Persistent Opioid Use After Hospital Admission From Surgery in New Zealand: A Population-Based Study.

BACKGROUND: Persistent opioid use (POU) is common after surgery and is associated with an increased risk of mortality and morbidity. There have been no population-based studies exploring POU in opioid-naïve surgical patients in New Zealand (NZ). This study aimed to determine the incidence and risk factors for POU in opioid-naïve patients undergoing surgery in all NZ hospitals. METHOD: We included all opioid-naïve patients who underwent surgery without a concomitant trauma diagnosis and received opioids after discharge from any NZ hospital between January 2007 and December 2019. Patients were considered opioid naïve if no opioids had been dispensed to them or if they did not have a prior diagnosis of an opioid-use disorder up to 365 days preceding the index date. The primary outcome was the incidence of POU, defined a priori as opioid use after discharge between 91 and 365 days. We used a multivariable logistic regression to identify risk factors for POU. RESULTS: We identified 1789,407 patients undergoing surgery with no concomitant diagnosis of trauma; 377,144 (21.1%) were dispensed opioids and 260,726 patients were eligible and included in the analysis. Of those included in the final sample, 23,656 (9.1%; 95% confidence interval [CI], 9.0%-9.2%) developed POU. Risk factors related to how opioids were prescribed included: changing to different opioid(s) after discharge (adjusted odds ratio [aOR], 3.21; 95% CI, 3.04-3.38), receiving multiple opioids on discharge (aOR, 1.37; 95% CI, 1.29-1.45), and higher total oral morphine equivalents (>400 mg) (aOR, 1.23; 95% CI, 1.23-1.45). Conversely, patients who were coprescribed nonopioid analgesics on discharge had lower odds of POU (aOR, 0.91; 95% CI, 0.87-0.95). Only small differences were observed between different ethnicities. Other risk factors associated with increased risk of POU included undergoing neurosurgery (aOR, 2.02; 95% CI, 1.83-2.24), higher comorbidity burden (aOR, 1.90; 95% CI, 1.75-2.07), preoperative nonopioid analgesic use (aOR, 1.65; 95% CI, 1.60-1.71), smoking (aOR, 1.44; 95% CI, 1.35-1.54), and preoperative hypnotics use (aOR, 1.35; 95% CI, 1.28-1.42). CONCLUSIONS: Approximately 1 in 11 opioid-naïve patients who were dispensed opioids on surgical discharge, developed POU. Potentially modifiable risk factors for POU, related to how opioids were prescribed included changing opioids after discharge, receiving multiple opioids, and higher total dose of opioids given on discharge. Clinicians should discuss the possibility of developing POU with patients before and after surgery and consider potentially modifiable risk factors for POU when prescribing analgesia on discharge after surgery.

Asthma control and associated risk factors among adults with current asthma: Findings from 2019 behavioral risk factor surveillance system asthma call-back survey.

BACKGROUND: Despite the availability of effective treatments, many adults with asthma have uncontrolled asthma. Uncontrolled asthma can lead to severe exacerbations. This study aimed to determine the prevalence and predictors of uncontrolled asthma among adults (≥18 years) with current asthma in the United States. METHODS: We analyzed the 2019 Behavior Risk Factor Surveillance System Asthma Call-Back Survey data from 27 states. Asthma control status was classified as "well-controlled" or "uncontrolled" according to the National Asthma Education and Prevention guidelines. The study population consisted of 7937 adults (weighted n = 13,793,220) with current asthma. We used multivariable logistic regression models to identify predictors of uncontrolled asthma. RESULTS: Overall, 62 % of adults with asthma reported having uncontrolled asthma, and 26 % had emergency or urgent care visits or hospitalizations in the past year. Potentially modifiable risk factors associated with uncontrolled asthma included cost barriers to asthma-related healthcare (OR = 2.94; 95%CI 1.96-4.40), complementary and alternative medicine use (OR = 1.84; 95%CI 1.45-2.32), current smoking (OR = 2.25; 95%CI 1.48-3.44), obesity (OR = 1.39; 95%CI 1.02-1.89), COPD (OR = 1.98; 95%CI 1.43-2.74), depression (OR = 1.47; 95%CI 1.16-1.88), fair/poor general health (OR = 1.54; 95%CI 1.14-2.07), household income <$15,000 (OR = 2.59; 95%CI 1.42-4.71), and less than high school education (OR = 2.59; 95%CI 1.42-4.71). Non-modifiable risk factor was Hispanic ethnicity (OR = 1.73; 95%CI 1.09-2.73). CONCLUSION: Our findings suggest that uncontrolled asthma is common among adults and can be impacted by several factors. Effective asthma control programs are needed to improve asthma management and reduce unnecessary healthcare utilization.

