Does Preoperative Opioid Consumption Increase the Risk of Chronic Postoperative Opioid Use After Total Joint Arthroplasty?

BACKGROUND: Risk-factor identification related to chronic opioid use after surgery may facilitate interventions mitigating postoperative opioid consumption. We evaluated the relationship between opioid use preceding total hip arthroplasty (THA) and total knee arthroplasty (TKA), and chronic use postoperatively, and the risk of chronic opioid use after total joint arthroplasty. METHODS: All primary THAs and TKAs performed during a 6-month period were identified. Opioid prescription and utilization data (in oxycodone equivalents) were determined via survey and electronic records. Relationship between preoperative opioid use and continued use >90 days after surgery was assessed via Chi-square, with significance set at P < .05. RESULTS: A total of 415 patients met inclusion criteria (240 THAs and 175 TKAs). Of the 240 THAs, 199 (82.9%) patients and of the 175 TKAs, 144 (82.3%) patients agreed to participate. Forty-three of 199 (21.6%) THA patients and 22 of 144 (15.3%) TKA patients used opioids within 30 days preoperatively. Nine of 199 (4.5%) THA and 10 of 144 (6.9%) TKA patients had continued use of opioids for >90 days postoperatively. Preoperative opioid consumption was significantly associated with chronic use postoperatively for THA (P = .011) and TKA (P = .024). Five of 43 (11.6%) THA and 4 of 22 (18.2%) TKA patients with preoperative opioid use had continued use for >90 days postoperatively. For opioid naïve patients, 2.6% (4/156) of THA and 4.9% (6/122) of TKA patients had chronic use postoperatively. CONCLUSIONS: Preoperative opioid use was associated with nearly 5-fold and 4-fold increase in percentage of patients with chronic opioid use after THA and TKA, respectively. Surgeons should counsel patients regarding this risk and consider strategies to eliminate preoperative opioid use.

Does the Impact of Joint Arthroplasty Extend Beyond the Patient? The Effect of Total Joint Arthroplasty on Patient's Significant Others.

BACKGROUND: This prospective cohort study evaluates the impact of total hip arthroplasty and total knee arthroplasty on patient's spouses/significant others (SSOs). METHODS: Patients and SSOs were provided similar outcome metrics (Global Health Patient-Reported Outcomes Measurement Information System, Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement) at preoperative and postoperative visits. Pearson correlation was used to evaluate scores. RESULTS: Our sample included 99 patients (58 total hip arthroplasties and 41 total knee arthroplasties). We found strong correlation between patient and SSO mental status scores. We found moderate correlation for some physical function domains. CONCLUSION: SSOs closely share total joint arthroplasty patient's mental and even some of the physical burden of disease and recovery.

Spine coding transition from ICD-9 to ICD-10: Not taking advantage of the specificity of a more granular system.

BACKGROUND: The transition from International Classification of Diseases, 9th Edition (ICD-9) to the 10th edition (ICD-10) in 2015 increased the number and specificity of diagnostic codes with the goal of facilitating clinical care and research possibilities.Considering the potential to default to less specified ICD-10 codes, the current study evaluated the number of codes utilized for spine-related conditions before versus after the transition to ICD-10. METHODS: The numbers of patients with an index encounter for a primary spine-related non-deformity diagnosis codes indexed as "dorsopathies" were abstracted from the Humana PearlDiver dataset. As the transition from ICD-9 to ICD-10 occurred in 2015, the current study compared the year prior (ICD-9) to the year after (ICD-10). The number of ICD-9 and ICD-10 codes was assessed, and distribution of utilization was compared using the Kolmogorov-Smirnov test. RESULTS: In 2014, 848,623 patients were assigned one of the 100 unique ICD-9 dorsopathy codes, of which 17 codes (17% of available codes) were used for more than 1% of the patients. In 2016, 840,310 patients were assigned one of the 504 unique ICD-10 dorsopathy codes, of which 21 (4% of available codes) were used for more than 1% of the patients. The top 20 codes in 2014 (ICD-9) and the top 20 codes in 2016 (ICD-10) both represented the majority of the patient population and were not statistically differently represented (p = 0.819). Further, analysis of ICD-10 codes demonstrated a clear bias toward utilizing less specified codes. CONCLUSIONS: Despite a five-fold increase in available diagnostic codes for spine conditions in ICD-10, in the year after implementation providers continued to select a small proportion of less specific diagnostic codes when treating spine patients.

What Happens to Unused Opioids After Total Joint Arthroplasty? An Evaluation of Unused Postoperative Opioid Disposal Practices.

