Predictors and Characteristics of Opioid Utilization >15 Days Following Total Knee Arthroplasty.

BACKGROUND: America is amid an opioid epidemic, best characterized by liberal prescribing practices; widespread opioid misuse, abuse, and diversion; and rising rates of prescription-related opioid overdose. While many contributors to opioid overprescribing exist, orthopedic surgery is identified as a key driver. The purpose of this study is to determine predictors of ongoing opioid use >15 days post-total knee arthroplasty (TKA) and those patients prescribed >1350 morphine milligram equivalents (MMEs) in the 15 days following surgery. METHODS: A retrospective cohort study was conducted in patients undergoing TKA (January 2016-December 2017) in an integrated healthcare system. Outcomes of interest were patient and clinical characteristics. RESULTS: A total of 621 patients were included in the study. The majority were female (57.6%), were non-Hispanic/Latino white (92.3%), and from metropolitan areas (64.3%) with fewer than 110,000 population. Mean age was 66.3. Being female (odds ratio [OR] = 1.547, P = .092), having a higher body mass index (OR = 1.043, P = .036), and receipt of more postdischarge prescriptions in the 60-day follow-up period (OR = 8.815, P < .0001) were associated with a greater likelihood of receipt of opioid prescriptions for more than 15 days. Older patients (OR = 0.954, P = .01) and those discharged to home (OR = 0.478, P = .045) were less likely to receive >1350 MME; longer length of stay (OR = 1.447, P = .013) was more likely in those prescribed >1350 MMEs. CONCLUSION: Several predictors were associated with longer duration and higher doses of opioid prescriptions post-TKA. Further research is needed to ascertain the challenges of opioid prescribing from both the metropolitan surgical team and rural healthcare provider perspective.

Improving Blood Pressure Control Using Smart Technology.

BACKGROUND: The authors sought to determine if wireless oscillometric home blood pressure monitoring (HBPM) that integrates with smartphone technology improves blood pressure (BP) control among patients with new or existing uncontrolled hypertension (HTN). METHODS: A prospective observational cohort study monitored BP control before and after an educational intervention and introduction to HBPM. Patients in the intervention group were instructed to track their BP using a smartphone device three to seven times per week. Cases were matched to controls at a 1:3 allocation ratio on several clinical characteristics over the same period and received usual care. The proportion of patients with controlled BP was compared between groups at pre- and postintervention, ∼9 months later. Results and Materials: The total study population included 484 patients with mean age 60 years (range 23-102 years), 47.7% female, and 84.6% Caucasian. Mean preintervention BP was 137.8 mm Hg systolic and 81.4 mm Hg diastolic. Mean BP control rates improved for patients who received HBPM from 42% to 67% compared with matched control patients who improved from 59% to 67% (p < 0.01). CONCLUSION: HBPM with smartphone technology has the potential to improve HTN management among patients with uncontrolled or newly diagnosed HTN. Technology needs to be easy to use and operate and would work best when integrated into local electronic health record systems. In systems without this capability, medical assistants or other personnel may be trained to facilitate the process. Nurse navigator involvement was instrumental in bridging communication between the patients and provider.

Bilateral Total Knee Arthroplasty: Predictors of Discharge Disposition.

BACKGROUND: Total knee arthroplasty is on the rise. Some patients choose to undergo simultaneous bilateral total knee arthroplasty (simultaneous BTKA). No studies were found that examined which patients may be better candidates to successfully undergo this procedure. PURPOSE: The purpose of this study was to determine personal and comorbid characteristics of patients undergoing simultaneous BTKA that are predictive of length of stay (LOS) and discharge to a skilled nursing facility (SNF). METHODS: A retrospective database study of 125 patients post-simultaneous BTKA was conducted. Binary and multiple linear regression models identified personal and clinical predictors of LOS and SNF discharge. RESULTS: Body mass index (BMI) (p < .001) and SNF discharge (p = .025) were significant predictors of increased LOS and explained 18% of the variance. Older age, female sex, and presence of cardiopulmonary disease predicted SNF admission; 21% of the variance for SNF discharge was explained by the model. CONCLUSION: Patients with a high BMI should be carefully screened before undergoing simultaneous BTKA; older patients, women, and those with cardiopulmonary disease may benefit from early discharge planning for SNF transfer, thereby decreasing LOS and hospital utilization.

