Newly Published
Pain Medicine  |   May 2019
Impact of an Opioid Safety Initiative on Patients Undergoing Total Knee Arthroplasty: A Time Series Analysis
Author Notes
  • From the Patient Safety Center of Inquiry, Veterans Affairs Boston Healthcare System, Boston, Massachusetts (Q.C.); the Patient Safety Center of Inquiry, Durham Veterans Affairs Healthcare System (H.-L.H., W.B., M.P., T.B., K.R.), the Department of Anesthesiology, Duke University Health System (H.-L.H., T.B., V.K., K.R.), and NoviSci, LLC. (R.O., M.A.B.), Durham, North Carolina; Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Healthcare System and the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California (E.R.M., S.C.M.); Veterans Affairs Pharmacy Benefits Management Services, Hines, Illinois (C.B.G.), and the Center for Value Based Pharmacy Initiatives, University of Pittsburgh Medical Center Health Plan, Pittsburgh, Pennsylvania (C.B.G.).
  • Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).
    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
  • Submitted for publication September 22, 2018. Accepted for publication April 3, 2019.
    Submitted for publication September 22, 2018. Accepted for publication April 3, 2019.×
  • Correspondence: Address correspondence to Dr. Raghunathan: Patient Safety Center of Inquiry at the Durham Veterans Affairs, Department of Anesthesiology, Duke University Medical Center, DUMC 3094, Durham, North Carolina 27710. Karthik.Raghunathan@duke.edu. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Pain Medicine / Pain Medicine / Opioid
Pain Medicine   |   May 2019
Impact of an Opioid Safety Initiative on Patients Undergoing Total Knee Arthroplasty: A Time Series Analysis
Anesthesiology Newly Published on May 30, 2019. doi:10.1097/ALN.0000000000002771
Anesthesiology Newly Published on May 30, 2019. doi:10.1097/ALN.0000000000002771
Abstract

Editor’s Perspective:

What We Know about This Topic:

  • Opioid overuse remains rampant even in hospitals, but whether administrative opioid safety initiatives reduce use remains unclear

What This Article Tells Us That Is New:

  • The authors evaluated the effects of a Veterans Administration national Opioid Safety Initiative using interrupted time series analysis to compare trends before and after starting the initiative

  • There was a trivial increase in pain scores, and a substantial reduction in patients with chronic preoperative and postoperative opioid prescriptions

Background: The Opioid Safety Initiative decreased high-dose prescriptions across the Veterans Health Administration. This study sought to examine the impact of this intervention (i.e., the Opioid Safety Initiative) on pain scores and opioid prescriptions in patients undergoing total knee arthroplasty.

Methods: This was an ecological study of group-level data among 700 to 850 patients per month over 72 consecutive months (January 2010 to December 2015). The authors examined characteristics of cohorts treated before versus after rollout of the Opioid Safety Initiative (October 2013). Each month, the authors aggregated at the group-level the differences between mean postoperative and preoperative pain scores for each patient (averaged over 6-month periods), and measured proportions of patients (per 1,000) with opioid (and nonopioid) prescriptions for more than 3 months in 6-month periods, preoperatively and postoperatively. The authors compared postintervention trends versus trends forecasted based on preintervention measures.

Results: After the Opioid Safety Initiative, patients were slightly older and sicker, but had lower mortality rates (postintervention n = 28,509 vs. preintervention n = 31,547). Postoperative pain scores were slightly higher and the decrease in opioid use was statistically significant, i.e., 871 (95% CI, 474 to 1,268) fewer patients with chronic postoperative prescriptions. In time series analyses, mean postoperative minus preoperative pain scores had increased from 0.65 to 0.81, by 0.16 points (95% CI, 0.05 to 0.27). Proportions of patients with chronic postoperative and chronic preoperative opioid prescriptions had declined by 20% (n = 3,355 vs. expected n = 4,226) and by 13% (n = 5,861 vs. expected n = 6,724), respectively. Nonopioid analgesia had increased. Sensitivity analyses confirmed all findings.

Conclusions: A system-wide initiative combining guideline dissemination with audit and feedback was effective in significantly decreasing opioid prescriptions in populations undergoing total knee arthroplasty, while minimally impacting pain scores.