Poor outcomes seen in elective total joint arthroplasty patients who take opioids preoperatively06/19/2019
According to recently published results, there was a significant correlation between increased health care costs and adverse perioperative surgical outcomes in patients who used opioids prior to total joint arthroplasty.
“For orthopedic surgeons, I believe that the key takeaway here is that preoperative opioid use is associated with poor outcomes for the patients [those] orthopedists are caring for,” Elizabeth Ann Stringer, PhD, told Healio.com/Orthopedics. “That includes longer length of stay, readmissions, infections [and] revisions, which then drive higher costs associated with those patients who are taking opioids preoperative[ly].”
She added, “What we found is that preoperative opioid use was also associated with persistent opioid use after the surgery and that worsened with dose. So, when we think not just in terms of acute outcomes within the those first 6 to 18 months post-surgery, we’re all thinking long term about how this affects patients who are in episodes of chronic pain and long-term outcomes.”
In a retrospective study of administrative medical and pharmaceutical claims, Stringer and colleagues identified 34,792 patients who underwent elective total knee replacement, total hip replacement or total shoulder replacement. Patients were considered preoperative opioid users if prescriptions were filled in two periods: at 1 day to 30 days and at 31 to 90 days preoperatively. The effects of preoperative opioid use and opioid dose, adjusted for demographics, comorbidities and utilization, were determined with zero-truncated Poisson regression, logistic regression, Cox regression and quantile regression.
Of the 34,792 patients identified, 6,043 patients were preoperative opioid users. The median morphine-equivalent daily dose was 32 mg. Preoperative opioid users had increased length of hospital stay, non-home discharge and 30-day unplanned readmission. These patients also had greater odds for surgical site infections (HR=1.35) and greater odds for surgical revision (HR=1.44). They had a 64% lower opioid cessation rate and a median $1,084 increase in medical costs during the 1 year after discharge vs. patients who did not fill two or more prescriptions during the two time periods.
“The effect of behavioral health conditions … [has] an effect on postsurgical outcomes and it highlights the need to address the care of patients comprehensively,” Stringer said. “So, orthopedists need to perform the care they are experts in, but we need to do a better job of coordinating care between experts and specialists with keeping the focus on what’s best [for] that individual patient and not thinking of the patients in isolated diseased states.”
Stringer said it is important to engage providers in education about what the consequences of long-term opioid use are if they proceed with surgery.
“I think we can also use this to help providers to have better conversations with their patients on the correct course of care for that individual patient and letting the patients play an active role in their own care,” she said.