Postsurgical opioid prescribing among veterans using community care for orthopedic surgery at non-VA hospitals compared to a VA hospital with a transitional pain service: a retrospective cohort study.

BACKGROUND: The USA provides medical services to its military veterans through Veterans Health Administration (VHA) medical centers. Passage of recent legislation has increased the number of veterans having VHA-paid orthopedic surgery at non-VHA facilities. METHODS: We conducted a retrospective cohort study among veterans who underwent orthopedic joint surgery paid for by the VHA either at the Salt Lake City VHA Medical Center (VAMC) or at non-VHA hospitals between January 2018 and December 2021. 562 patients were included in the study, of which 323 used a non-VHA hospital and 239 patients the VAMC. The number of opioid tablets prescribed at discharge, the total number prescribed by postdischarge day 90, and the number of patients still filling opioid prescriptions between 90 and 120 days after surgery were compared between groups. RESULTS: Veterans who underwent orthopedic surgery at a non-VHA hospital were prescribed more opioid tablets at discharge (median (IQR)); (40 (30-60) non-VHA vs 30 (20-47.5) VAMC, p<0.001) and in the first 90 days after surgery than patients who had surgery at the Salt Lake City VAMC (60 (40-120) vs 35 (20-60), p<0.001). Patients who had surgery at Salt Lake City VAMC were also significantly less likely to fill opioid prescriptions past 90 days after hospital discharge (OR (95% CI) 0.06 (0.01 to 0.48), p=0.007). CONCLUSION: These results suggest that veterans who have surgery at a veterans affairs hospital with a transitional pain service are at lower risk for larger opioid prescriptions both at discharge and within 90 days after surgery as well as persistent opioid use beyond 90 days after discharge than if they have surgery at a community hospital.

Long-term patient-reported outcomes among patients undergoing revascularization vs medical therapy for intermittent claudication.

OBJECTIVE: Society for Vascular Surgery guidelines recommend revascularization for patients with intermittent claudication (IC) if it can improve patient function and quality of life. However, it is still unclear if patients with IC achieve a significant functional benefit from surgery compared with medical management alone. This study examines the relationship between IC treatment modality (operative vs nonoperative optimal medical management) and patient-reported outcomes for physical function (PROMIS-PF) and satisfaction in social roles and activities (PROMIS-SA). METHODS: We identified patients with IC who presented for index evaluation in a vascular surgery clinic at an academic medical center between 2016 and 2021. Patients were stratified based on whether they underwent a revascularization procedure during follow-up vs continued nonoperative management with medication and recommended exercise therapy. We used linear mixed-effect models to assess the relationship between treatment modality and PROMIS-PF, PROMIS-SA, and ankle-brachial index (ABI) over time, clustering among repeat patient observations. Models were adjusted for age, sex, diabetes, Charlson Comorbidity Index, Clinical Frailty Score, tobacco use, and index ABI. RESULTS: A total of 225 patients with IC were identified, of which 40% (n = 89) underwent revascularization procedures (42% bypass; 58% peripheral vascular intervention) and 60% (n = 136) continued nonoperative management. Patients were followed up to 6.9 years, with an average follow-up of 5.2 ± 1.6 years. Patients who underwent revascularization were more likely to be clinically frail (P = .03), have a lower index ABI (0.55 ± 0.24 vs 0.72 ± 0.28; P < .001), and lower baseline PROMIS-PF score (36.72 ± 8.2 vs 40.40 ± 6.73; P = .01). There were no differences in patient demographics or medications between treatment groups. Examining patient-reported outcome trends over time; there were no significant differences in PROMIS-PF between groups, trends over time, or group differences over time after adjusting for covariates (P = .07, P = .13, and P =.08, respectively). However, all patients with IC significantly increased their PROMIS-SA over time (adjusted P = .019), with patients managed nonoperatively more likely to have an improvement in PROMIS-SA over time than those who underwent revascularization (adjusted P = .045). CONCLUSIONS: Patient-reported outcomes associated with functional status and satisfaction in activities are similar for patients with IC for up to 7 years, irrespective of whether they undergo treatment with revascularization or continue nonoperative management. These findings support conservative long-term management for patients with IC.

