperative narcotic use with postoperative outcomes after primary elective total knee arthroplasty (TKA) has remained poorly characterized. The NarxCare platform analyzes patients' state Prescription Drug Monitoring Program records to assign numerical scores that approximate a patient's overall opioid usage. The present study investigated the utility of admission NarxCare narcotic scores in predicting the odds of adverse events (AEs) after primary elective TKA.

METHODS

Elective primary TKA patients performed at a single institution between October 2017 and May 2020 were evaluated. NarxCare narcotic scores at the time of admission, patient characteristics, 30-day AEs, readmissions, revision surgeries, and mortality were abstracted. Elective TKA patients were binned based on admission NarxCare narcotic scores. The odds of experiencing adverse outcomes were compared.

RESULTS

In total, 1136 patients met the criteria for inclusion in the study (Narx Score 0: n = 293 [25.8%], 1 to 99: n = 253 [22.3%], 100 to 299: n = 368 [32.4%], 300 to 499: n = 161 [14.2%], and 500+: n = 61 [5.37%]). By logistic regression, patients with higher admission narcotic scores tended to have a dose-dependent increase in the odds of prolonged length of hospital stay, readmission within 30 days, and aggregated AEs.

DISCUSSION

Admission narcotic scores may be used to predict readmission and to stratify TKA patients by risk of AEs.

Reducing Postoperative Opioid-prescribing Following Posterior Lumbar Fusion Does Not Significantly Change Patient Satisfaction

STUDY DESIGN

Retrospective comparative; LOE-3.

OBJECTIVE

The purpose of this study was to investigate what effect, if any, an institutional opioid reduction prescribing policy following one- or two-level lumbar fusion has on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey results.

SUMMARY OF BACKGROUND DATA

Previous research has demonstrated that high levels of opioid-prescribing may be related, in part, to a desire to produce superior patient satisfaction.

METHODS

A retrospective review of prospectively collected data was conducted on patients who underwent one- or two-level lumbar fusions L3-S1 between October 2014 and October 2019 at a single institution. Patients with complete survey information were included in the analysis. Patients with a history of trauma, fracture, spinal deformity, fusions more than two levels, or prior lumbar fusion surgery L3-S1 were excluded. Cohorts were based on date of surgery relative to implementation of an institutional opioid reduction policy, which commenced in October 1, 2018. To better compare groups, opioid prescriptions were converted into milligram morphine equivalents (MME).

RESULTS

A total of 330 patients met inclusion criteria: 259 pre-protocol, 71 post-protocol. There were 256 one-level fusions and 74 two-level fusions included. There were few statistically significant differences between groups with respect to patient demographics (P > 0.05) with the exception of number of patients who saw the pain management service, which increased from 36.7% (95) pre-protocol to 59.2% (42) post-protocol; P < 0.001. Estimated blood loss (EBL) decreased from 533 ± 571 mL to 346 ± 328 mL (P = 0.003). Percentage of patients who underwent concomitant laminectomy decreased from 71.8% to 49.3% (P < 0.001). Average opioids prescribed on discharge in the pre-protocol period was 534 ± 425 MME, compared to after initiation of the protocol, that is 320 ± 174 MME (P < 0.001). There was no statistically significant difference with respect to satisfaction with pain control, 4.49 ± 0.85 pre-protocol versus 4.51 ± 0.82 post-protocol (P = 0.986).

CONCLUSION

A reduction in opioids prescribed at discharge after one- or two-level lumbar fusion is not associated with any statistically significant change in patient satisfaction with pain management, as measured by the HCAHPS survey.Level of Evidence: 3.

NarxCare Scores Greater Than 300 Are Associated with Adverse Outcomes After Primary THA

BACKGROUND

The association between preoperative prescription drug use (narcotics, sedatives, and stimulants) and complications and/or greater healthcare utilization (length of stay, discharge disposition, readmission, emergency department visits, and reoperation) after total joint arthroplasty has been established but not well quantified. The NarxCare score (NCS) is a weighted scalar measure of overall prescription opioid, sedative, and stimulant use. Higher scores reflect riskier drug-use patterns, which are calculated based on (1) the number of prescribing providers, (2) the number of dispensing pharmacies, (3) milligram equivalence doses, (4) coprescribed potentiating drugs, and (5) overlapping prescription days. The aforementioned factors have not been incorporated into association measures between preoperative prescription drug use and adverse events after THA. In addition, the utility of the NCS as a scalar measure in predicting post-THA complications has not been explored.

QUESTIONS/PURPOSES

(1) Is the NarxCare score (NCS) associated with 90-day readmission, reoperation, emergency department visits, length of stay, and discharge disposition after primary THA; and are there NCS thresholds associated with a higher risk for those adverse outcomes if such an association exists? (2) Is there an association between the type of preoperative active drug prescription and the aforementioned outcomes?