BACKGROUND: This study evaluates the fate of unused opioids after total hip arthroplasty (THA) and total knee arthroplasty (TKA) at our facility. METHODS: Medication disposal after primary elective THA and TKA was classified as appropriate (in accordance with United States Food and Drug Administration guidelines) or inappropriate for all patients undergoing these procedures during the second half of the fiscal year 2015. RESULTS: In total, 199 THAs and 144 TKAs met inclusion criteria. Total pills prescribed were 55,635. Approximately 8925 (16%) of pills were unused. About 39.9% of patients disposed of unused opioids appropriately, while 60.1% of patients reported still having (18.5%), not knowing where they were (8.2%), or other (33.4%). There was no significant association with the type of opioid prescribed. CONCLUSION: A large volume of unused opioids were improperly disposed of after total joint arthroplasty.

Duration of military service is associated with decision quality in Veterans considering total knee replacement: case series.

PURPOSE: Due to the nature of military service, the patient-physician relationship in Veterans is unlike that seen in civilian life. The structure of the military is hypothesized to result in barriers to open patient-physician communication and patient participation in elective care decision-making. Decision quality is a measure of concordance between a chosen treatment and the aspects of medical care that matter most to an informed patient; high decision quality is synonymous with patient-centered care. While past research has examined how age and other demographic factors affect decision quality in Veterans, duration of military service, rank at discharge, and years since discharge have not been studied. PATIENTS AND METHODS: We enrolled 25 Veterans with knee osteoarthritis at a VA hospital. Enrollees completed a survey with demographic, military service, and decision-making preference questions and the Hip-Knee Decision Quality Instrument (HK-DQI), which measures patients' knowledge about their disease process, concordance of their treatment decision, and the considered elements in their decision-making process. RESULTS: The HK-DQI knowledge score had a significant, positive correlation with duration of military service (R2=0.36, p=0.004). Rank at discharge and years since discharge did not show a significant correlation with decision quality (p=0.500 and p=0.317, respectively). The concordance score did not show a statistically significant correlation with rank, duration of service, and years since discharge (p=0.640, p=0.486 and p=0.795, respectively). Additionally, decision process score was not significantly associated with rank, duration of military service, and years since discharge (p=0.380, p=0.885, and p=0.474, respectively). CONCLUSION: Decision quality in Veterans considering treatment for knee osteoarthritis appears to be correlated positively with duration of military service. These findings may present an opportunity for identification of Veterans at most risk of low decision quality and customization of shared decision-making methods for Veterans by characteristics of military service.

Excess Opioid Medication and Variation in Prescribing Patterns Following Common Orthopaedic Procedures.

BACKGROUND: Postoperative pain management in orthopaedic surgery accounts for a substantial portion of opioid medications prescribed in the United States. Understanding prescribing habits and patient utilization of these medications following a surgical procedure is critical to establishing appropriate prescribing protocols that effectively control pain while minimizing unused opioid distribution. We evaluated prescribing habits and patient utilization following elective orthopaedic surgical procedures to identify ways of improving postoperative opioid-prescribing practices. METHODS: We performed a review of prescribing data of 1,199 procedures and gathered telephone survey results from 557 patients to determine the number of opioid pills prescribed postoperatively and the number of unused pills. The data were collected from adult patients who underwent 1 of the 5 most common elective orthopaedic procedures at our institution in fiscal year 2015: total hip arthroplasty, total knee arthroplasty, endoscopic carpal tunnel release, arthroscopic rotator cuff repair, or lumbar decompression. We converted all dosages to opioid equivalents of oxycodone 5 mg and performed analyses of prescribing patterns, patient utilization, and patient disposal of unused opioids. RESULTS: Prescribing patterns following the 5 orthopaedic procedures showed wide variation. The median numbers of oxycodone 5-mg equivalent opioid pills prescribed upon discharge were 90 pills (range, 20 to 330 pills) for total hip arthroplasty, 90 pills (range, 10 to 200 pills) for total knee arthroplasty, 20 pills (range, 0 to 168 pills) for endoscopic carpal tunnel release, 80 pills (range, 18 to 100 pills) for arthroscopic rotator cuff repair, and 80 pills (range, 10 to 270 pills) for lumbar decompression. Thirty-seven percent of patients overall requested and received at least 1 refill. The mean number of total pills prescribed (and standard deviation) including refills was 113.6 ± 75.7 for total hip arthroplasty, 176.4 ± 108.0 for total knee arthroplasty, 24.3 ± 29.0 for carpal tunnel release, 98.2 ± 59.6 for rotator cuff repair, and 107.4 ± 64.4 for lumbar decompression. Participants reported unused opioid medication in 61% of cases. During the study year, >43,000 unused opioid pills were prescribed. Forty-one percent of patients reported appropriate disposal of unused opioid pills. CONCLUSIONS: Prescribing patterns vary widely, and a large amount of opioid medications remains unused following elective orthopaedic surgical procedures. Effective prescribing protocols are needed to limit this source of potential abuse and opioid diversion within the community.