Opioid tapering after surgery and its association with patient-reported outcomes and behavioral changes: a mixed-methods analysis.

INTRODUCTION: Opioid tapering after surgery is recommended among patients with chronic opioid use, but it is unclear how this process affects their quality of life. The objective of this study was to evaluate how opioid tapering following surgery was associated with patient-reported outcome measures related to pain control and behavioral changes that affect quality of life. METHODS: We conducted an explanatory sequential mixed-methods study at a VA Medical Center among patients with chronic opioid use who underwent a spectrum of orthopedic, vascular, thoracic, urology, otolaryngology, and general surgery procedures between 2018 and 2020. Patients were stratified based on the extent that opioid tapering was successful (complete, partial, and no-taper) by 90 days after surgery, followed by qualitative interviews of 10 patients in each taper group. Longitudinal patient-reported outcome measures related to pain intensity, interference, and catastrophizing were compared using Kruskal Wallis tests over the 90-day period after surgery. Qualitative interviews were conducted among patients in each taper group to identify themes associated with the impact of opioid tapering after surgery on quality of life. RESULTS: We identified 211 patients with chronic opioid use (92% male, median age 66 years) who underwent surgery during the time period, including 42 (20%) individuals with complete tapering, 48 (23%) patients with partial tapering, and 121 (57%) patients with no taper of opioids following surgery. Patients who did not taper were more likely to have a history of opioid use disorder (10%-partial, 2%-complete vs 17%-no taper, p<0.05) and be discharged on a higher median morphine equivalent daily dose (52-partial, 30-complete vs 60-no taper; p<0.05) than patients in the partial and complete taper groups. Pain interference (-7.2-partial taper and -9.8-complete taper vs -3.5-no taper) and pain catastrophizing (-21.4-partial taper and -16.5-complete taper vs -1.7-no taper) scores for partial and complete taper groups were significantly improved at 90 days relative to baseline when compared with patients in the no-taper group (p<0.05 for both comparisons), while pain intensity was similar between groups. Finally, patients achieving complete and partial opioid tapering were more likely to report improvements in activity, mood, thinking, and sleep following surgery as compared with patients who failed to taper. CONCLUSIONS: Partial and complete opioid tapering within 90 days after surgery among patients with chronic opioid use was associated with improved patient-reported measures of pain control as well as behaviors that impact a patient's quality of life.

Predictors of Arteriovenous Fistula Maturation among Patients with Severe Obesity.

BACKGROUND: There is an increasing prevalence of obesity among patients who develop end-stage renal disease and require dialysis. While referrals for arteriovenous fistulas (AVFs) among patients with class 2-3 obesity (i.e., body mass index [BMI] ≥ 35) are increasing, it is unclear what type of autogenous access is most likely to mature in this patient population. This study was designed to evaluate factors that impact maturation of AVF among patients with class ≥2 obesity. METHODS: We retrospectively reviewed AVFs created at a single center from 2016 to 2019 for patients who had undergone dialysis within the same healthcare system. Ultrasound studies were used to evaluate factors that defined functional maturation, including diameter, depth, and volume flow rates through the fistula. Logistic regression models were used to evaluate the risk-adjusted association between class ≥2 obesity and functional maturation. RESULTS: A total of 202 AVFs [radiocephalic (24%), brachiocephalic (43%), and transposed brachiobasilic (33%)] were created during the study period, of which 53 (26%) patients had a BMI >35. Functional maturation was significantly lower among patients with class ≥2 obesity undergoing brachiocephalic (58% obese versus 82% normal-overweight; P = 0.017), but not radiocephalic or brachiobasilic AVFs. This was primarily a result of excessive AVF depth in severely obese patients (9.6 ± 4.0 mm obese versus 6.0 ± 2.7 mm normal-overweight; P < 0.001), whereas there was no significant difference found in average volume flow or AVF diameter between groups. In risk-adjusted models, a BMI ≥35 was associated with a significantly lower likelihood of achieving AVF functional maturation (odds ratio: 0.38; 95% confidence interval: 0.18-0.78; P = 0.009) after controlling for age, sex, socioeconomic status, and fistula type. CONCLUSIONS: Patients with a BMI >35 are less likely to mature AVFs after creation. This principally affects brachiocephalic AVFs and occurs because of increased fistula depth as opposed to diameter or volume flow parameters. These data can help guide decision-making when planning AVF placement in severely obese patients.