Intent-to-treat analysis of a simultaneous multisite telehealth diabetes prevention program.

OBJECTIVE: Determine the effectiveness of a 16-week modified diabetes prevention program (DPP) administered simultaneously to multiple rural communities from a single urban site, as compared with a similar face-to-face intervention. A 12-week intervention was evaluated to consider minimization of staff costs in communities where resources are limited. RESEARCH DESIGN AND METHODS: A prospective cohort study compared DPP interventions implemented in rural (via telehealth technology) and urban (face-to-face) communities using an intent-to-treat analysis. Primary outcome measures included 5% and 7% body weight loss. Logistic regression analyses were used to determine predictors of intervention success and included a variable for treatment effect. RESULTS: Between 2010 and 2015, up to 667 participants were enrolled in the study representing one urban and 15 rural communities across Montana. The 16-week urban and rural interventions were comparable; 33.5% and 34.6% of participants lost 7% body weight, respectively; 50% and 47% lost 5% (p=0.22). Participants who were male (OR=2.41; 95% CI 1.32 to 4.40), had lower baseline body mass index (OR=1.03; 95% CI 1.01 to 1.07), attended more sessions (OR=1.33; 95% CI 1.11 to 1.58), and more frequently reported (OR=3.84; 95% CI 1.05 to 14.13) and met daily fat gram (OR=4.26; 95% CI 1.7 to 10.6) and weekly activity goals (OR=2.46; 95% CI 1.06 to 5.71) were more likely to meet their 7% weight loss goal. Predictors of meeting weight loss goals were similar for participants enrolled in the 12-week intervention. CONCLUSIONS: Using telehealth technology to administer a modified DPP to multiple rural communities simultaneously demonstrated weight loss results comparable to those in a face-to-face intervention. Given the limitation of resources, linking rural areas to urban centers using telemedicine may increase access to much needed services to prevent or delay progression to diabetes.

Predictors of oversedation in hospitalized patients.

PURPOSE: Results of a study to determine demographic and clinical characteristics predictive of oversedation and potential opioid-induced respiratory depression (OIRD) in hospitalized patients are reported. METHODS: In a retrospective case-controlled study, an incident reporting database was searched to identify cases of in-hospital oversedation; to form the control group, patients who did not experience an oversedation event while hospitalized were sampled in reverse chronological order until the desired total sample size (n = 225) was obtained. An allocation ratio of 2:1 was specified to adjust for case variability. Binary logistic regression was employed to identify factors predictive of oversedation. RESULTS: Female sex (odds ratio [OR], 2.41; 95% confidence interval [CI], 1.05-5.50), comorbid renal disease (OR, 4.22; 95% CI, 1.66-10.70), untreated sleep apnea (OR, 32.32; 95% CI, 2.72-384.72), receipt of long-acting oxycodone (OR, 4.76; 95% CI, 1.70-13.33), and as-needed use of hydromorphone (OR, 2.73; 95% CI, 1.19-6.27) were significant predictors of oversedation; as-needed analgesia administered by the oral route (OR, 0.16; 95% CI, 0.07-0.36) or i.v. route (OR, 0.33; 95% CI, 0.14-0.80) had a significant protective effect. The final prediction model explained 47.8% of variance in oversedation risk and was found to have strong discriminatory performance. CONCLUSION: The identified risk factors for oversedation and potential OIRD in hospitalized patients can form the basis of quality-improvement initiatives to prevent oversedation through improved prescribing and patient monitoring.