Development of a Medicare Claims-Based Model to Predict Persistent High-Dose Opioid Use After Total Knee Replacement.
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ABSTRACT: Objective
To develop a claims-based model to predict persistent high-dose opioid use among patients undergoing total knee replacement (TKR).Methods
Using Medicare claims (2010-2014), we identified patients ages ≥65 years who underwent TKR with no history of high-dose opioid use (mean >25 morphine milligram equivalents [MMEs]/day) in the year prior to TKR. We used group-based trajectory modeling to identify distinct opioid use patterns. The primary outcome was persistent high-dose opioid use in the year after TKR. We split the data into training (2010-2013) and test (2014) sets and used logistic regression with least absolute shrinkage and selection operator regularization, utilizing a total of 83 preoperative patient characteristics as candidate predictors. A reduced model with 10 prespecified variables, which included demographic characteristics, opioid use, and medication history was also considered.Results
The final study cohort included 142,089 patients who underwent TKR. The group-based trajectory model identified 4 distinct trajectories of opioid use (group 1: short-term, low-dose; group 2: moderate-duration, low-dose; group 3: moderate-duration, high-dose; and group 4: persistent high-dose). The model predicting persistent high-dose opioid use achieved high discrimination (receiver operating characteristic area under the curve [AUC] 0.85 [95% confidence interval (95% CI) 0.84-0.86]) in the test set. The reduced model with 10 predictors performed equally well (AUC 0.84 [95% CI 0.84-0.85]).Conclusion
In this cohort of older patients, 10.6% became persistent high-dose (mean 22.4 MME/day) opioid users after TKR. Our model with 10 readily available clinical factors may help identify patients at high risk of future adverse outcomes from persistent opioid use after TKR.
SUBMITTER: Gopalakrishnan C
PROVIDER: S-EPMC8280246 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:OBJECTIVE:To examine patterns of prescription opioid use before total joint replacement (TJR) and factors associated with continuous use of opioids before TJR. DESIGN:We conducted an observational cohort study among Medicare enrollees aged ?65 years who underwent TJR between 2010 and 2014. Preoperative opioid use was defined as having any opioid prescription in the 12-month period before TJR. Patients who had an opioid prescription every month for a 12-month period were defined as continuous users. We examined patients' demographics, pain-related conditions, medication use, other comorbidities, healthcare utilization and their association with use of opioids before TJR. RESULTS:A total of 473,781 patients underwent TJR:,155,516 THR and 318,265 TKR. Among the total cohort, 60.2% patients had any use of opioids and of those, 12.4% used opioids at least once a month continuously over the 12-month baseline period. Correlates of continuous opioid use included African American race (OR = 2.14, 95% confidence intervals (CI) = 2.01-2.28, compared to White patients), history of drug abuse (OR = 5.18, 95% CI = 3.95-6.79) and back pain (OR = 2.32, 95% CI = 2.24-2.39). CONCLUSIONS:In this large cohort of patients undergoing TJR, over 60% ever used opioids and 12.4% of them continuously used opioids in the 12-month prior to surgery. Utilization of opioids became more frequent and high-dosed near the surgery. History of drug abuse, back pain, and African American race were strongly associated with continuous use of opioids preoperatively. Further research is needed to determine short-term and long-term risks of preoperative use of opioids in TJR patients and to optimize pre- and post-TJR pain management of patients with arthritis.
