Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
J Am Med Dir Assoc. 2023 Jul;24(7):971-977.e4. doi: 10.1016/j.jamda.2023.03.012. Epub 2023 Apr 17.
Pain management in post-acute care (PAC) requires careful balance, with both opioid use and inadequate pain treatment linked to poor outcomes. We describe opioid use among older adults following discharge from PAC for hip fracture in skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs).
Retrospective cohort.
Medicare beneficiaries with Medicare Provider Analysis (MedPAR) claims, aged 66 years and older with a hip fracture hospitalization between 2012 and 2018 followed by PAC in SNFs or IRFs and then discharge to the community.
Individuals were followed from PAC discharge for up to 1 year to assess opioid use. Covariate-standardized risk ratios (RR) and risk differences (RD) for opioid use within 7 days of PAC discharge were estimated via parametric g-formula with modified Poisson regression, and hazard ratios (HRs) for any post-PAC opioid use and long-term opioid use via Fine-Gray sub-distribution hazards regression.
Of 101,021 individuals, 80% (n = 80,495) were discharged from SNFs and 20% (n = 20,526) from IRFs. Opioids were dispensed to 50,433 patients (50%) overall and the 1-year cumulative incidence was notably higher in IRF (68%) than SNF (46%) patients. The adjusted risk of discharge from PAC with an opioid was 41% lower after SNFs versus IRFs [RR: 0.59; 95% confidence limits (CLs): 0.57-0.61; and RD: -0.16; 95% CLs: -0.17 to -0.15]. The adjusted rate of any opioid use in the year after PAC discharge was 44% lower (HR: 0.56; 95% CLs: 0.54-0.57) and of long-term opioid use was 17% lower (HR: 0.83; 95% CLs: 0.80-0.87) after SNFs versus IRFs.
Opioid use is highly prevalent upon discharge from PAC after hip fracture, with lower use after SNF versus IRF care. Future research should assess the benefits and harms of post-PAC opioid prescribing and whether care practices during PAC can be improved to optimize long-term opioid use.
在康复后期护理（PAC）中，疼痛管理需要谨慎平衡，阿片类药物的使用和疼痛治疗不足都与不良结局有关。我们描述了在熟练护理设施（SNF）和住院康复设施（IRF）中接受髋关节骨折 PAC 治疗的老年患者出院后的阿片类药物使用情况。
回顾性队列研究。
2012 年至 2018 年期间，有 Medicare Provider Analysis（MedPAR）索赔记录、年龄在 66 岁及以上、因髋关节骨折住院并在 SNF 或 IRF 接受 PAC 治疗、然后出院到社区的 Medicare 受益人的数据。
从 PAC 出院后对个人进行了长达 1 年的随访，以评估阿片类药物的使用情况。使用修正泊松回归的参数 g 公式估计 PAC 出院后 7 天内使用阿片类药物的校正风险比（RR）和风险差异（RD），并使用 Fine-Gray 亚分布风险回归估计任何 PAC 后阿片类药物使用和长期阿片类药物使用的风险比（HR）。
在 101021 名患者中，80%（n=80495）从 SNF 出院，20%（n=20526）从 IRF 出院。总体而言，有 50433 名患者（50%）开出了阿片类药物，IRF（68%）患者的 1 年累积发生率明显高于 SNF（46%）患者。与 IRF 相比，SNF 患者 PAC 出院时开具阿片类药物的风险降低了 41%[RR：0.59；95%置信区间（CLs）：0.57-0.61；和 RD：-0.16；95% CLs：-0.17 至-0.15]。PAC 出院后一年内任何阿片类药物使用的调整率（HR：0.56；95% CLs：0.54-0.57）和长期阿片类药物使用的调整率（HR：0.83；95% CLs：0.80-0.87）均降低了 44%。
髋关节骨折后 PAC 出院时阿片类药物的使用非常普遍，SNF 治疗后阿片类药物的使用低于 IRF。未来的研究应该评估 PAC 后阿片类药物处方的益处和危害，以及 PAC 期间的护理实践是否可以改进，以优化长期阿片类药物的使用。