METHODS

Of 3040 primary unilateral THAs performed between November 2018 and December 2019, 92% (2787) had complete baseline information and were subsequently included. The cohort with missing baseline information (NCS or demographic/racial determinants; 8%) had similar BMI distribution but slightly younger age and a lower Charlson Comorbidity Index (CCI). Outcomes in this retrospective study of a longitudinally maintained institutional database included 90-day readmissions (all-cause, procedure, and nonprocedure-related), reoperations, 90-day emergency department (ED) visits, prolonged length of stay (> 2 days), and discharge disposition (home or nonhome). The association between the NCS category and THA outcomes was analyzed through multivariable regression analyses and a confirmatory propensity score-matched comparison based on age, gender, race, BMI, smoking status, CCI, insurance status, preoperative diagnosis, and surgical approach, which removed significant differences at baseline. A similar regression model was constructed to evaluate the association between the type of preoperative active drug prescription (opioids, sedatives, and stimulants) and adverse outcomes after THA.

RESULTS

After controlling for potentially confounding variables like age, gender, race, BMI, smoking status, CCI, insurance status, preoperative diagnosis, and surgical approach, an NCS of 300 to 399 was associated with a higher odds of 90-day all-cause readmission (odds ratio 2.0 [95% confidence interval 1.1 to 3.3]; p = 0.02), procedure-related readmission (OR 3.3 [95% CI 1.4 to 7.9]; p = 0.006), length of stay > 2 days (OR 2.2 [95% CI 1.5 to 3.2]; p < 0.001), and nonhome discharge (OR 2.0 [95% CI 1.3 to 3.1]; p = 0.002). A score of 400 to 499 demonstrated a similar pattern, in addition to a higher odds of 90-day emergency department visits (OR 2.2 [95% CI 1.2 to 3.9]; p = 0.01). After controlling for potentially confounding variables like age, gender, race, BMI, smoking status, CCI, insurance status, preoperative diagnosis, and surgical approach, we found no clinically important association between an active opioid prescription and 90-day all-cause readmission (OR 1.002 [95% CI 1.001 to 1.004]; p = 0.05), procedure-related readmission (OR 1.003 [95% CI 1.001 to 1.006]; p = 0.02), length of stay > 2 days (OR 1.003 [95% CI 1.002 to 1.005]; p < 0.001), or nonhome discharge (OR 1.002 [95% CI 1.001 to 1.003]; p = 0.019); the large size of the database allowed us to find statistical associations, but the effect sizes are so small that the finding is unlikely to be clinically meaningful. A similarly small association that is unlikely to be clinically important was found between active sedative use and 90-day ED visits (OR 1.002 [95% CI 1.001 to 1.004]; p = 0.02).

CONCLUSION

Preoperative prescription drug use, as reflected by higher NCSs, has a dose-response association with adverse outcomes after THA. Surgeons may use the preoperative NCS to initiate and guide a patient-centered discussion regarding possible postoperative risks associated with prescription drug-use patterns (sedatives, opioids, or stimulants). An interdisciplinary approach can then be initiated to mitigate unfavorable patterns of prescription drug use and subsequently lower patient NCSs. However, given its nature and its reflection of drug-use patterns rather than patients' current health status, the NCS does not qualify as a basis for surgical denial or ineligibility.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Exploration of Overdose Risk Score and Postoperative Complications and Health Care Use After Total Knee Arthroplasty

IMPORTANCE

The adverse outcomes after total knee arthroplasty (TKA) associated with preoperative prescription drug use (ie, use of narcotics, sedatives, and stimulants) have been established but are not well quantified.

OBJECTIVE

To test the association of preoperative overdose risk score (ORS) with postoperative health care use.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted using data on a consecutive sample of individuals who underwent primary TKA from November 2018 through March 2020 at a tertiary care health system. Data were collected using the Orthopaedic Minimal Data Set Episode of Care, a validated data-collection system for all elective orthopedic surgical interventions taking place within the health care system. Outcomes were assessed at 90 days postoperatively. Individuals whose preoperative baseline characteristics or ORS were not provided or who declined to participate were excluded. Data were analyzed from September through October 2020.

EXPOSURE

Patient-specific preoperative ORS, as measured using NarxCare, associated with patterns of prescription drug use.

MAIN OUTCOMES AND MEASURES

Associations between patient-specific ORS categories and 90-day postoperative health care use (ie, prolonged hospital length of stay [LOS; ie, >2 days], nonhome discharge, all-cause 90-day readmission, emergency department [ED] visits, and reoperation) were evaluated. Outcomes were also compared between a group of individuals with ORS less than 300 vs those with ORS 300 or greater who were propensity score matched (4:1; caliper, 0.1) using demographic characteristics (ie, age, sex, race, body mass index, and smoking status) and baseline comorbidities.

