The Association of Preoperative Opioid Usage With Patient-Reported Outcomes, Adverse Events, and Return to Work After Lumbar Fusion: Analysis From the Michigan Spine Surgery Improvement Collaborative (MSSIC)

Abstract BACKGROUND It is important to delineate the relationship between opioid use and spine surgery outcomes. OBJECTIVE To determine the association between preoperative opioid usage and postoperative adverse events, patient satisfaction, return to work, and improvement in Oswestry Disability Index (ODI) in patients undergoing lumbar fusion procedures by using 2-yr data from a prospective spine registry. METHODS Preoperative opioid chronicity from 8693 lumbar fusion patients was defined as opioid-naïve (no usage), new users (<6 wk), short-term users (6 wk-3 mo), intermediate-term users (3-6 mo), and chronic users (>6 mo). Multivariate generalized estimating equation models were constructed. RESULTS All comparisons were to opioid-naïve patients. Chronic opioid users showed less satisfaction with their procedure at 90 d (Relative Risk (RR) 0.95, P = .001), 1 yr (RR 0.89, P = .001), and 2 yr (RR 0.89, P = .005). New opioid users were more likely to show improvement in ODI at 90 d (RR 1.25, P < .001), 1 yr (RR 1.17, P < .001), and 2 yr (RR 1.19, P = .002). Short-term opioid users were more likely to show ODI improvement at 90 d (RR 1.25, P < .001). Chronic opioid users were less likely to show ODI improvement at 90 d (RR 0.90, P = .004), 1 yr (RR 0.85, P < .001), and 2 yr (RR 0.80, P = .003). Chronic opioid users were less likely to return to work at 90 d (RR 0.80, P < .001). CONCLUSION In lumbar fusion patients and when compared to opioid-naïve patients, new opioid users were more likely and chronic opioid users less likely to have improved ODI scores 2 yr after surgery. Chronic opioid users are less likely to be satisfied with their procedure 2 yr after surgery and less likely to return to work at 90 d. Preoperative opioid counseling is advised.

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The Association Between Chronicity of Preoperative Opioid Usage Between Patient Satisfaction, Return to Work, and Achieving ODI MCID up to 2 Years After Lumbar Fusion: Analysis From the Michigan Spine Surgery Improvement Collaborative (MSSIC)

Neurosurgery ◽

10.1093/neuros/nyz310_179 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Hesham M Zakaria ◽

Tarek R Mansour ◽

Edvin Telemi ◽

Karam P Asmaro ◽

Theresa A Elder ◽

...

Keyword(s):

Patient Satisfaction ◽

Return To Work ◽

Spine Surgery ◽

Lumbar Fusion ◽

Favorable Outcome ◽

Satisfaction Index ◽

Fusion Analysis ◽

Opioid Users ◽

The Relationship ◽

Prospective Database

Abstract INTRODUCTION The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a multicenter quality improvement collaborative. Using the MSSIC database, we sought to identify the relationship between preoperative opioid usage and patient satisfaction, return to work, and achieving ODI MCID up to 2-yr after lumbar fusion. METHODS A total of 8693 lumbar fusion patients were analyzed. Patient satisfaction was measured by the NASS patient satisfaction index. Generalized estimating equations (GEE) models were constructed; variables tested include age, gender, race, PMH, and number of surgical levels. Preoperative opioid chronicity was defined as opioid naïve (no opioid usage), new opioid users (<6 wk), recent opioid users (6 wk-3 mo), frequent opioid users (3 mo-6 mo), and chronic opioid users (>6 mo). Comparisons were made to opioid naïve patients. RESULTS Chronic opioid users were less likely to be satisfied with their procedure at 90-d (OR 0.95, P < .001), 1-yr (OR 0.90, P < .001), and 2-yr (OR 0.87, P < .001) after surgery. New opioid users were more likely to achieve ODI MCID at 90-d (OR 1.25, P < .001), 1-yr (OR 1.15, P < .001), and 2-yr (OR 1.22, P < .002) postoperatively. Recent opioid users were more likely to achieve ODI MCID at 2 yr (OR 1.26, P < .001). Chronic opioid users were less likely to achieve ODI MCID at 90-d (OR 0.89, P < .001), 1-yr (OR 0.87, P = .002), and 2-yr (OR 0.82, P = .004). Chronic opioid users were also less likely to return to work at 90-d (OR 0.83, P < .001). CONCLUSION A multivariate analysis on preoperative opioid usage from a large, multicenter, prospective database on lumbar fusion patients was performed. We found that, as compared to opioid naïve patients, 2-yr postoperatively new opioid users (<6 wk) were more likely to have a favorable outcome, while chronic opioid users (>6 mo) were less likely to have a favorable outcome. Thus, preoperative opioid counseling is imperative to improve outcomes in spine surgery.