A systematic review and meta-analysis of the direct anterior approach for hemiarthroplasty for femoral neck fracture.

BACKGROUND: We performed a systematic review and meta-analysis to assess whether the direct anterior approach (DAA) is associated with improved functional and clinical outcomes compared to other surgical approaches for hemiarthroplasty for displaced femoral neck fractures. MATERIALS AND METHODS: Randomized trials and cohort studies of hemiarthroplasty performed via DAA versus another surgical approach (anterolateral, lateral, posterolateral, posterior) were included. Our primary outcome was postoperative functional mobility. Secondary outcomes included overall complication rate, dislocation rate, perioperative fracture, infection rate, re-operation rate, overall mortality, operative time, pain, intra-operative blood loss, and length of stay. RESULTS: Nine studies met inclusion criteria, comprising a total of 698 hips (330 direct anterior, 57 anterolateral, 89 lateral, 114 posterolateral, 108 posterior approach). With regard to functional mobility, DAA was favored in 4 studies, and no study favored another approach over DAA. DAA had a significantly lower dislocation rate compared to posterior capsular approaches. Analysis of other secondary outcomes did not identify statistically significant differences. CONCLUSION: This is the first systematic review and meta-analysis of the DAA for hemiarthroplasty. Available evidence suggests superior early functional mobility with the DAA. The DAA is associated with a significantly lower dislocation rate compared to posterior capsular approaches for hemiarthroplasty.

The Cost-Effectiveness of Total Hip Arthroplasty in Patients 80 Years of Age and Older.

BACKGROUND: This study investigates the cost-effectiveness of total hip arthroplasty (THA) in patients 80 years old. METHODS: A Markov, state-transition model projecting lifetime costs and quality-adjusted life years (QALYs) was constructed to determine cost-effectiveness from a societal perspective. Costs (in 2016 US dollars), health state utilities, and state transition probabilities were obtained from published literature. Primary outcome was incremental cost-effectiveness ratio, with a willingness-to-pay threshold of $100,000/QALY. Sensitivity analyses were performed to evaluate parameter assumptions. RESULTS: At our base-case values, THA was cost-effective compared to non-operative treatment with a total lifetime accrued cost of $186,444 vs $182,732, and a higher lifetime accrued utility (5.60 vs 5.09). Cost per QALY for THA was $33,318 vs $35,914 for non-operative management, and the incremental cost-effectiveness ratio was $7307 per QALY. Sensitivity analysis demonstrated THA to be cost-effective with a utility of successful primary THA above 0.67, a peri-operative mortality risk below 0.14, and a risk of primary THA failure below 0.14. Analysis further demonstrated that THA is a cost-effective option below a base-rate mortality threshold of 0.19, corresponding to the average base-rate mortality of a 93-year-old individual. Markov cohort analysis indicated that for patients undergoing THA at age 80 there was an approximate 28% reduction in total lifetime long-term assisted living expenditure compared to non-operatively managed patients with end-stage hip osteoarthritis. CONCLUSION: The results of our model demonstrate that THA is a cost-effective option compared to non-operative management in patients ≥80 years old. This analysis may inform policy regarding THA in elderly patients.

Residents' Impressions of the Impact of Advanced Practice Providers on Surgical Training.

BACKGROUND: To ensure that residents are appropriately trained in the era of the 80-hour work-week, training programs have restructured resident duties and hired advanced practice providers (APPs). However, the effect of APPs on surgical training remains unknown. STUDY DESIGN: We created a survey using a modified Delphi technique to examine the interaction between residents and APPs across practice settings (inpatient, outpatient, and operating room). We identified the following domains: administrative tasks, clinical experience, operative experience, and overall impressions. We administered the survey to residents across 7 surgical training programs at a single institution and assessed internal reliability with Cronbach's α. RESULTS: Fifty residents responded (77% participation rate). The majority reported APPs reduced the time spent on administrative tasks, such as completing documentation (96%) and answering pages (88%). For clinical experience, 62% of residents thought that APPs had no impact on the amount of time spent evaluating consult patients, and 80% reported no difference in the number of bedside procedures performed. However, 77% of residents reported a reduction in the time spent counseling patients. When APPs worked in the inpatient setting, 90% of residents reported leaving the operating room less frequently to manage patients. When APPs were present in the operating room, 34% of residents thought they were less likely to perform key parts of the case. Cronbach's α showed excellent to good reliability for the administrative tasks (0.96), clinical experience (0.76), operative experience (0.69), and overall impressions (0.66) domains. CONCLUSIONS: Most residents report that the integration of APPs has decreased the administrative burden. The reduction in patient counseling might be an unrecognized and unintended consequence of implementing APPs. The perceived effect on operative experience is dependent on the role of the APPs.