Predictors of persistent opioid use in non-cancer older adults: a retrospective cohort study.

BACKGROUND: Long-term opioid use and associated adverse outcomes have increased dramatically in recent years. Limited research is available on long-term opioid use in older adults. OBJECTIVE: We aimed to determine the incidence and predictors of long-term or persistent opioid use (POU) amongst opioid-naïve older adults without a cancer diagnosis. METHODS: This was a retrospective cohort study using five national administrative healthcare databases in New Zealand. We included all opioid-naïve older adults (≥65 years) who were initiated on opioid therapy between January 2013 and June 2018. The outcome of interest was POU, defined as having continuously filled ≥1 opioid prescription within 91-180 days after the index opioid prescription. Multivariable logistic regression was used to examine the predictors of POU. RESULTS: The final sample included 268,857 opioid-naïve older adults; of these, 5,849(2.2%) developed POU. Several predictors of POU were identified. The use of fentanyl (adjusted odds ratio (AOR) = 3.61; 95% confidence interval (CI) 2.63-4.95), slow-release opioids (AOR = 3.02; 95%CI 2.78-3.29), strong opioids (AOR = 2.03; 95%CI 1.55-2.65), Charlson Comorbidity Score ≥ 3 (AOR = 2.09; 95% CI 1.78-2.46), history of substance abuse (AOR = 1.52; 95%CI 1.35-1.72), living in most socioeconomically deprived areas (AOR = 1.40; 95%CI 1.27-1.54), and anti-epileptics (AOR = 2.07; 95%CI 1.89-2.26), non-opioid analgesics (AOR = 2.05; 95%CI 1.89-2.21), antipsychotics (AOR = 1.96; 95%CI 1.78-2.17) or antidepressants (AOR = 1.50; 95%CI 1.41-1.59) medication use were the strongest predictors of POU. CONCLUSION: A significant proportion of patients developed POU, and several factors were associated with POU. The findings will enable healthcare providers and policymakers to target early interventions to prevent POU and related adverse events.

Formal and informal venous thromboembolism risk assessment and impact on prescribing of thromboprophylaxis: a retrospective cohort study.

BACKGROUND: Hospital-acquired thrombosis (HAT) is a leading cause of preventable death and disability worldwide. HAT includes any venous thromboembolic (VTE) event occurring in-hospital or within 90-days of hospitalisation. Despite availability of evidence-based guidelines for HAT risk assessment and prophylaxis, guidelines are still underutilised. AIM: To determine the proportion of patients who developed HAT that could have been potentially prevented with appropriate VTE risk assessment and prophylaxis at a large public hospital in New Zealand. Additionally, the predictors of VTE risk assessment and thromboprophylaxis were examined. METHOD: VTE patients admitted under general medicine, reablement, general surgery, or orthopaedic surgery service were identified using ICD-10-AM codes. Data were collected on patient characteristics, VTE risk factors, and the thromboprophylaxis regimen prescribed. The hospital VTE guidelines were used to determine rates of VTE risk assessment and the appropriateness of thromboprophylaxis. RESULTS: Of 1302 VTE patients, 213 HATs were identified. Of these, 116 (54%) received VTE risk assessment, and 98 (46%) received thromboprophylaxis. Patients who received VTE risk assessment were 15 times more likely to receive thromboprophylaxis (odds ratio [OR] = 15.4; 95% CI 7.65-30.98) and 2.8 times more likely to receive appropriate thromboprophylaxis (OR = 2.79; 95% CI 1.59-4.89). CONCLUSION: A large proportion of high-risk patients who were admitted to medical, general surgery and reablement services and who developed HAT did not receive VTE risk assessment and thromboprophylaxis during their index admission, demonstrating a significant gap between guideline recommendations and clinical practice. Implementing mandatory VTE risk assessment and adherence to guidelines to improve thromboprophylaxis prescription in hospitalised patients may help reduce the burden of HAT.

Cost-effectiveness of pegfilgrastim versus filgrastim for prevention of chemotherapy-induced febrile neutropenia in patients with lymphoma: a systematic review.

