Surgeon Variation in Perioperative Opioid Prescribing and Medium- or Long-term Opioid Utilization after Total Knee Arthroplasty: A Cross-sectional Analysis

Abstract

BACKGROUND Whether a particular surgeon’s opioid prescribing behavior is associated with prolonged postoperative opioid use is unknown. We tested the hypothesis that the patients of surgeons with a higher propensity to prescribe opioids are more likely to utilize opioids long-term postoperatively. METHODS We identified 612,378 Medicare fee-for-service patients undergoing total knee arthroplasty between January 1, 2011 and December 31, 2016. We then defined “high-intensity” surgeons as those whose patients were, on average, in the upper quartile of opioid utilization in the immediate perioperative period (preoperative day 7 to postoperative day 7), We then estimated whether patients of “high-intensity” surgeons had higher opioid utilization in the mid-term (postoperative days 8-90) and long-term (postoperative days 91-365), utilizing an instrumental variables approach to minimize confounding from unobservable factors. RESULTS In the final sample of 604,093 patients, the average age was 74 years (SD 5) and there were 413,121 (68.4%) females. 180,926 patients (30%) were treated by “high-intensity” surgeons. On average, patients receiving treatment from a “high-intensity” surgeon received 36.1 (SD 35.0) oral morphine equivalents (MME)/day during the immediate perioperative period compared to 17.3 MME (SD 23.1) per day for all other patients (+18.9 MME/day difference; 95%CI 18.7 to 19.0; p<0.001). After adjusting for confounders, receiving treatment from a “high-intensity” surgeon was associated with higher opioid utilization in the mid-term opioid postoperative period (+2.4 MME/day difference, 95%CI 1.7 to 3.2, p<0.001, [11.4 MME/day vs 9.0]), and lower opioid utilization in the long-term postoperative period (-1.0 MME/day difference, 95%CI -1.4 to -0.6, p<0.001, [2.8 MME/day vs 3.8]). While statistically significant, these differences were clinically small. CONCLUSIONS Among Medicare fee-for-service patients undergoing total knee arthroplasty, surgeon-level variation in opioid utilization in the immediate perioperative period was associated with statistically significant but clinically insignificant differences in opioid utilization in the medium- and long-term postoperative periods.

Postoperative Opioid Prescribing: Finding the Balance

“…Findings demonstrated that surgeons in the highest quartile of perioperative opioid prescribers ("high-intensity prescribers") prescribed about 7 mg/day more morphine equivalents immediately before and after surgery than the average surgeon, after adjustment for patient characteristics, and prescribing variation was present. 2 The study did not find a clinically meaningful association between receiving care from a higher-intensity perioperative opioid prescriber with opioid receipt in the subsequent 3 months. Patients of higher-intensity prescribers received roughly 2 mg/day morphine equivalents above the mean rate of 10 mg/day.…”

“…In the current issue of Anesthesiology, Cen and colleagues assess the possible link between early perioperative opioid prescribing patterns of orthopedic surgeons and long-term receipt of opioids. 2 Such studies can help to inform how to balance the needs of individual patients with the health of populations in an evidence-based manner. The study objective was to estimate whether variation in surgeons' opioid prescribing patterns in the week before and after surgery (i.e., the immediate perioperative period) was associated with longterm differences in opioid utilization.…”

“…6,7 Such efforts highlight the positive impact that perioperative clinicians have already had on reducing supply side contributions to the opioid pool, and must continue to spread. Based on the findings of Cen and colleagues, 2 there appears to be little evidence that changing opioid prescribing practices immediately after surgery is likely to decrease long-term opioid use.…”

Surface-Enhanced Raman Spectroscopy for Quantitative Analysis of Anesthetic Agents: Toward Personalized Drug Monitoring in Anesthesia

“…The detection of psychoactive substances, an important subset of modern analytical chemistry, holds extensive legal and social implications. Intravenous opioids such as fentanyl and tramadol − are routinely employed analgesics following coronary artery bypass grafting (CABG) surgery. , A comprehensive retrospective study posits a significant risk of subsequent opioid misuse associated with prolonged postsurgery opioid use . The average annual rate of opioid overdose deaths since 1999 approximates 50,000 .…”