Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, Massachusetts.
J Bone Joint Surg Am. 2021 Mar 17;103(6):497-505. doi: 10.2106/JBJS.20.01401.
Although the risks of continued opioid use following inpatient total joint arthroplasty (TJA) have been well-studied, these risks in the outpatient setting are not well known. The purpose of the present study was to characterize opioid use following outpatient compared with inpatient TJA.
In this retrospective cohort study, opioid-naïve patients who underwent inpatient or outpatient (no overnight stay) primary, elective TJA from 2007 to 2017 were identified within a large national commercial-claims insurance database. For inclusion in the study, patients had to have been continuously enrolled in the database for ≥12 months prior to and ≥6 months after the TJA procedure. Multivariable analyses controlling for demographics, geography, procedure, year, and comorbidities were utilized to determine the association between surgical setting and risk of persistent opioid use, defined as the patient still filling new opioid prescriptions >90 days postoperatively.
We identified a total of 92,506 opioid-naïve TJA patients, of whom 57,183 (61.8%) underwent total knee arthroplasty (TKA). Overall, 7,342 patients (7.9%) underwent an outpatient TJA procedure, including 4,194 outpatient TKAs. Outpatient TJA was associated with reduced surgical opioid prescribing (78.9% compared with 87.6% for inpatient procedures; p < 0.001). Among the 80,393 patients (86.9%) who received surgical opioids, the total amount of opioids prescribed (in morphine milligram equivalents) was similar between inpatient (median, 750; interquartile range, 450 to 1,200) and outpatient procedures (median, 750; interquartile range, 450 to 1,140; p = 0.47); however, inpatient TJA patients were significantly more likely to still be taking opioids after 90 days postoperatively (11.4% compared with 9.0% for outpatient procedures; p < 0.001). These results persisted in adjusted analysis (adjusted odds ratio, 1.13; 95% confidence interval, 1.03 to 1.24; p = 0.01).
Outpatient TJA patients who received opioid prescriptions were prescribed a similar amount of opioids as those undergoing inpatient TJA procedures, but were significantly less likely to become persistent opioid users, even when controlling for patient factors. Outpatient TJA, as compared with inpatient TJA, does not appear to be a risk factor for new opioid dependence, and these findings support the continued transition to the outpatient-TJA model for lower-risk patients.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
尽管住院全关节置换术（TJA）后持续使用阿片类药物的风险已得到充分研究，但门诊环境中的这些风险尚不清楚。本研究的目的是描述门诊与住院 TJA 后阿片类药物的使用情况。
本回顾性队列研究从一个大型全国商业保险数据库中确定了 2007 年至 2017 年间接受门诊（无过夜）或住院（无过夜）初次、择期 TJA 的阿片类药物初治患者。纳入研究的患者必须在 TJA 术前至少连续 12 个月，术后至少 6 个月连续参加数据库。采用多变量分析控制人口统计学、地理位置、手术、年份和合并症，以确定手术部位与持续使用阿片类药物风险之间的关联，持续使用阿片类药物定义为患者术后 90 天以上仍在开新的阿片类药物处方。
共纳入 92506 例阿片类药物初治 TJA 患者，其中 57183 例（61.8%）接受全膝关节置换术（TKA）。总体而言，7342 例（7.9%）患者接受了门诊 TJA 手术，其中 4194 例为门诊 TKA。门诊 TJA 与减少手术阿片类药物处方相关（与住院手术相比，78.9%比 87.6%；p < 0.001）。在 80393 例（86.9%）接受手术阿片类药物的患者中，处方阿片类药物的总量（以吗啡毫克当量计）在住院（中位数 750；四分位距 450 至 1200）和门诊（中位数 750；四分位距 450 至 1140；p = 0.47）之间相似；然而，住院 TJA 患者术后 90 天仍服用阿片类药物的可能性明显更高（11.4%比门诊手术 9.0%；p < 0.001）。调整分析结果一致（调整后的优势比，1.13；95%置信区间，1.03 至 1.24；p = 0.01）。
接受阿片类药物处方的门诊 TJA 患者开的阿片类药物量与接受住院 TJA 手术的患者相似，但成为持续性阿片类药物使用者的可能性显著降低，即使控制了患者因素也是如此。与住院 TJA 相比，门诊 TJA 似乎不是新发阿片类药物依赖的危险因素，这些发现支持继续向低风险患者过渡到门诊 TJA 模式。
治疗性 III 级。请参阅作者说明以获取完整的证据水平描述。
