Effect of Opioid Tolerance on Re-Admission Rates in Elective Orthopedic Surgery Patients

Opioid tolerance is gradually being associated with increased healthcare utilization and unplanned readmissions are becoming a litmus test for quality of healthcare. A plethora of studies exists based on readmission rates especially within 30days and paucity of data extending beyond.
Our study is unique as it sets out to study the association between opioid tolerance and 60-day readmission rates in patients undergoing elective spine and orthopedic surgeries.
We hypothesize that opioid tolerant patients undergoing elective orthopedic surgery have higher readmission rates and healthcare utilization.
A retrospective analysis of 658 elective orthopedic and spinal surgical patients admitted over one year in a community hospital was conducted. Opioid tolerance was defined based on FDA (Food and Drug Administration) criteria. The primary outcome was 60-day readmission rate. Secondary outcomes included time to readmission and hospital length of stay.
There was an overall readmission rate of 43/658 (6.5%); the opioid tolerant group being most frequently readmitted (OR 16.76, 95% CI 4.66 to 60.33; P < 0.001). Leading readmission causes were due to aseptic pain 2 (14.3%) and hardware malfunction 2 (14.3%) followed by surgical site infections 1(7.1%), seen in the opioid tolerant group (n-14), P <0.001. Associated risk factors included underweight body mass index (BMI) (17.43, 95% CI 1.38 to 219.86; P=0.027 and higher Charlson Comorbidity Index (OR 3.48, 95% CI 1.36 to 8.93; P=0.009) showing increased odds of readmission. Opioid tolerant patients had a shorter median time to readmission (5.0 vs 12.00 vs 14; P=0.419). The mean hospital length of stay was shortest in opioid tolerant patients at index admission (2.14 vs 2.57 vs 2.30; P=0.027). Elective spine surgery had an increased risk of readmission (OR 3.57, 95% CI 1.39 to 9.14; P=0.008) compared to hip and knee surgeries.

There is an increased significant risk of readmission seen in opioid tolerant patients following elective orthopedic and spine surgery. Specific strategies should be targeted to improve readmission rates. Identifying eligible patients at admission, creating standardized multimodal pain medication order sets with less reliance on opioids, involvement of multimodal pain and interdisciplinary team with effective transition/discharge planning may help mitigate this.

References: 1. Hilliard PE, Waljee J, Moser S, et al. Prevalence of Preoperative Opioid Use and
Characteristics Associated With Opioid Use Among Patients Presenting for Surgery.
JAMA Surg. 2018;153(10):929. doi:10.1001/jamasurg.2018.2102
2.Gulur P, Williams L, Chaudhary S, Koury K, Jaff M. Opioid tolerance--a predictor of
increased length of stay and higher readmission rates. Pain Physician. 17(4):E503-7.
https://www.ncbi.nlm.nih.gov/pubmed/25054400. Accessed May 16, 2019.
3. Avinash M, Rajasekaran S, Aiyer SN. Unplanned 90-day readmissions in a specialty
orthopaedic unit-A prospective analysis of consecutive 12729 admissions. J Orthop.
2017;14(2):236-240. doi:10.1016/j.jor.2017.03.001
4. Gostic WJ, Bateman BT. Impact of Opioid Abuse and Dependence on 30-Day
Readmission After Elective Surgery.
https://www.asaabstracts.com/strands/asaabstracts/abstract.htm?year=2017&index=13&abs
num=4737. Published 2017. Accessed February 9, 2020.