| S-EPMC6751003 | biostudies-literature
Project description:BACKGROUND:Although new persistent opioid use and high-risk prescribing have been recognized as important postoperative complications among younger patients (18-64 years of age), little is known about the incidence for postoperative opioid use among older patients (>65 years of age). METHODS:We analyzed a 20% national sample of Medicare Part D claims among beneficiaries >65 years of age who underwent a major or minor surgical procedure between January 1, 2009, and June 30, 2015. We identified patients without an opioid prescription fill in the year before surgery and examined their perioperative and 6-month postoperative opioid prescription fills to examine the incidence of new persistent opioid use and high-risk prescribing. RESULTS:We identified 81,839 opioid naïve patients who underwent surgery and filled an opioid prescription perioperatively. Overall, 9.8% developed new persistent opioid use. Risk factors for new persistent opioid use included major surgery (adjusted odds ratio [aOR] 1.24, 95% confidence interval [CI] 1.17-1.31), more comorbid conditions (aOR 1.71, 95% CI 1.58-1.84), mood disorders (aOR 1.16, 95% CI 1.09-1.24), suicide or self-harm (aOR 1.60, 95% CI 1.05-2.44), substance abuse disorders (aOR 1.38, 95% CI 1.20-1.59), filling an opioid prescription before surgery (aOR 1.67, 95% CI 1.58-1.77), higher amounts of opioids filled (aOR 1.44, 95% CI 1.37-1.52), black race (aOR 1.23, 95% CI 1.12-1.36), and Medicaid eligibility (aOR 1.45, 95% CI 1.35-1.55). CONCLUSION:About 10% of Medicare beneficiaries who were previously opioid naïve continue to fill opioids past 3 months after surgery. In addition to comorbidities and mental health conditions, new persistent opioid use is associated with surgery type, preoperative opioid fill, high-risk prescribing practices, and sociodemographic factors.
| S-EPMC7216555 | biostudies-literature
Project description:BackgroundOpioids are commonly used to manage orthopedic pain in those undergoing total knee arthroplasty (TKA). There are limited studies assessing patterns of perioperative opioid use and risk factors for chronic use in patients undergoing TKA.MethodsThis is a retrospective longitudinal cohort study of Medicaid enrollees undergoing TKA between 2014 and 2017 using de-identified medical and pharmacy claims. The primary outcome was chronic opioid use (opioid prescription filled 90-270 days following TKA). Trajectory group membership was determined by identifying distinct groups of patients with similar patterns of daily morphine milligram equivalent (MME) values during the postsurgery follow-up period.ResultsIn total, 1666 TKA surgeries performed in 1507 patients were included; 69% of patients were classified as chronic opioid users. Multivariable analyses identified prior opioid use, high opioid doses during the month after TKA, concomitant mood therapies and benzodiazepines, and comorbid conditions as important risk factors. Group-based trajectory analysis identified five distinct post-TKA surgery opioid use phenotypes with several key characteristics predicting group membership.ConclusionsThis large-scale analysis demonstrated that chronic opioid use was common after TKA surgery and established several important risk factors for chronic use following TKA. Novel analysis revealed five distinct opioid use trajectories and identified key characteristics to help guide clinicians when determining perioperative opioid use. Results demonstrate that interventional studies attempting to reduce opioids after TKA are needed if reductions in long-term use are to be realized in this high-risk patient population.
| S-EPMC8981598 | biostudies-literature
Project description:ImportanceMany individuals who undergo total knee replacement (TKR) become long-term opioid users after TKR. Associations of physical therapy (PT) interventions before or after TKR with long-term use of opioids are not known.ObjectivesTo evaluate associations of PT interventions before and after TKR with long-term opioid use after TKR.Design, setting, and participantsThis cohort study used data from the OptumLabs Data Warehouse on 67 322 individuals aged 40 years or older who underwent TKR from January 1, 2001, to December 31, 2016, stratified by history of opioid use. The analyses for the study included data from January 1, 1999, to December 31, 2018.ExposuresAny PT interventions within 90 days before or after TKR, post-TKR PT dose as number of sessions (ie, 1-5, 6-12, and ≥13 sessions), post-TKR PT timing as number of days to initiation of care (ie, <30 days, 31-60 days, or 61-90 days after TKR), and post-TKR PT type (ie, active vs passive).Main outcomes and measuresThe association of pre- and post-TKR PT with risk of long-term opioid use occurring more than 90 days after TKR was assessed using logistic regression while adjusting for confounders, including age, sex, race and ethnicity (Asian, Black, Hispanic, or White), obesity, type of insurance, geographical location, and physical and mental