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Use of Patient Health Questionnaire–2 scoring to predict patient satisfaction and return to work up to 1 year after lumbar fusion: a 2-year analysis from the Michigan Spine Surgery Improvement Collaborative

Journal of Neurosurgery Spine ◽

10.3171/2019.6.spine1963 ◽

2019 ◽

Vol 31 (6) ◽

pp. 794-801 ◽

Cited By ~ 1

Author(s):

Hesham Mostafa Zakaria ◽

Tarek R. Mansour ◽

Edvin Telemi ◽

Karam Asmaro ◽

Mohamed Macki ◽

...

Keyword(s):

Multivariate Analysis ◽

Patient Satisfaction ◽

Return To Work ◽

Spine Surgery ◽

Lumbar Fusion ◽

Estimating Equation ◽

Patient Health Questionnaire ◽

Health Questionnaire ◽

Patient Health ◽

Prospective Longitudinal

OBJECTIVEThe Michigan Spine Surgery Improvement Collaborative (MSSIC) is a prospective, longitudinal, multicenter, quality-improvement collaborative. Using MSSIC, the authors sought to identify the relationship between a positive Patient Health Questionnaire–2 (PHQ-2) screening, which is predictive of depression, and patient satisfaction, return to work, and achieving Oswestry Disability Index (ODI) minimal clinically important difference (MCID) scores up to 2 years after lumbar fusion.METHODSData from a total of 8585 lumbar fusion patients were analyzed. Patient satisfaction was measured by the North American Spine Society patient satisfaction index. A positive PHQ-2 score is one that is ≥ 3, which has an 82.9% sensitivity and 90.0% specificity in detecting major depressive disorder. Generalized estimating equation models were constructed; variables tested include age, sex, race, past medical history, severity of surgery, and preoperative opioid usage.RESULTSMultivariate analysis was performed. Patients with a positive PHQ-2 score (i.e., ≥ 3) were less likely to be satisfied after lumbar fusion at 90 days (relative risk [RR] 0.93, p < 0.001), 1 year (RR 0.92, p = 0.001), and 2 years (RR 0.92, p = 0.028). A positive PHQ-2 score was also associated with decreased likelihood of returning to work at 90 days (RR 0.76, p < 0.001), 1 year (RR 0.85, p = 0.001), and 2 years (RR 0.82, p = 0.031). A positive PHQ-2 score was predictive of failure to achieve an ODI MCID at 90 days (RR 1.07, p = 0.005) but not at 1 year or 2 years after lumbar fusion.CONCLUSIONSA multivariate analysis based on information from a large, multicenter, prospective database on lumbar fusion patients was performed. The authors found that a positive score (≥ 3) on the PHQ-2, which is a simple and accurate screening tool for depression, predicts an inability to return to work and worse satisfaction up to 2 years after lumbar fusion. Depression is a treatable condition, and so in the same way that patients are medically optimized before surgery to decrease postoperative morbidity, perhaps patients should have preoperative psychiatric optimization to improve postoperative functional outcomes.

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Preoperative Opioid Use in Patients Undergoing Common Hand Surgeries

Hand ◽

10.1177/1558944720974122 ◽

2021 ◽

pp. 155894472097412

Author(s):

Ali Aneizi ◽

Dominique Gelmann ◽

Dominic J. Ventimiglia ◽

Patrick M. J. Sajak ◽

Vidushan Nadarajah ◽

...

