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Abstract：
UNASSIGNED: Limited evidence exists on health system characteristics associated with initial and long-term prescribing of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) following total hip and knee arthroplasty (THA/TKA), and if these characteristics differ among individuals based on preoperative NSAID exposure. We identified orthopedic surgeon opioid prescribing practices, hospital characteristics, and regional factors associated with initial and long-term prescribing of opioids and NSAIDs among older adults receiving THA/TKA.
UNASSIGNED: This observational study included opioid-naïve Medicare beneficiaries aged ≥65 years receiving elective THA/TKA between January 1, 2014 and July 4, 2017. We examined initial (days 1-30 following THA/TKA) and long-term (days 90-180) opioid or NSAID prescribing, stratified by preoperative NSAID exposure. Risk ratios (RRs) for the associations between 10 health system characteristics and case-mix adjusted outcomes were estimated using multivariable Poisson regression models.
UNASSIGNED: The study population included 23,351 NSAID-naïve and 10,127 NSAID-prevalent individuals. Increases in standardized measures of orthopedic surgeon opioid prescribing generally decreased the risk of initial NSAID prescribing but increased the risk of long-term opioid prescribing. For example, among NSAID-naïve individuals, the RRs (95% confidence intervals [CIs]) for initial NSAID prescribing were 0.95 (0.93-0.97) for 1-2 orthopedic surgeon opioid prescriptions per THA/TKA procedure, 0.94 (0.92-0.97) for 3-4 prescriptions per procedure, and 0.91 (0.89-0.93) for 5+ opioid prescriptions per procedure (reference: <1 opioid prescription per procedure), while the RRs (95% CIs) for long-term opioid prescribing were 1.06 (1.04-1.08), 1.08 (1.06-1.11), and 1.13 (1.11-1.16), respectively. Variation in postoperative analgesic prescribing was observed across U.S. regions. For example, among NSAID-naïve individuals, the RR (95% CIs) for initial opioid prescribing were 0.98 (0.96-1.00) for Region 2 (New York), 1.09 (1.07-1.11) for Region 3 (Philadelphia), 1.07 (1.05-1.10) for Region 4 (Atlanta), 1.03 (1.01-1.05) for Region 5 (Chicago), 1.16 (1.13-1.18) for Region 6 (Dallas), 1.10 (1.08-1.12) for Region 7 (Kansas City), 1.09 (1.06-1.12) for Region 8 (Denver), 1.09 (1.07-1.12) for Region 9 (San Francisco), and 1.11 (1.08-1.13) for Region 10 (Seattle) (reference: Region 1 [Boston]). Hospital characteristics were not meaningfully associated with postoperative analgesic prescribing. The relationships between health system characteristics and postoperative analgesic prescribing were similar for NSAID-naïve and NSAID-prevalent participants.
UNASSIGNED: Future efforts aiming to improve the use of multimodal analgesia through increased NSAID prescribing and reduced long-term opioid prescribing following THA/TKA could consider targeting orthopedic surgeons with higher standardized opioid prescribing measures.
UNASSIGNED: Orthopedic surgeon opioid prescribing measures and U.S. region were the greatest health system level predictors of initial, and long-term, prescribing of opioids and prescription NSAIDs among older Medicare beneficiaries following THA/TKA. These results can inform future studies that examine why variation in analgesic prescribing exists across geographic regions and levels of orthopedic surgeon opioid prescribing.
UNASSIGNED: This observational study included opioid-naïve Medicare beneficiaries aged ≥65 years receiving elective THA/TKA between January 1, 2014 and July 4, 2017. We examined initial (days 1-30 following THA/TKA) and long-term (days 90-180) opioid or NSAID prescribing, stratified by preoperative NSAID exposure. Risk ratios (RRs) for the associations between 10 health system characteristics and case-mix adjusted outcomes were estimated using multivariable Poisson regression models.