health comorbidities.ResultsA total of 38 408 opioid-naive individuals (21 336 women [55.6%]; mean [SD] age, 66.2 [9.2] years) and 28 914 opioid-experienced individuals (18 426 women [63.7%]; mean [SD] age, 64.4 [9.3] years) were included. Receipt of any PT before TKR was associated with lower odds of long-term opioid use in the opioid-naive (adjusted odds ratio [aOR], 0.75 [95% CI, 0.60-0.95]) and opioid-experienced (aOR, 0.75 [95% CI, 0.70-0.80]) cohorts. Receipt of any post-TKR PT was associated with lower odds of long-term use of opioids in the opioid-experienced cohort (aOR, 0.75 [95% CI, 0.70-0.79]). Compared with 1 to 5 sessions of PT after TKR, 6 to 12 sessions (aOR, 0.82 [95% CI, 0.75-0.90]) and 13 or more sessions (aOR, 0.71 [95% CI, 0.65-0.77) were associated with lower odds in the opioid-experienced cohort. Compared with initiation of PT within 30 days after TKR, initiation 31 to 60 days or 61 to 90 days after TKR were associated with greater odds in the opioid-naive (31-60 days: aOR, 1.45 [95% CI, 1.19-1.77]; 61-90 days: aOR, 2.15 [95% CI, 1.43-3.22]) and opioid-experienced (31-60 days: aOR, 1.10 [95% CI, 1.02-1.18]; 61-90 days: aOR, 1.32 [95% CI, 1.12-1.55]) cohorts. Compared with passive PT, active PT was not associated with long-term opioid use in the opioid-naive (aOR, 1.00 [95% CI, 0.81-1.24]) or opioid-experienced (aOR, 0.99 [95% CI, 0.92-1.07]) cohorts.Conclusions and relevanceThis cohort study suggests that receipt of PT intervention before and after TKR, receipt of 6 or more sessions of PT care after TKR, and initiation of PT care within 30 days after TKR were associated with lower odds of long-term opioid use. These findings suggest that PT may help reduce the risk of long-term opioid use after TKR.
| S-EPMC8552057 | biostudies-literature
Project description:BACKGROUND:Despite the importance of the hospital discharge destination field ("discharge code" hereafter) for research and payment reform, its accuracy is not well established. OBJECTIVES:The aim of this study was to examine the accuracy of discharge codes in Medicare claims. DATA SOURCES:2012-2015 Medicare claims of knee and hip replacement patients. RESEARCH DESIGN:We identified patients' discharge location in claims and compared it with the discharge code. We also used a mixed-effects logistic regression to examine the association of patient and hospital characteristics with discharge code accuracy. RESULTS:Approximately 9% of discharge codes were inaccurate. Long-term care hospital discharge codes had the lowest accuracy rate (41%), followed by acute care transfers (72%), inpatient rehabilitation facility (80%), and home discharges (83%). Most misclassifications occurred within 2 broad groups of postacute care settings: home-based and institutional care. The odds of inaccurate discharge codes were higher for Medicaid-enrolled patients and safety-net and low-volume hospitals. CONCLUSIONS:Inaccurate hospital discharge coding may have introduced bias in studies relying on these codes (eg, evaluations of Medicare bundled payment models). Inaccuracy was more common among Medicaid-enrolled patients and safety-net and low-volume hospitals, suggesting more potential bias in existing study findings pertaining to these patients and hospitals.
| S-EPMC7190286 | biostudies-literature
Project description:DisclaimerIn an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.PurposeTo identify the proportion of patients with continued opioid use after total hip or knee arthroplasty.MethodsThis systematic review and meta-analysis searched Embase, MEDLINE, the Cochrane Central Register of Controlled Trials, and International Pharmaceutical Abstracts for articles published from January 1, 2009, to May 26, 2021. The search terms (opioid, postoperative, hospital discharge, total hip or knee arthroplasty, and treatment duration) were based on 5 key concepts. We included studies of adults who underwent total hip or knee arthroplasty, with at least 3 months postoperative follow-up.ResultsThere were 30 studies included. Of these, 17 reported on outcomes of total hip arthroplasty and 19 reported on outcomes of total knee arthroplasty, with some reporting on outcomes of both procedures. In patients having total hip arthroplasty, rates of postoperative opioid use at various time points were as follows: at 3 months, 20% (95% CI, 13%-26%); at 6 months, 17% (95% CI, 12%-21%); at 9 months, 19% (95% CI, 13%-24%); and at 12 months, 16% (95% CI, 15%-16%). In patients who underwent total knee arthroplasty, rates of postoperative opioid use were as follows: at 3 months, 26% (95% CI, 19%-33%); at 6 months, 20% (95% CI, 17%-24%); at 9 months, 23% (95% CI, 17%-28%); and at 12 months, 21% (95% CI, 12%-29%). Opioid naïve patients were less likely to have continued postoperative opioid use than those who were opioid tolerant preoperatively.ConclusionOver 1 in 5 patients continued opioid use for longer than 3 months after total hip or knee arthroplasty. Clinicians should be aware of this trajectory of opioid consumption after surgery.
