In Medicare patients with severe osteoarthritis (OA), substantial statewide variation has been reported with respect to the use of long-term opioid therapy, which cannot be completely explained by differences in access to healthcare providers or state-level policies, according to results from an observational cohort study published in Arthritis & Rheumatology.
The investigators sought to evaluate the variation in long-term use of opioids among patients with OA according to geographic locale and access to healthcare. The independent variables of interest included state of residence and healthcare access, quantified at the primary care service area level as categories of number of practicing primary care providers and categories of rheumatologists per 1000 Medicare beneficiaries. The outcome variable was the percentage of patients with OA who used long-term opioids (≥90 days in the 360 days immediately before total joint replacement) within each primary care service area.
The study included a total of 358,121 patients with advanced OA from a total of 4080 primary care service areas. The mean patient age was 74 years, 67.8% of the patients were women, and 91.9% were white. The proportion of patients undergoing total joint replacement who used long-term opioids remained relatively stable during the study years (16.8% in 2011, 16.8% in 2012, 16.6% in 2013, and 16.4% in 2014).
The unadjusted mean proportion of long-term opioid users varied widely across states, ranging from 8.9% in Minnesota to 26.4% in Alabama, with this variation persisting in adjusted models. Access to primary care providers was only moderately associated with rates of long-term opioid use. The adjusted mean difference between primary care service areas with highest (>8.6) vs lowest (<3.6) concentration of primary care providers per 1000 beneficiaries was 1.4% (95% CI, 0.8%-2.0%). In contrast, access to rheumatologists was not associated with long-term opioid use, with the highest (>0.29) vs lowest (0) concentration of rheumatologists per 1000 beneficiaries at 0.6% (95% CI, −0.1% to 1.3%).
The investigators concluded that long-term opioid use was frequent among elderly patients with severe knee or hip OA before total joint replacement surgery. The study findings imply that geographically targeted dissemination strategies for safe opioid prescribing guidelines may be required to address the high use of opioids reported in certain states.
Desai RJ, Jin Y, Franklin PD, et al. Association of geography and access to healthcare providers with long term prescription opioid use in Medicare patients with severe osteoarthritis: a cohort study [published online January 28, 2019]. Arthritis Rheumatol. doi: 10.1002/art.40834