(153) Administrations of Pro Re Nata (PRN) Analgesics Among Skilled Nursing Facility Residents Following a Hip Fracture

Publication Number: 827

Background: Seventy percent of older adults in the US who are hospitalized for hip fracture are discharged to skilled nursing facilities (SNFs). Pain management is critical in this post-acute care SNF period to facilitate rehabilitation and recovery of function. Many data sources do not contain detailed information on analgesic medication use during this time, particularly pro re nata (PRN, or as needed) use. Such data limitations have precluded a comprehensive understanding of the use and effects of analgesics during post-acute care in SNFs after hip fracture.

Objectives: To describe the type and scheduling of initial analgesic medication treatment among patients discharged to SNFs after hip fracture by leveraging unique data that overcome the limitations of prior datasets.

Methods: Using electronic health records (EHR) from a single SNF chain with 44 facilities, we identified all patients’ first SNF admission after a hip fracture between January 1, 2018 and August 1, 2021. We identified each person’s first order in the SNF EHR for each of the following analgesic classes: opioids, nonsteroidal anti-inflammatory agents (NSAIDs), acetaminophen (APAP), and products containing a combination of these classes. To assess initial analgesic use, we restricted to orders placed within 14 days of the hip fracture date and classified them as within 0-7 vs. 8-14 days. Using text fields for the order directions, we classified the scheduling of each order as standing (administration at certain times) or PRN. Within these groups, we further categorized orders by frequency of administration (e.g., once daily).

Results: We identified 1,201 eligible patients admitted to a SNF after a hip fracture (mean age 81 [standard deviation 11] years]; 68% female; 85% White) with 1,704 initial analgesic orders (45% opioids, 38% APAP, 6% NSAIDs, 11% combination products). Overall, most (71%) orders were placed ≤7 days after the fracture, and 75% were PRN. By class, initial orders for opioids (85%), APAP (64%), and combination products (91%) were more likely to be PRN vs. standing. NSAID orders were more likely to be standing (54%). Over 94% of PRN orders contained directions to be administered more than once per day, and over 75% of PRN orders for opioids and combination products were ≥4 times daily.

Conclusions: Analgesics are mostly used PRN in SNFs after hip fracture. The high prevalence of frequent PRN use could result in substantial exposure misclassification. Since claims (e.g., Medicare Part D) and other datasets (e.g., Minimum Data Set assessments) are unable to measure the PRN status or actual administration of analgesics, EHR data must become a mainstay of SNF pain management research.