| S-EPMC8513405 | biostudies-literature
Project description:ImportancePrescription opioid use is common among patients with moderate to severe knee osteoarthritis before undergoing total knee replacement (TKR). Preoperative opioid use may be associated with worse clinical and safety outcomes after TKR.ObjectiveTo determine the association of preoperative opioid use among patients 65 years and older with mortality and other complications at 30 days post-TKR.Design, setting, and participantsThis cohort study used claims data from January 1, 2010, to December 31, 2014, from a random sample of US Medicare enrollees 65 years and older who underwent TKR. Based on opioid dispensing in 360 days prior to TKR, patients were classified as continuous (≥1 opioid dispensing in each of the past 12 months) or intermittent (any dispensing of opioids in the past 12 months but not continuous use) opioid users or as opioid-naive patients (no opioids dispensed in the past 12 months). Data analyses were conducted from October 3, 2017, to November 8, 2018.Main outcomes and measuresPrimary outcomes included in-hospital mortality and 30-day post-TKR mortality, hospital readmission, and revision operation. Secondary safety outcomes at 30 days post-TKR included opioid overdose and vertebral and nonvertebral fracture. Multivariable Cox proportional hazards models estimated hazard ratios (HRs) and 95% CIs.ResultsOf 316 593 patients (mean [SD] age, 73.9 [5.8] years; 214 677 [67.8%] women) who underwent TKR, 22 895 (7.2%) were continuous opioid users, 161 511 (51.0%) were intermittent opioid users, and 132 187 (41.7%) were opioid naive. In-hospital mortality occurred in 276 patients (0.09%). At 30 days post-TKR, 828 patients (0.26%) died, 16 786 patients (5.30%) had hospital readmission, and 921 patients (0.29%) had a revision operation. All primary and secondary outcomes occurred more frequently among continuous opioid users compared with opioid-naive patients. Compared with opioid-naive patients and after adjusting for demographic characteristics, combined comorbidity score, number of different prescription medications, and frailty, continuous opioid users had greater risk of revision operations (HR, 1.63; 95% CI, 1.15-2.32), vertebral fractures (HR, 2.37; 95% CI, 1.37-4.09), and opioid overdose (HR, 4.82; 95% CI, 1.36-17.07) at 30 days post-TKR. However, after adjusting covariates, there were no statistically significant differences in in-hospital (HR, 1.18; 95% CI, 0.73-1.90) or 30-day (HR, 1.05; 95% CI, 0.73-1.51) mortality between continuous opioid users and opioid-naive patients.Conclusions and relevanceAfter adjusting for baseline risk profiles, including comorbidities and frailty, continuous opioid users had a higher risk of revision operations, vertebral fractures, and opioid overdose at 30 days post-TKR but not of in-hospital or 30-day mortality, compared with opioid-naive patients. These results highlight the need for better understanding of patient characteristics associated with chronic opioid use to optimize preoperative assessment of overall risk after TKR.
