Dataset Information

Institutional Guidelines Can Decrease the Amount of Opioids Prescribed After Total Joint Replacement.

ABSTRACT: Background:In the midst of the nationwide opioid epidemic, our institution began an effort to improve the education of opioid prescribers and disseminate procedure-specific guidelines for the number of opioid pills to prescribe post-operatively for total joint arthroplasty. The number of opioid pills suggested for total hip or knee replacement was 70 tablets. Questions/Purposes:We sought to evaluate the impact of the new institutional guideline on opioid prescribing practices, hypothesizing that it would lead to a decrease in the number of pills prescribed but an increase in patient call volume after discharge. Methods:After the new guidelines were implemented in February 2018, we retrospectively reviewed all opioid prescriptions written for patients on the joint-replacement service from March 2016 to March 2018. In addition, we tabulated post-operative telephone calls made to the nurse practitioner service before and after guideline implementation. The majority of calls to the nurse practitioner service are for opioid renewals. Results:We included 9514 patients in the analysis. Prior to guideline implementation, the mean number of pills prescribed after primary total joint arthroplasty was 91?±?26.6 pills and after it was 65?±?16.3 pills. The monthly number of unique patient telephone interactions was statistically significantly lower after the implementation of the new guidelines. Conclusion:An institutional guideline for opioid prescribing after total joint arthroplasty significantly reduced the number of pills prescribed to patients without causing a significant increase in the number of phone calls to the service.

SUBMITTER: Kahlenberg CA

PROVIDER: S-EPMC6384212 | biostudies-literature | 2019 Feb

REPOSITORIES: biostudies-literature

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Institutional Guidelines Can Decrease the Amount of Opioids Prescribed After Total Joint Replacement.

Kahlenberg Cynthia A CA Stepan Jeffrey G JG Premkumar Ajay A Lovecchio Francis D FD Cross Michael B MB

HSS journal : the musculoskeletal journal of Hospital for Special Surgery 20181001 1

<h4>Background</h4>In the midst of the nationwide opioid epidemic, our institution began an effort to improve the education of opioid prescribers and disseminate procedure-specific guidelines for the number of opioid pills to prescribe post-operatively for total joint arthroplasty. The number of opioid pills suggested for total hip or knee replacement was 70 tablets.<h4>Questions/purposes</h4>We sought to evaluate the impact of the new institutional guideline on opioid prescribing practices, hyp ...[more]

PMID: 30863229

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Project description:Importance:The United States is experiencing an opioid abuse epidemic. Opioid overprescription by physicians may contribute to this epidemic. Objectives:To determine if there was a correlation between a postoperative patient's 24-hour predischarge opioid use and the amount of opioids prescribed at hospital discharge and to determine the number of patients who used no opioids prior to discharge but were still prescribed opioids after hospital discharge. Design, Setting, and Participants:This cross-sectional study performed a retrospective record review of 18 343 postoperative patients at Boston Medical Center and Lahey Hospital and Medical Center-Burlington Campus who were discharged home after a postoperative inpatient admission of at least 24 hours. Data collection spanned from May 22, 2014, to June 30, 2016, in the Boston Medical Center data set and from March 23, 2015, to September 7, 2016, in the Lahey Hospital and Medical Center-Burlington Campus data set. Exposures:Surgery requiring a postoperative inpatient hospital stay longer than 24 hours. Main Outcomes and Measures:The main outcome measures were the patient's 24-hour predischarge opioid use and the total quantity of opioids prescribed at hospital discharge. Potential overprescription was defined as the number of patients who used no opioids in the 24 hours prior to hospital discharge but were still prescribed opioids after hospital discharge. Results:Among the 18 343 patients (10 069 women and 8274 men; mean age, 52.2 years) who underwent 21 452 surgical procedures, there was wide variation in the amount of opioids prescribed at hospital discharge given a postoperative patient's 24-hour predischarge opioid use. A total of 6548 patients (35.7%) used no opioids in the 24 hours prior to hospital discharge; however, 2988 of these patients (45.6%) were prescribed opioids at hospital discharge, suggesting potential overprescription. Services that had the highest rates of potential overprescription (obstetrics [adjusted odds ratio (AOR), 3.146; 95% CI, 2.094-4.765] and gynecology [AOR, 2.355; 95% CI, 1.663-3.390], orthopedics [AOR, 0.943; 95% CI, 0.719-1.242], and plastic surgery [AOR, 0.733; 95% CI, 0.334-1.682]) generally had the highest rates of patients still using opioids at hospital discharge. Pediatric surgery was the only service that did not have any cases of potential overprescription (AOR, 2.09 × 10-7; 95% CI, 0.000-0.016). Conclusions and Relevance:Opioids are not regularly prescribed in a patient-specific manner to postoperative patients. Potential opioid overprescription occurs regularly after surgery among almost all surgical specialties.

