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J Knee Surg
DOI: 10.1055/s-0044-1786021
Original Article

Social Determinants of Long-Term Opioid Use Following Total Knee Arthroplasty

Katherine Hadlandsmyth 
1   Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
2   Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, Iowa
,
Brian C. Lund
1   Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
3   Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa
,
Yubo Gao
1   Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
4   Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
,
Andrea L. Strayer
5   College of Nursing, University of Iowa, Iowa City, Iowa
6   Department of Veterans Affairs, Veterans Health Administration, Office of Academic Affiliations VA Quality Scholars Advanced Fellowship Program, Iowa City, Iowa
,
Heather Davila
1   Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
4   Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
,
Leslie R. M. Hausmann
7   Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
8   Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
,
Susanne Schmidt
9   Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
,
Paula K. Shireman
10   Department of Primary Care and Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, Texas
,
Michael A. Jacobs
7   Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
,
Michael J. Mader
11   Research Service, South Texas Veterans Healthcare System, San Antonio, Texas
,
Robert A. Tessler
7   Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
12   Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
,
Carly A. Duncan
7   Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
,
Daniel E. Hall   *
7   Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
12   Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
13   Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
14   Wolff Center at University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
,
Mary Vaughan Sarrazin   *
1   Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
4   Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
› Author Affiliations Funding This research was supported by the VHA Office of Research and Development (HSR&D I01HX003095). This research was also supported by VHA IIR 19–414 award and a U01TR002393 from the National Center for Advancing Translational Sciences and the Office of the Director. This work was also supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Academic Affiliations VA Quality Scholars Advanced Fellowship Program: award number 3Q052019C.
The authors disclose other grant funding from the NIH and VHA ORD outside the scope of this work.
The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The opinions expressed here are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
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Abstract

Total knee arthroplasty (TKA) risks persistent pain and long-term opioid use (LTO). The role of social determinants of health (SDoH) in LTO is not well established. We hypothesized that SDoH would be associated with postsurgical LTO after controlling for relevant demographic and clinical variables. This study utilized data from the Veterans Affairs Surgical Quality Improvement Program, VA Corporate Data Warehouse, and Centers for Medicare and Medicaid Services, including Veterans aged ≥ 65 who underwent elective TKA between 2013 and 2019 with no postsurgical complications or history of significant opioid use. LTO was defined as > 90 days of opioid use beginning within 90 days postsurgery. SDoH variables included the Area Deprivation Index, rurality, and housing instability in the last 12 months identified via medical record screener or International Classification of Diseases, Tenth Revision codes. Multivariable risk adjustment models controlled for demographic and clinical characteristics. Of the 9,064 Veterans, 97% were male, 84.2% white, mean age was 70.6 years, 46.3% rural, 11.2% living in highly deprived areas, and 0.9% with a history of homelessness/housing instability. Only 3.7% (n = 336) developed LTO following TKA. In a logistic regression model of only SDoH variables, housing instability (odds ratio [OR] = 2.38, 95% confidence interval [CI]: 1.09–5.22) and rurality conferred significant risk for LTO. After adjusting for demographic and clinical variables, LTO was only associated with increasing days of opioid supply in the year prior to surgery (OR = 1.52, 95% CI: 1.43–1.63 per 30 days) and the initial opioid fill (OR = 1.07; 95% CI: 1.06–1.08 per day). Our primary hypothesis was not supported; however, our findings do suggest that patients with housing instability may present unique challenges for postoperative pain management and be at higher risk for LTO.

Keywords

total knee arthroplasty - SDoH - long-term opioids - homelessness or housing instability

* Hall and Vaughan-Sarrazin are co-senior authors


Supplementary Material



Publication History

Received: 24 January 2024

Accepted: 26 March 2024

Article published online:
10 April 2024

© 2024. Thieme. All rights reserved.

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