Postsurgical Opioid Use Among Veterans Discharged to Skilled Care Facilities Compared to Veterans Discharged to Home After Orthopedic Surgery.

OBJECTIVES: To compare opioid use patterns among Veterans who were discharged to a skilled care facility vs home after orthopedic surgery at a VA hospital. DESIGN: We conducted a retrospective cohort study of Veterans who had orthopedic surgery at the Salt Lake City VA Medical Center (VAMC) between January 2018 and December 2021 and were followed by a transitional pain service. The principal outcome of interest was the time to stop opioid use after discharge from the hospital. SETTING AND PARTICIPANTS: Veterans not already on chronic opioid therapy who had orthopedic surgery at the Salt Lake City VAMC and were followed by a transitional pain service. METHODS: 448 patients were included in the study, of which 371 (83%) were discharged to home and 77 (17%) were discharged to a skilled care facility. Median days to opioid cessation were estimated using the Kaplan-Meier method with 95% CIs and compared with discharge disposition using a log-rank test. Time to opioid cessation following hospital discharge was compared to baseline characteristics using univariable and multivariable Cox proportional hazards models. RESULTS: Patients who were discharged to a skilled care facility used opioids for twice as long as those who were discharged home [median days (interquartile range)]: 22 (19, 26) vs 11 (10, 12), P < .001, respectively. When controlling for baseline characteristics in the multivariable analysis, discharge to a skilled care facility was significantly associated with continued opioid use at all time points [hazard ratio 0.63 (95% CI 0.44, 0.89), P = .009]. CONCLUSIONS AND IMPLICATIONS: Veterans discharged to a skilled care facility after orthopedic surgery used opioids for twice as long as those who were discharged to home. As postsurgical pain management guidelines change to focus on nonopioid pain modalities and opioid reduction, skilled care providers should adapt those strategies for their facilities.

Impact of frailty on risk of long-term functional decline following vascular surgery.

OBJECTIVE: Frailty is a clinical syndrome associated with slow recovery after vascular surgery. However, the degree and length of functional impairment frail patients experience after surgery is unclear. The objective of this study was to prospectively measure changes in functional status among frail and non-frail patients undergoing a spectrum of different vascular surgery procedures. METHODS: Patients consented to undergo elective minor and major vascular surgery procedures at an academic medical center between May 2018 and March 2019 were prospectively identified. Prior to surgery, all patients underwent provider assessment of frailty using the validated Clinical Frailty Scale (CFS), as well as baseline assessment of functional status using the Katz Activities of Daily Living (ADL) index and the Lawton Instrumental Activities of Daily Living (iADL) index. These same instruments were used to evaluate each patient's functional status at 2-weeks, 1-month, 1-year, and 2-year time points following surgery. Changes in iADL and ADL scores among frail (CFS ≥5) and non-frail patients were compared using paired Wilcoxon signed-rank tests and logistic regression models. RESULTS: A total of 126 patients were assessed before and after minor (55%) and major (45%) vascular procedures, of which 43 patients (34%) were determined to be frail prior to surgery. Frail patients were older and more likely than non-frail patients to have medical comorbidities including chronic kidney disease, chronic obstructive pulmonary disease, or diabetes (all P < .05). When compared with the non-frail cohort, frail patients had significantly lower ADL and iADL scores before surgery and experienced a greater decline in ability to independently complete ADL and iADL activities after surgery that was sustained at 2 years (P < .05 and P < .001, respectively). After risk-adjustment, frailty was associated with an increased likelihood of decline in ADLs (odds ratio, 5.4; 95% confidence interval, 1.9-15.4; P < .05) and iADLs (odds ratio, 6.3; 95% confidence interval, 2.6-15.1; P < .001) at 2 years following surgery. CONCLUSIONS: Frail patients experience a significant decline in ability to perform ADL and iADLs that persists 2 years following vascular surgery. These data highlight the degree of functional decline occurring immediately following surgery, as well as risk for long-term, sustained impairment that should be shared with frail patients before undergoing a procedure.