Keyword(s):

Outcome Measures ◽

Hand Surgery ◽

Patient Characteristics ◽

Patient Reported Outcome Measures ◽

Pain Scale ◽

Patient Reported Outcome ◽

Measurement Information ◽

Opioid Use ◽

Patient Reported ◽

Opioid Users

Background: The objectives of this study were to determine the baseline patient characteristics associated with preoperative opioid use and to establish whether preoperative opioid use is associated with baseline patient-reported outcome measures in patients undergoing common hand surgeries. Methods: Patients undergoing common hand surgeries from 2015 to 2018 were retrospectively reviewed from a prospective orthopedic registry at a single academic institution. Medical records were reviewed to determine whether patients were opioid users versus nonusers. On enrollment in the registry, patients completed 6 Patient-Reported Outcomes Measurement Information System (PROMIS) domains (Physical Function, Pain Interference, Fatigue, Social Satisfaction, Anxiety, and Depression), the Brief Michigan Hand Questionnaire (BMHQ), a surgical expectations questionnaire, and Numeric Pain Scale (NPS). Statistical analysis included multivariable regression to determine whether preoperative opioid use was associated with patient characteristics and preoperative scores on patient-reported outcome measures. Results: After controlling for covariates, an analysis of 353 patients (opioid users, n = 122; nonusers, n = 231) showed that preoperative opioid use was associated with higher American Society of Anesthesiologists class (odds ratio [OR], 2.88), current smoking (OR, 1.91), and lower body mass index (OR, 0.95). Preoperative opioid use was also associated with significantly worse baseline PROMIS scores across 6 domains, lower BMHQ scores, and NPS hand scores. Conclusions: Preoperative opioid use is common in hand surgery patients with a rate of 35%. Preoperative opioid use is associated with multiple baseline patient characteristics and is predictive of worse baseline scores on patient-reported outcome measures. Future studies should determine whether such associations persist in the postoperative setting between opioid users and nonusers.

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Impact of Preoperative Opioid Use on Patient-Reported Outcomes after Revision Total Knee Arthroplasty: A Propensity Matched Analysis

The Journal of Knee Surgery ◽

10.1055/s-0041-1729966 ◽

2021 ◽

Author(s):

Eitan Ingall ◽

Christian Klemt ◽

Christopher M. Melnic ◽

Wayne B. Cohen-Levy ◽

Venkatsaiakhil Tirumala ◽

...

Keyword(s):

Total Knee Arthroplasty ◽

Propensity Score ◽

Knee Arthroplasty ◽

Patient Reported Outcomes ◽

Opioid Use ◽

Absolute Increase ◽

Patient Reported ◽

Total Knee ◽

Opioid Users ◽

Revision Tka

AbstractThis is a retrospective study. Prior studies have characterized the deleterious effects of narcotic use in patients undergoing primary total knee arthroplasty (TKA). While there is an increasing revision arthroplasty burden, data on the effect of narcotic use in the revision surgery setting remain limited. Our aim was to characterize the effect of active narcotic use at the time of revision TKA on patient-reported outcome measures (PROMs). A total of 330 consecutive patients who underwent revision TKA and completed both pre- and postoperative PROMs was identified. Due to differences in baseline characteristics, 99 opioid users were matched to 198 nonusers using the nearest-neighbor propensity score matching. Pre- and postoperative knee disability and osteoarthritis outcome score physical function (KOOS-PS), patient reported outcomes measurement information system short form (PROMIS SF) physical, PROMIS SF mental, and physical SF 10A scores were evaluated. Opioid use was identified by the medication reconciliation on the day of surgery. Propensity score–matched opioid users had significantly lower preoperative PROMs than the nonuser for KOOS-PS (45.2 vs. 53.8, p < 0.01), PROMIS SF physical (37.2 vs. 42.5, p < 0.01), PROMIS SF mental (44.2 vs. 51.3, p < 0.01), and physical SF 10A (34.1 vs. 36.8, p < 0.01). Postoperatively, opioid-users demonstrated significantly lower scores across all PROMs: KOOS-PS (59.2 vs. 67.2, p < 0.001), PROMIS SF physical (43.2 vs. 52.4, p < 0.001), PROMIS SF mental (47.5 vs. 58.9, p < 0.001), and physical SF 10A (40.5 vs. 49.4, p < 0.001). Propensity score–matched opioid-users demonstrated a significantly smaller absolute increase in scores for PROMIS SF Physical (p = 0.03) and Physical SF 10A (p < 0.01), as well as an increased hospital length of stay (p = 0.04). Patients who are actively taking opioids at the time of revision TKA report significantly lower preoperative and postoperative outcome scores. These patients are more likely to have longer hospital stays. The apparent negative effect on patient reported outcomes after revision TKA provides clinically useful data for surgeons in engaging patients in a preoperative counseling regarding narcotic use prior to revision TKA to optimize outcomes.