| S-EPMC6669774 | biostudies-literature
Project description:BackgroundAs America's third highest opioid prescribers, orthopedic surgeons have contributed to the opioid abuse crisis. This study evaluated opioid use after primary total joint replacement. We hypothesized that patients who underwent total hip arthroplasty (THA) use fewer opioids than patients who underwent total knee arthroplasty (TKA) and that both groups use fewer opioids than prescribed.MethodsA prospective study of 110 patients undergoing primary THA or TKA by surgeons at an academic center during 2018 was performed. All were prescribed oxycodone 5 mg, 84 tablets, without refills. Demographics, medical history, and operative details were collected. Pain medication consumption and patient-reported outcomes were collected at 2 and 6 weeks postoperatively. Analysis of variance was performed on patient and surgical variables.ResultsSixty-one patients scheduled for THA and 49 for TKA were included. THA patients consumed significantly fewer opioids than TKA patients at 2 weeks (28.1 tablets vs 48.4, P = .0003) and 6 weeks (33.1 vs 59.3, P = .0004). Linear regression showed opioid use decreased with age at both time points (P = .0002). A preoperative mental health disorder was associated with higher usage at 2 weeks (58.3 vs 31.4, P < .0001) and 6 weeks (64.7 vs 39.2, P = .006). Higher consumption at 2 weeks was correlated with worse outcome scores at all time points.ConclusionsTKA patients required more pain medication than THA patients, and both groups received more opioids than necessary. In addition, younger patients and those with a preexisting mental health disorder required more pain medication. These data provide guidance on prescribing pain medication to help limit excess opioid distribution.
| S-EPMC7851352 | biostudies-literature
Project description:Few studies have assessed postoperative trends in opioid cessation and predictors of persistent opioid use after total knee arthroplasty (TKA) and total hip arthroplasty (THA). Preoperatively, 574 TKA and THA patients completed validated, self-report measures of pain, functioning, and mood and were longitudinally assessed for 6 months after surgery. Among patients who were opioid naive the day of surgery, 8.2% of TKA and 4.3% of THA patients were using opioids at 6 months. In comparison, 53.3% of TKA and 34.7% of THA patients who reported opioid use the day of surgery continued to use opioids at 6 months. Patients taking >60 mg oral morphine equivalents preoperatively had an 80% likelihood of persistent use postoperatively. Day of surgery predictors for 6-month opioid use by opioid-naive patients included greater overall body pain (P = 0.002), greater affected joint pain (knee/hip) (P = 0.034), and greater catastrophizing (P = 0.010). For both opioid-naive and opioid users on the day of surgery, decreases in overall body pain from baseline to 6 months were associated with decreased odds of being on opioids at 6 months (adjusted odds ratio [aOR] = 0.72, P = 0.050; aOR = 0.62, P = 0.001); however, change in affected joint pain (knee/hip) was not predictive of opioid use (aOR = 0.99, P = 0.939; aOR = 1.00, P = 0.963). In conclusion, many patients taking opioids before surgery continue to use opioids after arthroplasty and some opioid-naive patients remained on opioids; however, persistent opioid use was not associated with change in joint pain. Given the growing concerns about chronic opioid use, the reasons for persistent opioid use and perioperative prescribing of opioids deserve further study.
| S-EPMC4868627 | biostudies-literature
Project description:Background and objectivesPain scores are routinely reported in clinical practice, and we wanted to examine whether this routinely measured, patient-reported variable provides prognostic information, especially with regard to chronic opioid use, after taking preoperative and perioperative variables into account in a preoperative opioid user population.MethodsIn 32,874 preoperative opioid users undergoing primary total knee arthroplasty at Veterans Affairs hospitals between 2010 and 2015, we compared preoperative and perioperative characteristics in patients reporting lower versus higher acute pain (scores ?4/10 vs >4/10 averaged over days 1-3). We calculated the propensity for lower acute pain based on all available data. After 1:1 propensity score matching, to identify similar patients differing only in acute pain, we contrasted rates of chronic significant opioid use (mean >30 mg/d in morphine equivalents) beyond postoperative month 3, discharge prescriptions, and changes in postoperative versus preoperative dose categories. Sensitivity analysis examined associations with dose escalation.ResultsRates of chronic significant opioid use (21% overall) differed in patients with lower versus higher acute pain (36% vs 64% of the overall cohort). After propensity matching (total n = 20,926 patients) and adjusting for all significant factors, lower acute pain was associated with less chronic significant opioid use (rates 12% vs 16%), smaller discharge prescriptions (ie, supply <30 days and daily oral morphine equivalent <30 mg/d), and more reduction in dose, all P < 0.001. In sensitivity analysis, dose escalation was 15% less likely with lower acute pain (odds ratio, 0.85; 95% confidence interval, 0.80-0.91).ConclusionsAcute pain predicts chronic opioid use. Prospective studies of efforts to reduce acute pain, in terms of long-term effects, are needed.
| S-EPMC6319560 | biostudies-literature