BACKGROUND: Febrile neutropenia (FN) is a prevalent and potentially life-threatening complication in patients with lymphoma receiving myelosuppressive chemotherapy. Pegfilgrastim is more effective than filgrastim as prophylaxis for FN. However, its usage has been limited because of its higher cost. Pegfilgrastim's value for money remains unclear. OBJECTIVE: To systematically review the cost-effectiveness of pegfilgrastim compared to filgrastim as a primary or secondary prophylaxis for chemotherapy-induced FN among patients with lymphoma. METHODS: A systematic literature search was conducted in PubMed, EMBASE, Cochrane Library databases, and Google Scholar. The most widely used economic evaluations (cost-effectiveness analysis, cost-utility analysis and cost-benefit analysis) were included in the review. Data extraction was guided by the Consolidated Health Economic Evaluation Reporting Standards checklist, and the quality of reviewed articles was assessed using the Joanna Briggs Institute (JBI) checklist. Cost-effectiveness data were rigorously summarized and synthesized narratively. Costs were adjusted to US$ 2020. RESULTS: We identified eight economic evaluation studies (two cost-utility analyses, three cost-effectiveness analyses, and three studies reporting both cost-effectiveness and cost-utility analyses). Half of these studies were from Europe (n = 4), the other half were from Iran, USA, Canada, and Singapore. Six studies met > 80% of the JBI quality assessment criteria. Cost-effectiveness estimates in the majority (n = 6) of these studies were for Non-Hodgkin Lymphoma patients receiving myelosuppressive chemotherapy with high-risk of FN (> 20%). The studies considered a wide range of baseline FN risk (17-97.4%) and mortality rates (5.8-8.9%). Reported incremental cost-effectiveness ratios ranged from US$ 2199 to US$ 8,871,600 per quality-adjusted life-year (QALY) gained, dominant to US$ 44,358 per FN averted, and US$ 4261- US$ 7251 per life-years gained. The most influential parameters were medication and hospitalization costs, the relative risk of FN, and assumptions of mortality benefit. CONCLUSIONS: Most studies showed that pegfilgrastim is cost-effective compared to filgrastim as primary and secondary prophylaxis for chemotherapy-induced FN among patients with lymphoma at a cost-effectiveness threshold of US$ 50,000 per QALY gained. The findings could assist clinicians and healthcare decision-makers to make informed decisions regarding resource allocation for the management of chemotherapy-induced FN in settings similar to those studied.

Postdischarge opioid use and persistent use after general surgery: A retrospective study.

BACKGROUND: Opioid overprescribing after surgery is a significant public health issue in most developed countries, including New Zealand. However, there is a lack of literature on the patterns and risk factors for postoperative opioid use among general surgical patients in New Zealand. This study aimed to examine opioid use in patients undergoing general surgery at Auckland District Health Board between January and December 2019 and to identify factors associated with opioid use after surgery and persistent opioid use (defined as having filled ≥1 opioid prescription in the 91 to 180 days after surgery). METHODS AND MATERIALS: This is a retrospective cohort study. Data from patients' electronic clinical records and community pharmacy dispensing records were extracted to obtain data on sociodemographics, surgical characteristics, comorbidities, co-prescribed medications, and opioid use. RESULTS: A total of 1,110 patients were included in the study, with 42.4% dispensed an opioid following discharge after surgery. Of opioid-naïve patients who filled opioids after surgery (n = 401), 9.5% became persistent opioid users. Preoperative use of nonopioid analgesics, longer hospital stays, higher operation severity, procedure type, and higher pain scores were positively associated with opioid use, whereas older age was a negative predictor. Longer hospital stays, an initial discharge prescription with high opioid load, and female sex increased the risk of persistent opioid use. Conversely, a higher severity of surgery was associated with lower risk of persistent opioid use. CONCLUSION: The findings suggest that a considerable proportion of patients become persistent opioid users after surgery. The risk factors identified can guide clinicians to prescribe in a manner that reduces opioid-related adverse outcomes and help guide future interventions.

Factors predicting high-dose and combined antipsychotic prescribing in New Zealand: High-dose antipsychotic prescribing.