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Effects of an opioid stewardship program on opioid consumption and related outcomes after multilevel lumbar spine fusion: a pre- and postimplementation analysis of 268 patients

Journal of Neurosurgery Spine ◽

10.3171/2021.8.spine21599 ◽

2021 ◽

pp. 1-9

Author(s):

Marie-Jacqueline Reisener ◽

Alexander P. Hughes ◽

Ichiro Okano ◽

Jiaqi Zhu ◽

Artine Arzani ◽

...

Keyword(s):

Side Effects ◽

Spine Surgery ◽

Effect Size ◽

Lumbar Fusion ◽

Opioid Consumption ◽

Opioid Use ◽

Chi Square ◽

Opioid Prescribing ◽

Pain Scores ◽

Stewardship Program

OBJECTIVE Opioid stewardship programs combine clinical, regulatory, and educational interventions to minimize inappropriate opioid use and prescribing for orthopedic and spine surgery. Most evaluations of stewardship programs quantify effects on prescriber behavior, whereas patient-relevant outcomes have been relatively neglected. The authors evaluated the impact of an opioid stewardship program on perioperative opioid consumption, prescribing, and related clinical outcomes after multilevel lumbar fusion. METHODS The study was based on a retrospective, quasi-experimental, pretest-posttest design in 268 adult patients who underwent multilevel lumbar fusion in 2016 (preimplementation, n = 141) or 2019 (postimplementation, n = 127). The primary outcome was in-hospital opioid consumption (morphine equivalent dose [MED], mg). Secondary outcomes included numeric rating scale pain scores (0–10), length of stay (LOS), incidence of opioid-induced side effects (gastrointestinal, nausea/vomiting, respiratory, sedation, cognitive), and preoperative and discharge prescribing. Outcomes were measured continuously during the hospital admission. Differences in outcomes between the epochs were assessed in bivariable (Wilcoxon signed-rank or Fisher’s exact tests) and multivariable (Wald’s chi-square test) analyses. RESULTS In bivariable analyses, there were significant decreases in preoperative opioid use (46% vs 28% of patients, p = 0.002), preoperative opioid prescribing (MED 30 mg [IQR 20–60 mg] vs 20 mg [IQR 11–39 mg], p = 0.003), in-hospital opioid consumption (MED 329 mg [IQR 188–575 mg] vs 199 mg [100–372 mg], p < 0.001), the incidence of any opioid-related side effect (62% vs 50%, p = 0.03), and discharge opioid prescribing (MED 90 mg [IQR 60–135 mg] vs 60 mg [IQR 45–80 mg], p < 0.0001) between 2016 and 2019. There were no significant differences in postanesthesia care unit pain scores (4 [IQR 3–6] vs 5 [IQR 3–6], p = 0.33), nursing floor pain scores (4 [IQR 3–5] vs 4 [IQR 3–5], p = 0.93), or total LOS (118 hours [IQR 81–173 hours] vs 103 hours [IQR 81–132 hours], p = 0.21). On multivariable analysis, the opioid stewardship program was significantly associated with decreased discharge prescribing (Wald’s chi square = 9.45, effect size −52.4, 95% confidence interval [CI] −86 to −19.0, p = 0.002). The number of lumbar levels fused had the strongest effect on total opioid consumption during the hospital stay (Wald’s chi square = 16.53, effect size = 539, 95% CI 279.1 to 799, p < 0.001), followed by preoperative opioid use (Wald’s chi square = 44.04, effect size = 5, 95% CI 4 to 7, p < 0.001). CONCLUSIONS A significant decrease in perioperative opioid prescribing, consumption, and opioid-related side effects was found after implementation of an opioid stewardship program. These gains were achieved without adverse effects on pain scores or LOS. These results suggest the major impact of opioid stewardship programs for spine surgery may be on changing prescriber behavior.