UNASSIGNED: The study population included 23,351 NSAID-naïve and 10,127 NSAID-prevalent individuals. Increases in standardized measures of orthopedic surgeon opioid prescribing generally decreased the risk of initial NSAID prescribing but increased the risk of long-term opioid prescribing. For example, among NSAID-naïve individuals, the RRs (95% confidence intervals [CIs]) for initial NSAID prescribing were 0.95 (0.93-0.97) for 1-2 orthopedic surgeon opioid prescriptions per THA/TKA procedure, 0.94 (0.92-0.97) for 3-4 prescriptions per procedure, and 0.91 (0.89-0.93) for 5+ opioid prescriptions per procedure (reference: <1 opioid prescription per procedure), while the RRs (95% CIs) for long-term opioid prescribing were 1.06 (1.04-1.08), 1.08 (1.06-1.11), and 1.13 (1.11-1.16), respectively. Variation in postoperative analgesic prescribing was observed across U.S. regions. For example, among NSAID-naïve individuals, the RR (95% CIs) for initial opioid prescribing were 0.98 (0.96-1.00) for Region 2 (New York), 1.09 (1.07-1.11) for Region 3 (Philadelphia), 1.07 (1.05-1.10) for Region 4 (Atlanta), 1.03 (1.01-1.05) for Region 5 (Chicago), 1.16 (1.13-1.18) for Region 6 (Dallas), 1.10 (1.08-1.12) for Region 7 (Kansas City), 1.09 (1.06-1.12) for Region 8 (Denver), 1.09 (1.07-1.12) for Region 9 (San Francisco), and 1.11 (1.08-1.13) for Region 10 (Seattle) (reference: Region 1 [Boston]). Hospital characteristics were not meaningfully associated with postoperative analgesic prescribing. The relationships between health system characteristics and postoperative analgesic prescribing were similar for NSAID-naïve and NSAID-prevalent participants.
UNASSIGNED: Future efforts aiming to improve the use of multimodal analgesia through increased NSAID prescribing and reduced long-term opioid prescribing following THA/TKA could consider targeting orthopedic surgeons with higher standardized opioid prescribing measures.
UNASSIGNED: Orthopedic surgeon opioid prescribing measures and U.S. region were the greatest health system level predictors of initial, and long-term, prescribing of opioids and prescription NSAIDs among older Medicare beneficiaries following THA/TKA. These results can inform future studies that examine why variation in analgesic prescribing exists across geographic regions and levels of orthopedic surgeon opioid prescribing.
