Association of Preoperative Opioid Use With Mortality and Short-term Safety Outcomes After Total Knee Replacement
Association of Preoperative Opioid Use With Mortality and Short-term Safety Outcomes After Total Knee Replacement
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DOI：
10.1001/jamanetworkopen.2019.8061
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发表时间：
2019-07-01
影响因子：
13.8
通讯作者：
Desai, Rishi J.
中科院分区：
文献类型：
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作者：
Kim, Seoyoung C.;Jin, Yinzhu;Desai, Rishi J.
重要性在接受全膝关节置换术（TKR）之前，处方阿片类药物在中度至重度膝关节骨关节炎患者中很常见。术前阿片类药物的使用可能与TKR.OBJECTIVE后较差的临床和安全性结局相关，以确定65岁及以上患者术前阿片类药物使用与TKR.DESIGN后30天死亡率和其他并发症的相关性，设置和参与者本队列研究使用2010年1月1日至2014年12月31日的索赔数据，随机抽取接受TKR的65岁及以上美国医疗保险入组者。根据TKR前360天内的阿片类药物分发情况，将患者分类为连续（过去12个月内每次>= 1次阿片类药物分发）或间歇性（过去12个月内任何阿片类药物分发但非连续使用）阿片类药物使用者或阿片类药物初治患者（过去12个月内未分发阿片类药物）。数据分析时间为2017年10月3日至2018年11月8日。主要结局和指标主要结局包括院内死亡率和TKR术后30天死亡率、再入院和翻修手术。TKR后30天的次要安全性结局包括阿片类药物过量以及椎骨和非椎骨骨折。多变量考克斯比例风险模型估计风险比（HR）和95% CI。（平均[SD]年龄，73.9 [5.8]岁; 214 677例[67.8%]女性）接受TKR，22 895例161511例（51.0%）为间歇性阿片类药物使用者，132187例（41.7%）为阿片类药物初治者。276例患者（0.09%）发生院内死亡。TKR术后30天，828例患者（0.26%）死亡，16786例患者（5.30%）再次入院，921例患者（0.29%）接受翻修手术。与阿片类药物初治患者相比，连续阿片类药物使用者的所有主要和次要结局发生频率更高。与阿片类药物初治患者相比，在调整人口统计学特征、合并合并症评分、不同处方药数量和虚弱后，持续阿片类药物使用者的翻修手术风险更大（HR，1.63; 95% CI，1.15-2.32）、椎体骨折（HR，2.37; 95% CI，1.37-4.09）和阿片类药物过量（HR，4.82; 95% CI，1.36-17.07）。然而，调整协变量后，住院期间无统计学显著差异（HR，1.18; 95% CI，0.73-1.90）或30天（HR，1.05; 95%CI，0.73-1.51）死亡率之间的连续阿片类药物使用者和阿片类药物初治患者。与未接受过阿片类药物治疗的患者相比，持续使用阿片类药物的患者在TKR后30天时翻修手术、椎骨骨折和阿片类药物过量的风险更高，但住院或30天死亡率没有增加。这些结果强调需要更好地了解与长期使用阿片类药物相关的患者特征，以优化TKR后总体风险的术前评估。
IMPORTANCE Prescription opioid use is common among patients with moderate to severe knee osteoarthritis before undergoing total knee replacement (TKR). Preoperative opioid use may be associated with worse clinical and safety outcomes after TKR.OBJECTIVE To determine the association of preoperative opioid use among patients 65 years and older with mortality and other complications at 30 days post-TKR.DESIGN, SETTING, AND PARTICIPANTS This cohort study used claims data from January 1, 2010, to December 31, 2014, from a random sample of US Medicare enrollees 65 years and older who underwent TKR. Based on opioid dispensing in 360 days prior to TKR, patients were classified as continuous (>= 1 opioid dispensing in each of the past 12 months) or intermittent (any dispensing of opioids in the past 12 months but not continuous use) opioid users or as opioid-naive patients (no opioids dispensed in the past 12 months). Data analyses were conducted from October 3, 2017, to November 8, 2018.MAIN OUTCOMES AND MEASURES Primary outcomes included in-hospital mortality and 30-day post-TKR mortality, hospital readmission, and revision operation. Secondary safety outcomes at 30 days post-TKR included opioid overdose and vertebral and nonvertebral fracture. Multivariable Cox proportional hazards models estimated hazard ratios (HRs) and 95% CIs.RESULTS Of 316 593 patients (mean [SD] age, 73.9 [5.8] years; 214 677 [67.8%] women) who underwent TKR, 22 895 (7.2%) were continuous opioid users, 161 511 (51.0%) were intermittent opioid users, and 132 187 (41.7%) were opioid naive. In-hospital mortality occurred in 276 patients (0.09%). At 30 days post-TKR, 828 patients (0.26%) died, 16 786 patients (5.30%) had hospital readmission, and 921 patients (0.29%) had a revision operation. All primary and secondary outcomes occurred more frequently among continuous opioid users compared with opioid-naive patients. Compared with opioid-naive patients and after adjusting for demographic characteristics, combined comorbidity score, number of different prescription medications, and frailty, continuous opioid users had greater risk of revision operations (HR, 1.63; 95% CI, 1.15-2.32), vertebral fractures (HR, 2.37; 95% CI, 1.37-4.09), and opioid overdose (HR, 4.82; 95% CI, 1.36-17.07) at 30 days post-TKR. However, after adjusting covariates, there were no statistically significant differences in in-hospital (HR, 1.18; 95% CI, 0.73-1.90) or 30-day (HR, 1.05; 95% CI, 0.73-1.51) mortality between continuous opioid users and opioid-naive patients.CONCLUSIONS AND RELEVANCE After adjusting for baseline risk profiles, including comorbidities and frailty, continuous opioid users had a higher risk of revision operations, vertebral fractures, and opioid overdose at 30 days post-TKR but not of in-hospital or 30-day mortality, compared with opioid-naive patients. These results highlight the need for better understanding of patient characteristics associated with chronic opioid use to optimize preoperative assessment of overall risk after TKR.