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The association of patient education level with outcomes after elective lumbar surgery: a Michigan Spine Surgery Improvement Collaborative study

Journal of Neurosurgery Spine ◽

10.3171/2021.9.spine21421 ◽

2021 ◽

pp. 1-9

Author(s):

Travis Hamilton ◽

Mohamed Macki ◽

Seok Yoon Oh ◽

Michael Bazydlo ◽

Lonni Schultz ◽

...

Keyword(s):

Spine Surgery ◽

Patient Reported Outcomes ◽

Minimum Clinically Important Difference ◽

Estimating Equation ◽

Generalized Estimating Equation ◽

Measurement Information ◽

Patient Reported ◽

Physical Function Score ◽

Measurement Information System ◽

College Educated

OBJECTIVE Socioeconomic factors have been shown to impact a host of healthcare-related outcomes. Level of education is a marker of socioeconomic status. This study aimed to investigate the relationship between patient education level and outcomes after elective lumbar surgery and to characterize any education-related disparities. METHODS The Michigan Spine Surgery Improvement Collaborative registry was queried for all lumbar spine operations. Primary outcomes included patient satisfaction determined by the North American Spine Society patient satisfaction index, and reaching the minimum clinically important difference of Patient-Reported Outcomes Measurement Information System Physical Function score and return to work up to 2 years after surgery. Multivariate Poisson generalized estimating equation models reported adjusted risk ratios. RESULTS A total of 26,229 lumbar spine patients had data available for inclusion in this study. On multivariate generalized estimating equation analysis all comparisons were done versus the high school (HS)/general equivalency development (GED)–level cohort. For North American Spine Society satisfaction scores after surgery the authors observed the following: at 90 days the likelihood of satisfaction significantly decreased by 11% (p < 0.001) among < HS, but increased by 1% (p = 0.52) among college-educated and 3% (p = 0.011) among postcollege-educated cohorts compared to the HS/GED cohort; at 1 year there was a decrease of 9% (p = 0.02) among < HS and increases of 3% (p = 0.02) among college-educated and 9% (p < 0.001) among postcollege-educated patients; and at 2 years, there was an increase of 5% (p = 0.001) among postcollege-educated patients compared to the < HS group. The likelihood of reaching a minimum clinically important difference of Patient-Reported Outcomes Measurement Information System Physical Function score at 90 days increased by 5% (p = 0.005) among college-educated and 9% (p < 0.001) among postcollege-educated cohorts; at 1 year, all comparison cohorts demonstrated significance, with a decrease of 12% (p = 0.007) among < HS, but an increase by 6% (p < 0.001) among college-educated patients and 14% (p < 0.001) among postcollege-educated compared to the HS/GED cohort; at 2 years, there was a significant decrease by 19% (p = 0.003) among the < HS cohort, an increase by 8% (p = 0.001) among the college-educated group, and an increase by 16% (p < 0.001) among the postcollege-educated group. For return to work, a significant increase was demonstrated at 90 days and 1 year when comparing the HS or less group with college or postcollege cohorts. CONCLUSIONS This study demonstrated negative associations on all primary outcomes with lower levels of education. This finding suggests a potential disparity linked to education in elective spine surgery.

