General Session: Cervical Degenerative - Hall F

Presented by: N. Jain

Author(s):

N. Jain(1), J. Brock(2), F. Phillips(3), T. Weaver(1), S. Khan(1)

(1) Ohio State University Wexner Medical Center, Columbus, OH, United States
(2) Perelman School of Medicine, Philadelphia, PA, United States
(3) Midwest Orthopaedics at Rush, Chicago, IL, United States

Abstract

Introduction: Opioid use has become prevalent in the conservative management of degenerative pathology of the cervical spine. Cervical fusion is the most effective procedure for unrelieved neck and/or arm pain in appropriately selected patients. Consequently, many patients are on chronic opioid therapy (COT) before fusion. As healthcare transitions to value-based models, there has been an increased focus on patient factors that can influence intra- and post-operative adverse events, resource use, and costs. Many studies have reported risk factors for systemic complications after cervical fusion, but none have studied chronic opioid use as a risk factor. We analyzed a national patient cohort who underwent primary cervical fusion for degenerative pathology to answer the following:(1) What is the patient profile associated with pre-operative COT? (2) Is pre-operative COT a risk factor for 90-day systemic complications, emergency department (ED) visits, readmission, and one-year adverse events? (3) What are the risk factors and one-year adverse events related to long-term post-operative opioid use? and (4) How much did payers reimburse for management of complications and adverse events?

Methods: The Humana Ortho (HORTHO) claims files from private/commercially insured and Medicare Advantage beneficiaries were analyzed. Patients and procedures of interest were primarily selected based on International Classification of Diseases (ICD) coding. We queried all primary cervical fusions done for degenerative cervical pathology between 2007 and Q3-2015, and excluded patients operated for fracture and malignancy. Patients with opioid prescriptions for >6 months before surgery were considered as having pre-operative chronic opioid therapy. Patients with continued opioid use till one-year after surgery were considered as long-term users. Descriptive analysis of patient cohorts has been done. Multiple-variable logistic regression analyses were done to answer first three study questions. Reimbursement data from insurers has been reported to answer our fourth study question.

Results: 29,101 patients with cervical fusions were included in our analysis. Patient profile associated with pre-operative COT has been described. Pre-operative COT was associated with a higher risk of 90-day wound complications (OR 1.31, 95% CI:1.10-1.56, p< 0.001), all-cause 90-day ED visits (adjusted OR 1.19, 95% CI:1.11-1.28, p< 0.001), and pain-related ED visits (adjusted OR 1.33, 95% CI:1.19-1.48, p< 0.001). Patients who had pre-operative COT were also more likely to receive epidural and/or facet joint injections within one-year after surgery (adjusted OR 1.22, 95% CI: 1.07-1.38, p=0.003). These patients were also more likely to undergo a repeat cervical fusion within a year as compared to patients who did not have pre-operative COT (adjusted OR 1.22, 95% CI: 1.02-1.43, p=0.02). Pre-operative COT had a higher likelihood of long-term use after surgery (adjusted OR 3.97, 95% CI:3.71-4.25, p< 0.001, and in turn long-term users had a higher risk of new-onset constipation (adjusted OR 1.34, 95% CI:1.22-1.48, p< 0.001). The cost of additional resource use for medications, ED visits, constipation, injections and revision fusion ranged from $623-$27,360 per patient.

Conclusions: Pre-operative opioid use among cervical fusion patients increases healthcare resource utilization in several ways and has the potential to add thousands of dollars of additional costs for each patient. Better understanding and management of pain in the pre-operative period with judicious use of opioids can help control these added costs.