Opioid use prior to total knee replacement: comparative analysis of trends in England and Sweden

Yu, Dahai; Hellberg, Clara; Appleyard, Tom; Dell’Isola, Andrea; Thomas, G; Turkiewicz, Aleksandra; Englund, Martin; Peat, George

doi:10.1016/j.joca.2022.02.621

Cited by 8 publications

(11 citation statements)

References 31 publications

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“…Sweden and England are 2 European countries with similar health system structures; both countries provide free health care at the point of use, funded via taxation (see Supplementary Table 1, available on the Arthritis Care & Research website at http://onlinelibrary.wiley.com/doi/10.1002/acr.25033). Furthermore, while both countries have subtle differences in the recording of information, both provide comprehensive data available for analysis and comparable rates of TKR and OA management strategies (22).…”

Section: Methodsmentioning

confidence: 99%

“…Comorbidities were defined by the presence of codes in patients’ health records throughout the 10‐year study period. Codes for comorbidities had been previously developed and used in prior studies (22).…”

Section: Methodsmentioning

confidence: 99%

“…wiley.com/doi/10.1002/acr.25033). Furthermore, while both countries have subtle differences in the recording of information, both provide comprehensive data available for analysis and comparable rates of TKR and OA management strategies (22).…”

Section: Methodsmentioning

confidence: 99%

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Road to Total Knee Replacement: Utilization of Knee Surgeries Up to Ten Years Before Total Knee Replacement in England and Sweden

Dell’Isola

Appleyard

et al. 2022

Arthritis Care & Research

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Objective. To compare the prevalence and timing of knee surgery (including meniscal, ligamentous, synovial, and osteotomy) in the 10 years prior to primary total knee replacement (TKR) between England and Sweden.Methods. This was a population-based, case-control study within England and southern Sweden using electronic health care databases. Patients underwent primary TKR between 2015 and 2019. Risk-set sampling showed that general population controls matched 1:1 by age, sex, and practice/municipality. The annual prevalence and prevalence ratio of having at least 1 recorded surgery in each of the 10 years preceding TKR was estimated using Poisson regressions.Results. We included 6,308 and 47,010 TKR cases in Sweden and England, respectively. Meniscal surgeries were the most frequent procedure prior to TKR in both countries; prevalence was higher in England across all time points. The prevalence of meniscal surgery increased in both countries in the years approaching TKR, reaching 33.2 (95% confidence interval [95% CI] 31.6-34.9) per 1,000 persons in England, and 9.83 (95% CI 7.66-12.61) in Sweden. In England, we observed a decrease from 2014 to 2018 in the utilization of this procedure in the 4 years preceding a TKR. The prevalence of all analyzed surgeries was consistently lower in controls.Conclusion. There are comparable trends in the use of knee surgery in the years preceding TKR across England and Sweden. Of note, meniscal surgeries remain common, even within the year prior to TKR, highlighting that these patients may experience low-value care. Careful consideration of knee surgery in those with late-stage disease is required.

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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Road to Total Knee Replacement: Utilization of Knee Surgeries Up to Ten Years Before Total Knee Replacement in England and Sweden

Dell’Isola

Appleyard

et al. 2022

Arthritis Care & Research

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“…It is hard to compare the MMEs prescribed in this population to those of prior studies because we provided a rate over all the operated arthroplasties, irrespective of opioid use, and most other studies assessed the proportion of prescriptions. Recent studies showed that in England, Finland, and Denmark, weak opioids such as tramadol, and in Sweden, strong opioids such as oxycodone, are more commonly prescribed [13,18,27]. These international observations over time underline the importance of analyzing national data, thus enabling a full understanding of the prescription behavior of local caregivers and, consequently, allowing the development of national policies and guidelines to curb the opioid epidemic.…”