Effect of Multidisciplinary Transitional Pain Service on Health Care Use and Costs Following Orthopedic Surgery.

Background: Opioid use disorder is a significant cause of morbidity, mortality, and health care costs. A transitional pain service (TPS) approach to perioperative pain management has been shown to reduce opioid use among patients undergoing orthopedic joint surgery. However, whether TPS also leads to lower health care use and costs is unknown. Methods: We designed this study to estimate the effect of TPS implementation relative to standard care on health care use and associated costs of care following orthopedic surgery. We evaluated postoperative health care use and costs for patients who underwent orthopedic joint surgery at 6 US Department of Veterans Affairs medical centers (VAMCs) between 2018 and 2019 using difference-in-differences analysis. Patients enrolled in the TPS at the Salt Lake City VAMC were matched to control patients undergoing the same surgeries at 5 different VAMCs without a TPS. We stratified patients based on history of preoperative opioid use into chronic opioid use (COU) and nonopioid use (NOU) groups and analyzed them separately. Results: For NOU patients, TPS was associated with a mean increase in the number of outpatient visits (6.9 visits; P < .001), no change in outpatient costs, and a mean decrease in inpatient costs (-$12,170; P = .02) during the 1-year follow-up period. TPS was not found to increase health care use or costs for COU patients. Conclusions: Although TPS led to an increase in outpatient visits for NOU patients, there was no increase in outpatient costs and a decrease in inpatient costs after orthopedic surgery. Further, there was no added cost for managing COU patients with a TPS. These findings suggest that TPS can be implemented to reduce opioid use following joint surgery without increasing health care costs.

Breaking the vicious circle-the Asthma Referral Identifier (ReferID) tool.

Asthma is associated with a significant burden of disease, especially for patients with severe or uncontrolled asthma. Many patients with severe asthma still receive treatment in primary care settings and despite the availability of effective options, inadequate asthma treatment remains a concern, particularly the use of systemic corticosteroids to treat exacerbations and severe asthma. Around the world, many patients are stuck in a vicious circle of misdiagnosis, undertreatment, and poor understanding of disease severity and management. In this manuscript, we describe the development of The Asthma Referral Identifier (ReferID) tool, a simple, 4-item questionnaire that healthcare providers can use to help identify patients with uncontrolled and/or potentially severe asthma. ReferID was developed specifically for use in primary care clinics in low- and middle-income countries and other clinics, where the optimisation of asthma assessments and treatment recommended for countries with well-established healthcare systems, are not possible. ReferID was developed through an informal collaborative process involving international asthma experts as well as general practitioners, nurses, and specialists throughout the Asia Pacific, Latin America and Middle East regions, in conjunction with current evidence and treatment guidelines. In collaboration with local and regional partners around the world, the developers have adapted ReferID and translated it into 21 languages, and implementation is ongoing in 30 countries. ReferID has the potential to help break the vicious circle, improving disease outcomes and health-related quality of life for patients with asthma.

Complete opioid cessation after surgery improves patient-reported pain measures among chronic opioid users.