摘要：
关于全髋关节和膝关节置换术（THA/TKA）后与阿片类药物和非甾体类抗炎药（NSAIDs）的初始和长期处方相关的卫生系统特征的证据有限，以及这些特征是否基于术前NSAID暴露而在个体之间存在差异。我们确定了整形外科医生阿片类药物处方的做法，医院特色,以及与接受THA/TKA的老年人初始和长期处方阿片类药物和NSAIDs相关的区域因素。
这项观察性研究包括年龄≥65岁的阿片类药物初始医疗保险受益人，在2014年1月1日至2017年7月4日期间接受选择性THA/TKA。我们检查了初始（THA/TKA后1-30天）和长期（90-180天）阿片类药物或NSAID处方，通过术前NSAID暴露分层。使用多变量Poisson回归模型估计10个卫生系统特征与病例组合调整结果之间关联的风险比（RR）。
■研究人群包括23,351名非甾体抗炎药初治者和10,127名非甾体抗炎药流行者。整形外科医生阿片类药物处方的标准化措施的增加通常降低了初始NSAID处方的风险，但增加了长期阿片类药物处方的风险。例如,在NSAID-天真的个体中，初始NSAID处方的RRs（95％置信区间[CI]）为0.95（0.93-0.97），每个THA/TKA手术1-2个整形外科医生阿片类药物处方，0.94（0.92-0.97）每个程序3-4处方，和0.91（0.89-0.93）的5+阿片类药物处方每程序（参考：<1阿片类药物处方每程序），而长期阿片类药物处方的RR(95%CI)为1.06(1.04-1.08)，1.08(1.06-1.11),和1.13（1.11-1.16），分别。在美国各地区观察到术后镇痛处方的差异。例如,在NSAID-天真的个体中，区域2(纽约)初始阿片类药物处方的RR(95%CI)为0.98(0.96-1.00)，区域3（费城）的1.09（1.07-1.11），第4区（亚特兰大）的1.07（1.05-1.10），第5区（芝加哥）的1.03（1.01-1.05），第6区（达拉斯）的1.16（1.13-1.18），第7区（堪萨斯城）的1.10（1.08-1.12），区域8（丹佛）的1.09（1.06-1.12），第9区（旧金山）的1.09（1.07-1.12），10区（西雅图）和1.11（1.08-1.13）（参考：1区[波士顿]）。医院特征与术后镇痛处方无显著关联。NSAID初治和NSAID流行参与者的卫生系统特征与术后镇痛处方之间的关系相似。
■未来的努力旨在通过增加NSAID处方和减少THA/TKA后的长期阿片类药物处方来改善多模式镇痛的使用，可以考虑以更高的标准化阿片类药物处方措施针对骨科医生。
■骨科外科医生阿片类药物处方措施和美国地区是最初的最大卫生系统水平预测因素，从长远来看，THA/TKA后，老年医疗保险受益人开具阿片类药物和非甾体抗炎药处方。这些结果可以为未来的研究提供信息，以检查为什么不同地理区域和整形外科医生阿片类药物处方水平之间存在镇痛处方的差异。
这项观察性研究包括年龄≥65岁的阿片类药物初始医疗保险受益人，在2014年1月1日至2017年7月4日期间接受选择性THA/TKA。我们检查了初始（THA/TKA后1-30天）和长期（90-180天）阿片类药物或NSAID处方，通过术前NSAID暴露分层。使用多变量Poisson回归模型估计10个卫生系统特征与病例组合调整结果之间关联的风险比（RR）。
■研究人群包括23,351名非甾体抗炎药初治者和10,127名非甾体抗炎药流行者。整形外科医生阿片类药物处方的标准化措施的增加通常降低了初始NSAID处方的风险，但增加了长期阿片类药物处方的风险。例如,在NSAID-天真的个体中，初始NSAID处方的RRs（95％置信区间[CI]）为0.95（0.93-0.97），每个THA/TKA手术1-2个整形外科医生阿片类药物处方，0.94（0.92-0.97）每个程序3-4处方，和0.91（0.89-0.93）的5+阿片类药物处方每程序（参考：<1阿片类药物处方每程序），而长期阿片类药物处方的RR(95%CI)为1.06(1.04-1.08)，1.08(1.06-1.11),和1.13（1.11-1.16），分别。在美国各地区观察到术后镇痛处方的差异。例如,在NSAID-天真的个体中，区域2(纽约)初始阿片类药物处方的RR(95%CI)为0.98(0.96-1.00)，区域3（费城）的1.09（1.07-1.11），第4区（亚特兰大）的1.07（1.05-1.10），第5区（芝加哥）的1.03（1.01-1.05），第6区（达拉斯）的1.16（1.13-1.18），第7区（堪萨斯城）的1.10（1.08-1.12），区域8（丹佛）的1.09（1.06-1.12），第9区（旧金山）的1.09（1.07-1.12），10区（西雅图）和1.11（1.08-1.13）（参考：1区[波士顿]）。医院特征与术后镇痛处方无显著关联。NSAID初治和NSAID流行参与者的卫生系统特征与术后镇痛处方之间的关系相似。
■未来的努力旨在通过增加NSAID处方和减少THA/TKA后的长期阿片类药物处方来改善多模式镇痛的使用，可以考虑以更高的标准化阿片类药物处方措施针对骨科医生。
■骨科外科医生阿片类药物处方措施和美国地区是最初的最大卫生系统水平预测因素，从长远来看，THA/TKA后，老年医疗保险受益人开具阿片类药物和非甾体抗炎药处方。这些结果可以为未来的研究提供信息，以检查为什么不同地理区域和整形外科医生阿片类药物处方水平之间存在镇痛处方的差异。