Section: Limitationsmentioning

confidence: 99%

“…It is therefore important to assess the changes in preoperative opioid prescriptions in patients undergoing TKA and THA. Previous studies have reported differences in the use of opioids before knee and hip arthroplasty, with a proportion ranging from 10% in Finland to 60% in the United States [11,12,18,19,22,27]. However, most studies did not focus on changes over time; instead, they made comparisons between the different operation years (such as 2010 versus 2015) or focused on opioid use in multiple years before arthroplasty surgery (for example, from 5 years before surgery until the year before surgery) [11,12,18,19,22].…”

Section: Introductionmentioning

confidence: 99%

What Changes Have Occurred in Opioid Prescriptions and the Prescribers of Opioids Before TKA and THA? A Large National Registry Study

Brug

Nelissen²,

Rosendaal³

et al. 2023

Clin Orthop Relat Res

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Background Opioid use before TKA or THA is linked to a higher risk of revision surgery and less functional improvement. In Western countries, the frequency of preoperative opioid use has varied, and robust information on temporal changes in opioid prescriptions over time (in the months before surgery as well as annual changes) and among prescribers is necessary to pinpoint opportunities to improve on low-value care patterns, and when they are recognized, to target physician populations for intervention strategies. Questions/purposes (1) What proportion of patients undergoing arthroplasties receive an opioid prescription in the year before TKA or THA, and what were the preoperative opioid prescription rates over time between 2013 and 2018? (2) Does the preoperative prescription rate vary between 12 and 10 months and between 3 and 1 months in the year before TKA or THA, and did it change between 2013 and 2018? (3) Which medical professionals were the main prescribers of preoperative opioids 1 year before TKA or THA? Methods This was a large-database study drawn from longitudinally maintained national registry sources in the Netherlands. The Dutch Foundation for Pharmaceutical Statistics was linked to the Dutch Arthroplasty Register from 2013 to 2018. TKAs and THAs performed because of osteoarthritis in patients older than 18 years, which were also uniquely linked by age, gender, patient postcode, and low–molecular weight heparin use, were eligible. Between 2013 and 2018, 146,052 TKAs were performed: 96% (139,998) of the TKAs were performed for osteoarthritis in patients older than 18 years; of them, 56% (78,282) were excluded because of our linkage criteria. Some of the linked arthroplasties could not be linked to a community pharmacy, which was necessary to follow patients over time, leaving 28% (40,989) of the initial TKAs as our study population. Between 2013 and 2018, 174,116 THAs were performed: 86% (150,574) were performed for osteoarthritis in patients older than 18 years, one arthroplasty was excluded because of an outlier opioid dose, and a further 57% (85,724 of 150,574) were excluded because of our linkage criteria. Some of the linked arthroplasties could not be linked to a community pharmacy, leaving 28% (42,689 of 150,574) of THAs, which were performed between 2013 and 2018. For both TKA and THA, the mean age before surgery was 68 years, and roughly 60% of the population were women. We calculated the proportion of patients undergoing arthroplasties who had at least one opioid prescription in the year before arthroplasty and compared data from 2013 to 2018. Opioid prescription rates are given as defined daily dosages and morphine milligram equivalents (MMEs) per arthroplasty. Opioid prescriptions were assessed by preoperative quarter and by operation year. Possible changes over time in opioid exposure were investigated using linear regression, adjusted for age and gender, in which the month of operation since January 2013 was used as the determinant and MME as the outcome. This was done for all opioids combined and per opioid type. Possible changes in opioid prescription rates in the year before arthroplasty were assessed by comparing the time period of 1 to 3 months before surgery with the other quarters. Additionally, preoperative prescriptions