1/ FRESH OFF THE PRESS: we looked at language barriers and postoperative opioid prescription use after total knee arthroplasty in @ERCSPjournal and found lower fill rates for pts with limited English proficiency tinyurl.com/tka2022. See thread🧵 below...
2/ Total knee arthroplasty is a common surgery to address advanced osteoarthritis. Racial minorities are less likely to undergo TKA and have higher complication/readmission rates
3/ We were interested in how limited English proficiency (LEP) was associated with TKA outcomes and specifically, pain management. Identifying disparities in medication utilization after TKA provides insight into barriers faced by vulnerable patient populations
4/ Our primary predictor variable was English proficiency status where LEP was defined as self-reporting a non-English primary language and requesting interpreter services at the time of admission.
5/ Primary outcome variables included opioid pain medication refill requests between 0 and 30 days, 0–60 days, and 0–90 days from discharge after TKA
6/ We also collected demographic information, preoperative health status, perioperative information, discharge disposition, and post-discharge opioid orders. Perioperative and postoperative variables included preoperative pain level, 1-h postoperative pain level.
7/ Multivariable logistic regression modeling was performed to calculate the odds ratio of opioid refill requests 0–30 days after discharge
8/ Covariates included age, gender, BMI, ASA rating, median income based on residential zip code, insurance type, length of hospitalization, history of preoperative opioid use, 1-h postoperative pain scores, and discharge disposition
9/ 2148 patients underwent TKA between January 2015 and December 2019. 9.8% (211) of these patients were classified as having LEP. All pts recieved pre, peri, and postop multimodal pain regimens.
10/ Everyone was discharged with a single standardized prescription for 40 pills of oxycodone 5 mg prn w/o refills. Protocols were adjusted for patients with chronic pain and higher opioid requirements.
11/ Self-reported preoperative and 1-h postoperative pain levels did not differ between LEP and EP patients. The proportions of patients who reported prior opioid use also did not differ between LEP and EP patients
12/ In bivariate analyses, LEP patients were less likely to request opioid prescription refills in the first 30 days (35.3% vs 52.4%, p < 0.001), 60 days (48.7% vs 61.0%, p = 0.004), and 90 days (54.0% vs 62.9%, p = 0.041) after discharge for TKA
13/ KEY FINDING: In multivariate logistic regression models, being classified as LEP was significantly associated with lower odds of requesting an opioid prescription refill 0–30 days after discharge (OR: 0.61, CI: 0.41–0.92, p = 0.019)
14/ Even after adjusting for potential confounding factors, LEP patients were found to be less likely to request opioid refills up to 30 days after discharge for TKA compared to EP patients, despite the lack of differences in preoperative or 1-h postoperative pain levels
15/ WHY? There are patient level factors and cultural components that impact how pain is experienced, and how likely someone is to request a refill after discharge
16/ Prior literature suggests inadequate access to professional interpreters as a mediator of postoperative healthcare disparities for LEP patients. This may be especially true in orthopedic surgery, where there is a heavy reliance on ad hoc interpreters.
17/ Along with provider bias, pharmacy staff are less likely to effectively counsel patients with LEP regarding opioid use. Pharmacies in minority neighborhoods are also less likely to stock opioids.
18/ Future studies can extrapolate OME data from pharmacy records to further explore the relationship between LEP and post-discharge opioid access.
19/ Future projects should also aim to interview patients and providers to elucidate provider- and patient-specific factors that affect opioid prescribing and usage after discharge for TKA
20/ From a #hospitalist perspective, it is striking to see such disparities for a single procedure with a well-defined pain regimen.
21/ This underscores the challenges of researching pain management in hospital medicine given the heterogenous patient population with so many diverse medical conditions
22/ Shout to my wonderful and multidisciplinary co-authors Kevin Nguyen, Derek Ward, & @Solmaz_MD. Appreciative to my support from @UCSFDHM @UCSFMedicine. #pharmacoequity
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