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Towards Opioid-Free Elective Spine Surgery: A Prospective Cohort Study

Neurosurgery ◽

10.1093/neuros/nyz310_114 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Ahilan Sivaganesan ◽

Amanda Wright ◽

Regis W Haid ◽

Praveen V Mummaneni ◽

Richard Berkman

Keyword(s):

Cohort Study ◽

Prospective Cohort Study ◽

Spine Surgery ◽

Prospective Cohort ◽

Multivariate Regression ◽

Opioid Use ◽

Pain Scores ◽

Patient Reported ◽

Average Pain ◽

Student’S T

Abstract INTRODUCTION The opioid crisis is a national emergency. We conducted a prospective cohort study to determine whether elective spine surgery can be performed without any opioids whatsoever. METHODS Every consecutive elective spine surgery performed by author R.A.B. between January 1st and December 31st of 2018 was included. For cohort A, between January and April 15th, opioids were minimized but PRN doses were given. For cohort B, between April 15th and December, the goal was to eliminate opioids altogether. Pain scores were collected at discharge, 1 wk, and 1-mo follow-up. Patient-reported outcomes (PRO) were collected at baseline and at 3 mo for lumbar procedures. Emergency room visits and readmissions were tracked. Student's t-tests were used to compare pain scores and PROs, and multivariate regression analyses were performed to understand drivers of opioid use. RESULTS A total of 158 patients were included. In cohort A, 37.9% of patients took no opioids between PACU and 1 mo. Average pain scores were 5.2 in PACU and 2.5 at 1 mo. In cohort B, 86.7% took no opioids after PACU. Average pain scores were 4.2 in PACU and 2.5 at 1 mo. Both cohorts had equivalent improvements in PROs. Multivariate regression revealed that, adjusting for case mix differences, cohort B had lower odds of opioid use after PACU (P < .0001). Moreover, preoperative opioid use is a driver of postoperative opioid use (P = .02), whereas procedure type/invasiveness is not. CONCLUSION We have shown that opioid-free spine surgery, including lumbar fusions, is feasible and effective. In all 87% of patients in our opioid-elimination cohort took no opioids from PACU until 1 mo after surgery, and 94% were taking none at the 1-mo visit. Pain scores and PROs were favorable. We have also shown that preoperative opioids are a driver of postoperative opioid use, however procedural invasiveness is not.

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P.219 The effect of peri-operative adverse events on long-term patient reported outcomes after lumbar spine surgery

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2021.330 ◽

2021 ◽

Vol 48 (s3) ◽

pp. S83-S83

Author(s):

O Ayling ◽

C FIsher

Keyword(s):

Lumbar Spine ◽

Adverse Events ◽

Spine Surgery ◽

Physical Disability ◽

Research Network ◽

Lumbar Spine Surgery ◽

Degenerative Disorders ◽

Patient Reported ◽

Euroqol 5D

Background: Peri-operative adverse events (AE) lead to patient disappointment and greater costs. There is a paucity of data on how AEs affect long-term outcomes. The purpose of this study is to examine peri-operative AEs and their impact on outcome after lumbar spine surgery. Methods: 3556 consecutive patients undergoing surgery for lumbar degenerative disorders enrolled in the Canadian Spine Outcomes and Research Network were analyzed. AEs were defined using the validated Spine AdVerse Events Severity system. Outcomes at 3,12, and 24 months post-operatively included the Owestry Disability Index (ODI), SF-12 Physical (PCS) and Mental (MCS) scales, visual analog scale (VAS) leg and back, Euroqol-5D (EQ5D), and satisfaction. Results: Adverse events occurred in 767 (21.6%) patients, 85 (2.4%) suffered major AEs. Patients with major AEs had worse OD (physical disability) scores and did not reach minimum clinically important differences at 2 years (no AE 25.7±19.2, major: 36.4±19.1, p<0.001). Major AEs were associated with worse ODI (physical disability) scores on multivariable linear regression (p=0.011). Conclusions: Major AEs after lumbar spine surgery lead to worse functional outcomes and lower satisfaction. This highlights the need to implement strategies aimed at reducing adverse events.

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