Comparative analysis of length of stay, hospitalization costs, opioid use, and discharge status among spine surgery patients with postoperative pain management including intravenous versus oral acetaminophen

Abstract

Background: Recovery from spine surgery is oriented toward restoring functional health outcomes while reducing resource use. Optimal pain management is a key to reaching these objectives. We compared outcomes of spine surgery patients who received standard pain management including intravenous (IV) acetaminophen (APAP) vs. oral APAP. Methods: We performed a retrospective analysis of the Premier database (January 2012 to September 2015) comparing spine surgery patients who received pain management with IV APAP to those who received oral APAP, with no exclusions based on additional pain management. We performed multivariable logistic regression for the discharge and all cause 30-day readmission to the same hospital outcomes and instrumental variable regressions using the quarterly rate of IV APAP use for all hospitalizations by hospital as the instrument in two-stage least squares regressions for length of stay (LOS), hospitalization costs, and average daily morphine equivalent dose (MED) outcomes. Models adjusted for age, gender, race, admission type, 3M All Patient Refined Diagnosis Related Group severity of illness and risk of mortality, hospital size, and indicators for whether the hospital was an academic center and whether it was urban or rural. Results: We identified 112,586 spine surgery patients with 51,835 (46%) having received IV APAP. Subjects averaged 57 and 59 years of age respectively in the IV APAP and oral APAP cohorts and were predominantly non-Hispanic Caucasians and female. In our adjusted models, IV APAP was associated with 0.68 days shorter LOS (95% CI: À0.76 to À0.59, p < .0001), $1175 lower hospitalization costs (95% CI: À$1611 to À$739, p < .0001), 13 mg lower average daily MED (95% CI: À14 mg to À12 mg, p < .0001), 34% lower risk of discharge to a skilled nursing facility (95% CI: 0.63 to 0.69, p < .0001), and 13% less risk of 30-day readmission (95% CI: 0.73 to 1.03). Conclusions: Compared to oral APAP, managing post-spine-surgery pain with IV APAP is associated with less resource use, lower costs, lower doses of opioids, and improved discharge status.

Cost‐effectiveness of intravenous acetaminophen and ketorolac in adolescents undergoing idiopathic scoliosis surgery

“…ERAS protocols are increasingly used following spinal fusion in patients with idiopathic scoliosis to facilitate early discharge; however, the cost efficacy of the therapeutic components used has not been studied in detail . Our results are consistent with prior research findings in adults undergoing orthopedic surgeries, where use of IV acetaminophen was found to decrease costs and lower LOS . In adults undergoing obstetric, cardiovascular, colorectal, and orthopedic surgeries, authors report decreased opioid‐related complications by 28.7% and LOS by 18.5% by the use of IV acetaminophen, with estimated cost savings of $4.5 million .…”

“…The cost impact to decreasing postoperative LOS has been suggested to be minimal . In our study, we found that costs following spine fusion in relatively healthy adolescents were mainly driven by room/board, OT/PT and pharmacy costs, as has been previously described . Observed increase in costs on POD4 was unexpected and is partly explained by 4‐fold higher costs for OT/PT on POD4 than POD3.…”

“…16 Our results are consistent with prior research findings in adults undergoing orthopedic surgeries, where use of IV acetaminophen was found to decrease costs and lower LOS. 17,18 In adults undergoing obstetric, cardiovascular, colorectal, and orthopedic surgeries, authors report decreased opioid-related complications by 28.7%…”

Perioperative pain management strategies among women having reproductive surgeries

“…The addition of acetaminophen to opioid-based postoperative pain management results in a reduction in opioid consumption of 20–40% over the first 24 hours after various major and minor surgical procedures (20)(21,22) (12,23). Whether efficacy of acetaminophen differs by route of administration is controversial; although some studies suggest benefit to IV acetaminophen (24), the majority of studies have not shown any significant benefit to the administration of IV over oral acetaminophen in decreasing opioid use (25–27). There are also currently no high quality data specifically demonstrating the impact of postoperative acetaminophen on opioid consumption after reproductive/gynecologic surgery, but it is likely that the benefits observed for other surgeries will translate.…”

Intravenous paracetamol or intravenous propacetamol can provide effective postoperative analgesia for some patients

“…Compared with oral formulations, Intravenous paracetamol was associated with reduced length of stay, lower hospital costs and lower risk of discharge to a skilled nursing facility with a 13% less risk of 30-day readmission. 4 Evidence from another recent analysis suggests that intravenous paracetamol for prevention and treatment of newborn pain may not be the best practice. The efficacy and safety of paracetamol for the prevention or treatment of procedural and postoperative pain as well as the effects of doses and routes (enteral, intravenousor rectal) were explored for 614 infants in eight trials.…”