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

Abstract

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.

Opioid and Sedative NarxCare Scores Greater Than 300 Are Associated with Adverse Outcomes After Non-Emergent Spine Surgery

“…The NarxCare platform (Appriss Health; Louisville, KY) integrated into patients’ charts queries the PDMP with each patient encounter to provide updated NCS 6,8,14–18. The resultant NCS for each prescription drug type [ i.e.…”

“…6,8,[14][15][16][17][18] The resultant NCS for each prescription drug type [i.e., opioids (NCS-opioids) and sedatives (NCS-sedatives)] is a threedigit numerical score that ranges between zero (drug naïve patient) up to 999, with higher scores indicating an increased risk of overdose. 6,8,[14][15][16][17][18] In the current study, patients' updated preoperative NCSs were those obtained at index surgical admission. This numerical score is obtained through algorithmic analysis of current and past PDMPrecorded prescription drug use patterns, including drug dose (in milligram equivalences), multiple prescription overlap, the number of prescribing providers, and the number of dispensing pharmacies.…”

“…Of note, more recent investigations suggest an association between NCSs >300 and prolonged LOS ( i.e. , >2 d), nonhome discharge, 90-day readmission, and ED visits after primary elective total hip and knee arthroplasty 16,20. Therefore, the objective of the present analysis aimed to explore a potential association between preoperative drug-specific NCS and adverse outcomes after nonemergent spine surgery using an extensive prospective institutional cohort.…”

“…Of note, more recent investigations suggest an association between NCSs > 300 and prolonged LOS (i.e., > 2 d), nonhome discharge, 90-day readmission, and ED visits after primary elective total hip and knee arthroplasty. 16,20 Therefore, the objective of the present analysis aimed to explore a potential association between preoperative drug-specific NCS and adverse outcomes after nonemergent spine surgery using an extensive prospective institutional cohort. Specifically, we aimed to explore a potential association between the preoperative opioid-specific NCS (NCS-opioids) as well as sedative-specific NCS (NCS-sedatives) as a measure of patients' prescription drug use and (1) 90-day postoperative readmissions; (2) ED visits; (3) reoperation; (4) prolonged ( > 2 d) hospital LOS; and (5) nonhome discharge disposition.…”

Combinations of Preoperative Patient-Reported Outcome Measure Phenotype (Pain, Function, and Mental Health) Predict Outcome After Total Knee Arthroplasty

“…In recognizing the impact of preoperative narcotics usage on outcomes following total joint arthroplasty (TJA) [30], each model was repeated with the addition of the NarxCare Narcotic score as a categorical variable in groups of 100 with prescription naive as the reference (Supplementary Figs. 2-4).…”