BACKGROUND: Preoperative chronic opioid use is common, but it is unclear whether complete opioid tapering can be achieved postoperatively without adversely affecting pain control and quality of life. This study was designed to assess the association between complete opioid tapering after surgery and patient-reported outcomes for pain intensity and pain interference. METHODS: We identified chronic opioid use patients undergoing a spectrum of nonemergency surgical procedures at a single Veterans Affairs medical institution between December 2017 and 2021. All patients were prospectively followed by a transitional pain service that promoted opioid tapering, assessed opioid use (morphine milligram equivalent), and patient-reported outcomes measurement information system for pain intensity (PROMIS-3a) and pain interference (PROMIS-6b). After stratifying based on whether complete versus partial/no opioid tapering was achieved after surgery, longitudinal changes in patient-reported outcomes and morphine milligram equivalents were compared over time. Independent predictors of complete opioid tapering were assessed using logistic regression models. RESULTS: In total, 341 surgical patients (91% male, mean age 64 years) with chronic opioid use underwent surgery during the study period, of which 44 (13%) completely tapered off opioids within 60 days after discharge from the hospital. Patients who completely tapered had significant improvement in the change in patient-reported outcomes for pain intensity and interference with significant differences at 30 and 60 days after discharge for both measures when compared to the partial/no taper group (both P < .05). In risk-adjusted analyses, patients with lower baseline morphine milligram equivalents and those staying longer in the hospital were more likely to achieve complete opioid tapering (both P < .01). CONCLUSION: Complete opioid tapering can be successfully achieved after surgery among patients with chronic opioid use with corresponding improvements in self-reported pain intensity and pain interference. Our results suggest that the highest potential for improving patient-reported outcomes with opioid tapering occurs among patients undergoing orthopedic procedures early after surgical discharge.

Patient-reported physical function as a preoperative predictor of recovery after vascular surgery.

OBJECTIVE: Preoperative risk assessment in vascular surgery often relies on the clinical subjectivity of providers and assessment tools with poor discrimination. Patient-reported outcome measures (PROMs) may provide a more objective assessment of an individual's own health status before surgery and ability to recover after a vascular procedure. We designed this study to determine whether PROMs assessed for physical function (PROM-PF) prior to vascular surgery could be used to predict patient risk for postoperative complications and delayed recovery. METHODS: We identified all patients who completed a PROM-PF survey prior to undergoing a vascular surgery procedure captured in the Society for Vascular Surgery-Vascular Quality Initiative registry (carotid endarterectomy, abdominal aortic aneurysm, endovascular aneurysm repair, thoracic endovascular aneurysm repair, peripheral vascular intervention, infra-inguinal bypass, and supra-inguinal bypass) at a single academic institution between January 2016 and June 2020. PROM-PF assessment was obtained electronically using the validated Patient-Reported Outcome Measurement Information System short form (v1.2) instrument. All patient demographics and comorbidities were collected as part of the Society for Vascular Surgery-Vascular Quality Initiative registry. After stratifying patients based on high vs low preoperative PROM-PF, multivariable regression models were used to assess the risk-adjusted odds ratios (ORs) for perioperative complications, extended hospital length of stay (LOS), and discharge to a care facility. RESULTS: A total of 240 patients (mean age, 68 years; 69% male; and 88% Caucasian) completed a PROM-PF assessment <30 days before a vascular surgery intervention, of which 54% had low PF. Patients with high PF were more likely than those with low PF to undergo an open vascular procedure (43% high PF vs 42% low PF; P < .001). Rates of perioperative complications and/or mortality were similar between groups, although patients with low-PF were more likely to have an extended hospital LOS (48% low PF vs 33% high PF; P < .05) and/or be discharged to a care facility (17% low PF vs 7% high PF; P < .05). These results were confirmed in risk-adjusted models showing that patients with low PF scores were significantly more likely to have an extended LOS (adjusted OR, 1.86; 95% confidence interval, 1.06-3.28) and be discharged to a care facility (adjusted OR, 2.72; 95% confidence interval, 1.06-7.00). CONCLUSIONS: Low preoperative PROM-PF was associated with a higher risk of extended inpatient LOS and discharge to a care facility following vascular surgery. PROMs allow patients to provide valuable presurgical information about their own health status that can be used to anticipate postoperative recovery.