RESULTS

Among 4326 individuals who underwent primary TKA, 2623 (60.63%) were women, 3602 individuals (83.26%) were White, the mean (SD) BMI was 32.8 (6.9), and the mean (SD) age was 66.6 (9.2) years; 90-day follow-up was available for the entire cohort. The predominant preoperative diagnosis was osteoarthritis, occurring among 4170 individuals (96.4%). For individuals with an ORS of 300 to 399, there were significantly higher odds of a prolonged LOS (odds ratio [OR], 2.03; 95% CI, 1.46-2.82; P < .001), nonhome discharge (OR, 2.01; 95% CI, 1.37-2.94; P < .001), all-cause 90-day readmission (OR, 1.56; 95% CI, 1.01-2.42; P < .001), and ED visits (OR, 1.62; 95% CI, 1.11-2.38; P = .01) compared with individuals who were prescription drug naive (ie, ORS = 0). Individuals in the highest ORS category (ie, ORS ≥ 500) had the highest ORs for prolonged LOS (OR, 3.71; 95% CI, 2.00-6.87; P < .001), nonhome discharge (OR, 4.09; 95% CI, 2.02-8.29; P < .001), 90-day readmission (OR, 4.41; 95% CI, 2.23-8.71; P < .001), and 90-day reoperation (OR, 6.09; 95% CI, 1.44-25.80; P = .01). Propensity score matching confirmed the association between an ORS of 300 or greater and the incidence of prolonged LOS (244 individuals [11.6%] vs 130 individuals [23.0%]; P < .001), nonhome discharge (176 individuals [8.4%] vs 93 individuals [16.4%]; P < .001), all-cause 90-day readmission (119 individuals [5.7%] vs 65 individuals [11.5%]; P < .001), and all-cause ED visits (198 individuals [9.4%] vs 76 individuals [13.4%]; P = .006).

CONCLUSIONS AND RELEVANCE

This study found that higher ORS was associated with increased health care use after primary TKA. These findings suggest that an ORS of 300 or greater could be used to designate increased risk and guide the preoperative surgeon-patient discussion to modify prescription drug use patterns.

Predictors of Patient Satisfaction in Spine Surgery: A Systematic Review

BACKGROUND

Recently, there has been increased interest in patient satisfaction measures such as Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. In this systematic review, the spine surgery literature is analyzed to evaluate factors predictive of patient satisfaction as measured by these surveys.

METHODS

A thorough literature search was performed in PubMed/MEDLINE, Google Scholar, and Cochrane databases. All English-language articles from database inception to July 2020 were screened for study inclusion according to PRISMA guidelines.

RESULTS

Twenty-four of the 1899 published studies were included for qualitative analysis. There has been a statistically significant increase in the number of publications across years (P = 0.04). Overall, the studies evaluated the relationship between patient satisfaction and patient demographics (71%), preoperative and intraoperative clinical factors (21%), and postoperative factors (33%). Top positive predictors of patient satisfaction were patient and nursing/medical staff relationship (n = 4; 17%), physician-patient relationship (n = 4; 17%), managerial oversight of received care (n = 3; 13%), same sex/ethnicity between patient and physician (n = 2; 8%), and older age (n = 2; 8%). Top negative predictors of patient satisfaction were high Charlson Comorbidity Index/high disability/worse overall health functioning (n = 7; 29%), increased length of hospital stay (n = 4; 17%), high rating for pain/complications/readmissions (n = 4; 17%), and psychosocial factors (n = 3; 13%).

CONCLUSIONS

There is heterogeneity in terms of different factors, both clinical and nonclinically related, that affect patient satisfaction ratings. More research is warranted to investigate the role of hospital consumer surveys in the spine surgical patient population.

Opioid Dependence After Lung Cancer Resection: Institutional Analysis of State Prescription Drug Database

BACKGROUND

The national opioid epidemic is a public health crisis. Thoracic surgery has also been associated with high incidence of new persistent opioid use. Our purpose was to describe the incidence and predictors of opioid use after lung cancer resection.

METHODS

Retrospective review of lung cancer resections from 2015 to 2018 was performed using the Ohio Automated Rx Reporting System. Opioid dosing was recorded as milligram morphine equivalents (MME). Patients were stratified by preoperative opioid use. Chronic preoperative opioid users (opioid dependent) filled > 120 days supply of opioid pain medication in the 12 months prior to surgery; intermittent opioid users filled < 120 days. Chronic postoperative opioid users continued monthly use after 180 days postoperatively.

RESULTS

137 patients underwent resection. 16.1% (n = 22) were opioid dependent preoperatively, 29.2% (n = 40) were intermittent opioid users, and 54.7% (n = 75) were opioid naïve. Opioid dependent patients had higher daily inpatient opioid use compared to intermittent users and opioid naïve (43[30.0-118.1] MME vs 17.9[3.5-48.8] MME vs 8.8[2.1-25.0] MME, p < 0.001). Twenty-six percent (n = 35) of all patients were opioid users beyond 180 days postoperatively. Variables associated with opioid use > 180 days were: chronic preoperative opioid use (OR 23.8, p < 0.01), daily inpatient opioid requirement (1.02, p < 0.01), and neoadjuvant chemotherapy (28.2, p < 0.01).

CONCLUSIONS

A quarter of patients are opioid dependent after lung cancer resection. This is due to both preexisting and new persistent opioid use. Improved strategies are needed to prevent chronic pain and opioid dependence after lung cancer resection.