Peluso Heather, Araya Sthefano, Patel Heli, Najafali Daniel, Thota Bhavana, Talemal Lindsay, Hackley Madison, Moss Civanni, Patel Sameer A, Walchak Adam
Division of Plastic and Reconstructive Surgery, Mid-Atlantic Group Permanente Medical Group, Upper Marlboro, MD, USA.
Catalyst Medical Consulting LLC, Simpsonville, SC, USA.
Clin Orthop Relat Res. 2025 May 1;483(5):918-927. doi: 10.1097/CORR.0000000000003346. Epub 2024 Dec 20.
Opioid use disorder (OUD) has been implicated as a potential risk factor for adverse outcomes and readmissions in various surgical procedures. Patients admitted with an open fracture of the lower extremity often have multifarious pain needs, require surgical procedures, and have prolonged rehabilitation; previous OUD complicates this process. Our goal was to describe at a national level how OUD is associated with readmission, complications, and healthcare expenditure for patients admitted with open lower extremity fractures.
QUESTIONS/PURPOSES: (1) Do patients with OUD who were treated for open lower extremity fractures have higher odds of readmission compared with patients without OUD? (2) Do patients with OUD who were treated for open lower extremity fractures have higher healthcare utilization (specifically, length of stay and hospitalization charges and costs)?
This was a retrospective, comparative study using the Nationwide Readmissions Database, which is the largest nationally representative readmissions database in the United States. Patients were included if they had an ICD-10-CM principal diagnosis of open lower extremity fracture. Between January 1, 2019, and September 30, 2019, a total of 17,811 patients were admitted for open lower extremity fractures and entered in the National Readmissions Database. Of the 17,811 patients, 2.3% (410) had a secondary diagnosis of OUD and 97.7% (17,401) did not. The mean age was 46 years for both groups. The most common operative procedure was debridement, and 1.5% of patients received a flap for reconstruction. Opioid disorders were identified using ICD-10-CM codes. Ninety-day complications and readmissions were characterized for the calendar year. Patients undergoing flap-based reconstructions were identified with ICD-10-PR codes. Confounders (patient demographic and hospital characteristics) were adjusted for using multivariable regression analysis models.
After controlling for potentially confounding variables such as primary payer, Charlson comorbidity index, Gustillo type, and bone density, we found that patients with OUD had greater odds of readmission after open lower extremity fractures (adjusted OR 1.45 [95% confidence interval (CI) 1.0 to 2.0]; p = 0.03). The 90-day infection occurrence was higher in patients with OUD (adjusted OR 1.96 [95% CI 1.0 to 3.8]; p = 0.049) and was the primary reason for readmission in both groups. Moreover, 11% (11 of 103) of patients with OUD were readmitted with opioid-induced complications, which was exclusively observed in this cohort. Patients with OUD also had longer hospital stays (adjusted mean difference 2.2 days [95% CI 0.5 to 3.8]; p = 0.01) and higher hospitalization charges (adjusted mean difference in USD 34,000 [95% CI 1000 to 66,000]; p = 0.04) and costs (adjusted mean difference in USD 7000 [95% CI 2000 to 13,000]; p = 0.007) than those without OUD.
These findings suggest that mitigating infection and opioid overdose, addiction, and constipation in patients with OUD could reduce readmissions in lower extremity fracture patients. Future research should focus on antibiotic and wound care compliance and the early and frequent engagement of postoperative opioid addiction support services.
Level III, therapeutic study.
阿片类物质使用障碍（OUD）被认为是各种外科手术中不良结局和再入院的潜在风险因素。因下肢开放性骨折入院的患者通常有多种疼痛需求，需要进行外科手术，且康复期较长；既往存在的OUD会使这一过程变得复杂。我们的目标是在全国范围内描述OUD如何与下肢开放性骨折患者的再入院、并发症及医疗费用相关联。
问题/目的：（1）与无OUD的患者相比，接受下肢开放性骨折治疗的OUD患者再入院几率是否更高？（2）接受下肢开放性骨折治疗的OUD患者是否有更高的医疗资源利用率（具体而言，住院时间、住院费用和成本）？
这是一项回顾性比较研究，使用了全国再入院数据库，该数据库是美国最大的具有全国代表性的再入院数据库。如果患者的ICD-10-CM主要诊断为下肢开放性骨折，则纳入研究。在2019年1月1日至2019年9月30日期间，共有17811例因下肢开放性骨折入院的患者被纳入全国再入院数据库。在这17811例患者中，2.3%（410例）有OUD的次要诊断，97.7%（17401例）没有。两组的平均年龄均为46岁。最常见的手术操作是清创术，1.5%的患者接受了皮瓣重建术。使用ICD-10-CM编码识别阿片类物质障碍。对日历年的90天并发症和再入院情况进行了描述。使用ICD-10-PR编码识别接受皮瓣重建术的患者。使用多变量回归分析模型对混杂因素（患者人口统计学和医院特征）进行了调整。
在控制了诸如主要支付方、查尔森合并症指数、 Gustillo类型和骨密度等潜在混杂变量后，我们发现OUD患者下肢开放性骨折后再入院的几率更高（调整后的比值比为1.45 [95%置信区间（CI）1.0至2.0]；p = 0.03）。OUD患者90天感染发生率更高（调整后的比值比为1.96 [95% CI 1.0至3.8]；p = 0.049），且是两组再入院的主要原因。此外，11%（103例中的11例）的OUD患者因阿片类物质引起的并发症再次入院，这仅在该队列中观察到。与无OUD的患者相比，OUD患者的住院时间也更长（调整后的平均差异为2.2天 [95% CI 0.5至3.8]；p = 0.01），住院费用更高（调整后的平均差异为34000美元 [95% CI 1000至66000]；p = 0.04），成本更高（调整后的平均差异为7000美元 [95% CI 2000至13000]；p = 0.007）。
这些发现表明，减轻OUD患者的感染以及阿片类物质过量、成瘾和便秘问题，可能会降低下肢骨折患者的再入院率。未来的研究应关注抗生素和伤口护理的依从性，以及术后阿片类物质成瘾支持服务的早期和频繁介入。
III级，治疗性研究。