per operation year were assessed per prescriber category: general practitioners, orthopaedic surgeons, rheumatologists, and others. All analyses were stratified by TKA or THA. Results The proportion of patients undergoing arthroplasties who had an opioid prescription before TKA increased from 25% (1079 of 4298) in 2013 to 28% (2097 of 7460) in 2018 (difference 3% [95% CI 1.35% to 4.65%]; p < 0.001), and before THA increased from 25% (1111 to 4451) to 30% (2323 to 7625) (difference 5% [95% CI 3.8% to 7.2%]; p < 0.001). The mean preoperative opioid prescription rate increased over time between 2013 and 2018 for both TKA and THA. For TKA, an adjusted monthly increase of 3.96 MME was observed (95% CI 1.8 to 6.1 MME; p < 0.001). For THA, the monthly increase was 3.8 MME (95% CI 1.5 to 6.0; p = 0.001. For both TKA and THA, there was a monthly increase in the preoperative oxycodone rate (3.8 MME [95% CI 2.5 to 5.1]; p < 0.001 and 3.6 [95% CI 2.6 to 4.7]; p < 0.001, respectively). For TKA, but not for THA, there was a monthly decrease in tramadol prescriptions (-0.6 MME [95% CI -1.0 to -0.2]; p = 0.006). Regarding the opioids prescribed in the year before surgery, there was a mean increase of 48 MME (95% CI 39.3 to 56.7 MME; p < 0.001) for TKA between 10 and 12 months and the last 3 months before surgery. For THA, this increase was 121 MME (95% CI 110 to 131 MME; p < 0.001). Regarding possible differences between 2013 and 2018, we only found differences in the period 10 to 12 months before TKA (mean difference 61 MME [95% CI 19.2 to 103.3]; p = 0.004) and the period 7 to 9 months before TKA (mean difference 66 MME [95% CI 22.0 to 110.9]; p = 0.003). For THA, there was an increase in the MMEs prescribed between 2013 and 2018 for all four quarters, with mean differences ranging from 43.9 to 55.4 MME (p < 0.05). The average proportion of preoperative opioid prescriptions prescribed by general practitioners ranged between 82% and 86% (41,037 of 49,855 for TKA and 49,137 of 57,289 for THA), between 4% and 6% (2924 of 49,855 for TKA and 2461 of 57,289 for THA), by orthopaedic surgeons, 1% by rheumatologists (409 of 49,855 for TKA and 370 of 57,289 for THA), and between 9% and 11% by other physicians (5485 of 49,855 for TKA and 5321 of 57,289 for THA). Prescriptions by orthopaedic surgeons increased over time, from 3% to 7% for THA (difference 4% [95% CI 3.6 to 4.9]) and 4% to 10% for TKA (difference 6% [95% CI 5% to 7%]; p < 0.001). Conclusion Between 2013 and 2018, preoperative opioid prescriptions increased in the Netherlands, mainly because of a shift to more oxycodone prescriptions. We also observed an increase in opioid prescriptions in the year before surgery. Although general practitioners were the main prescribers of preoperative oxycodone, prescriptions by orthopaedic surgeons also increased during the study period. Orthopaedic surgeons should address opioid use and its associated negative effects in preoperative consultations. More intradisciplinary collaboration seems important to limit the prescribing of preoperative opioids. Additionally, research is necessary to assess whether opioid cessation before surgery reduces the risk of adverse outcomes. Level of Evidence Level III, therapeutic study.

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Frequent use of prescription NSAIDs among people with knee or hip osteoarthritis despite contraindications to or precautions with NSAIDs

Neogi,

Dell’Isola,

Englund

et al. 2024

Osteoarthritis and Cartilage

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Opioid use prior to total knee replacement: comparative analysis of trends in England and Sweden

Cited by 8 publications

References 31 publications

Road to Total Knee Replacement: Utilization of Knee Surgeries Up to Ten Years Before Total Knee Replacement in England and Sweden

Road to Total Knee Replacement: Utilization of Knee Surgeries Up to Ten Years Before Total Knee Replacement in England and Sweden

What Changes Have Occurred in Opioid Prescriptions and the Prescribers of Opioids Before TKA and THA? A Large National Registry Study

Frequent use of prescription NSAIDs among people with knee or hip osteoarthritis despite contraindications to or precautions with NSAIDs

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