Project description:BackgroundTotal hip and total knee replacement (THR/TKR) are common and effective surgeries to reduce the pain and disability associated with arthritis but are associated with small but significant risks of preventable complications such as surgical site infection (SSI) and venous-thrombo-embolism (VTE). This study aims to determine the degree to which hospital care was compliant with clinical guidelines for the prevention of SSI and VTE after THR/TKR; and whether non-compliant prophylaxis is associated with increased risk of complications.Methods and findingsA prospective multi-centre cohort study was undertaken in consenting adults with osteoarthritis undergoing elective primary TKR/THR at one of 19 high-volume Australian public or private hospitals. Data were collected prior to surgery and for one-year post-surgery. Four adjusted logistic regression analyses were undertaken to explore associations between binary non-compliance and the risk of surgical complications: (1) composite (simultaneous) non-compliance with both (VTE and antibiotic) guidelines and composite complications [all-cause mortality, VTE, readmission/reoperation for joint-related reasons (one-year) and non-joint-related reasons (35-days)], (2) VTE non-compliance and VTE outcomes, (3) antibiotic non-compliance and any SSI, and (4) antibiotic non-compliance and deep SSI. Data were analysed for 1875 participants. Guideline non-compliance rates were high: 65% (VTE), 87% (antibiotics) and 95% (composite guideline). Composite non-compliance was not associated with composite complication (12.8% vs 8.3%, adjusted odds ratio [AOR] = 1.41, 95%CI 0.68-3.45, p = 0.40). Non-compliance with VTE guidelines was associated with VTE outcomes (5% vs 2.4%, AOR = 2.83, 95%CI 1.59-5.28,p < 0.001). Non-compliance with antibiotic guidelines was associated with any SSI (14.8% vs 6.1%, AOR = 1.98, 95%CI 1.17-3.62,p = 0.02) but not deep infection (3.7% vs 1.2%,AOR = 2.39, 95%CI 0.85-10.00, p = 0.15).ConclusionsWe found high rates of clinical variation and statistically significant associations between non-compliance with VTE and antibiotic guidelines and increased risk of VTE and SSI, respectively. Complications after THR/TKR surgery may be decreased by improving compliance with clinical guidelines.

Project description:ImportanceChanges in financial incentives have led to more patients being discharged home than to institutional forms of postacute care, such as skilled nursing facilities (SNFs), after elective lower extremity total joint replacement (LEJR).ObjectiveTo evaluate the association of this change with hospital readmissions, surgical complications, and mortality.Design, setting, and participantsThis cohort study used cross-temporal propensity-matching to identify 104 828 adult patients who were discharged home following LEJR between 2016 and 2018 (after changes in financial incentives) and 84 121 adult patients discharged to institutional forms of postacute care (eg, SNFs) between 2011 and 2013 (before changes in financial incentives). A difference-in-differences design was used to compare differences in outcomes between these groups to a propensity-matched group of patients discharged to institutional postacute care in both periods. Data were collected from Pennsylvania all-payer claims database, which includes all surgical procedures and hospitalizations across payers and hospitals in Pennsylvania. Data were analyzed between August 2019 and February 2020.ExposuresType of postacute care (home, including home with home health vs institutional postacute care, including SNF, inpatient rehabilitation facilities, and long-term acute care hospitals).Main outcomes and measuresMain outcomes were 30- and 90-day hospital readmissions, LEJR complication rates, and mortality rates.ResultsOf 189 949 patients, 113 981 (60.0%) were women, and 83 444 (43.9%) were aged 40 to 64 years. The rate of discharge home increased from 63.6% (54 097 of 85 121) in 2011 to 2013 to 78.4% (82 199 of 104 828) in 2016 to 2018. In the adjusted difference-in-differences comparison, matched patients discharged home in 2016 to 2018 had significantly lower 30-day (difference, -2.9%; 95% CI, -4.2% to -1.6%) and 90-day (difference, -3.9%; 95% CI, -5.8% to -2.0%) readmission rates compared with similar patients sent to institutional postacute care in 2011 to 2013. Surgical complication and mortality rates were unchanged. Results were similar across payers and across hospital bundled payment participation status.Conclusions and relevanceIn this cohort study, increases in discharges home following LEJR surgery did not seem to be associated with increased harm during a period in which changes in financial incentives likely spurred observed changes in postacute care.

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Institutional Guidelines Can Decrease the Amount of Opioids Prescribed After Total Joint Replacement.

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Institutional Guidelines Can Decrease the Amount of Opioids Prescribed After Total Joint Replacement.

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