OBJECTIVE: Guidelines recommend using antipsychotic monotherapy at the lowest effective dose, however high-dose and antipsychotic polypharmacy prescribing (APP) remain commonplace. The aim of this study was to determine the prevalence and patterns of high-dose antipsychotic prescribing and APP among mental health service users in New Zealand (NZ). METHODS: A retrospective audit of service users discharged from inpatient (n=657), or registered with community (n=1560), mental health services at Auckland District Health Board was undertaken. Case notes were reviewed and data on demographics, antipsychotic routes and doses were collected. Outcomes measures included: frequency of total high-dose prescribing, high-dose monotherapy, APP, high-dose APP, and factors associated with these prescribing practices. Logistic regression models were used to examine the relationships between explanatory and outcome variables. RESULTS: Of the service users prescribed an antipsychotic (n = 2217), 14% were prescribed a high-dose antipsychotic. The frequency of high-dose monotherapy, APP, and high-dose APP was 3%, 26% and 11%, respectively. Being male, Maori, on compulsory treatment, having a schizophrenia diagnosis, or being prescribed polypharmacy were associated with high-dose antipsychotics. Olanzapine was most frequently prescribed in both high dosing (55%) and APP (40%). CONCLUSIONS: There is a high prevalence of high-dose prescribing and APP in this NZ setting.

Persistent opioid use and opioid-related harm after hospital admissions for surgery and trauma in New Zealand: a population-based cohort study.

INTRODUCTION: Opioid use has increased globally for the management of chronic non-cancer-related pain. There are concerns regarding the misuse of opioids leading to persistent opioid use and subsequent hospitalisation and deaths in developed countries. Hospital admissions related to surgery or trauma have been identified as contributing to the increasing opioid use internationally. There are minimal data on persistent opioid use and opioid-related harm in New Zealand (NZ), and how hospital admission for surgery or trauma contributes to this. We aim to describe rates and identify predictors of persistent opioid use among opioid-naïve individuals following hospital discharge for surgery or trauma. METHODS AND ANALYSIS: This is a population-based, retrospective cohort study using linked data from national health administrative databases for opioid-naïve patients who have had surgery or trauma in NZ between January 2006 and December 2019. Linked data will be used to identify variables of interest including all types of hospital surgeries in NZ, all trauma hospital admissions, opioid dispensing, comorbidities and sociodemographic variables. The primary outcome of this study will be the prevalence of persistent opioid use. Secondary outcomes will include mortality, opioid-related harms and hospitalisation. We will compare the secondary outcomes between persistent and non-persistent opioid user groups. To compute rates, we will divide the total number of outcome events by total follow-up time. Multivariable logistic regression will be used to identify predictors of persistent opioid use. Multivariable Cox regression models will be used to estimate the risk of opioid-related harms and hospitalisation as well as all-cause mortality among the study cohort in a year following hospital discharge for surgery or trauma. ETHICS AND DISSEMINATION: This study has been approved by the Auckland Health Research Ethics Committee (AHREC- AH1159). Results will be reported in accordance with the Reporting of studies Conducted using Observational Routinely collected health data statement (RECORD).

Te Wero tonu-the challenge continues: Maori access to medicines 2006/07-2012/13 update.

AIM: Analysis of dispensings of prescription medicines in New Zealand in 2006/07 reported large inequities between Maori and non-Maori. This present study has now updated the earlier work by describing variations in disease burden-adjusted medicines access by ethnicity in 2012/13, and changes over time. METHOD: The update has linked prescription medicine data with burden of disease estimates by ethnicity for 2012/13 and comparing with 2006/07. This has re-examined the shortfall in prescriptions for Maori vs non-Maori adjusting for age, population and burden of disease (ie, health loss, in disability-adjusted life years (DALYs)). RESULTS: After adjusting for age, population and burden of disease, large inequalities still existed for Maori compared with non-Maori, with generally no improvement over the six years. In 2012/13, Maori had 41% lower dispensings overall than non-Maori; this was nominally worse compared with the 37% relative gap in 2006/07, but the trend was not statistically significant. Many complexities and limitations hamper valid interpretation, but large inequities in access and persistence, across many therapeutic groups, remain. The full University of Auckland report details these inequities. CONCLUSION: Large inequities in medicines access for Maori continue. Inequities in access are unacceptable, their causes likely complex and entrenched; we believe they need deeper understanding of systems and barriers, pragmatic ways to monitor outcomes, and an all-of-sector approach and beyond. PHARMAC has committed to strategic action to eliminate inequities in access to medicines by 2025, recognising it needs partners to drive the necessary change. Kei a tatou tonu katoa te wero kia mahikaha, kia mahi tino mohio, me te mahitahi (The challenge continues for us to work harder, work smarter, and work together); everyone in the health sector has a role.