How Is Preoperative Opioid Use Associated With Readmissions and Outcomes in Lower Extremity Trauma?

Background: Opioid use disorder (OUD) has been implicated as a potential risk factor for adverse outcomes and readmissions in various surgical procedures. Patients admitted with an open fracture of the lower extremity often have multifarious pain needs, require surgical procedures, and have prolonged rehabilitation; previous OUD complicates this process. Our goal was to describe at a national level how OUD is associated with readmission, complications, and healthcare expenditure for patients admitted with open lower extremity fractures.

Questions/purposes: (1) Do patients with OUD who were treated for open lower extremity fractures have higher odds of readmission compared with patients without OUD? (2) Do patients with OUD who were treated for open lower extremity fractures have higher healthcare utilization (specifically, length of stay and hospitalization charges and costs)?

Methods: This was a retrospective, comparative study using the Nationwide Readmissions Database, which is the largest nationally representative readmissions database in the United States. Patients were included if they had an ICD-10-CM principal diagnosis of open lower extremity fracture. Between January 1, 2019, and September 30, 2019, a total of 17,811 patients were admitted for open lower extremity fractures and entered in the National Readmissions Database. Of the 17,811 patients, 2.3% (410) had a secondary diagnosis of OUD and 97.7% (17,401) did not. The mean age was 46 years for both groups. The most common operative procedure was debridement, and 1.5% of patients received a flap for reconstruction. Opioid disorders were identified using ICD-10-CM codes. Ninety-day complications and readmissions were characterized for the calendar year. Patients undergoing flap-based reconstructions were identified with ICD-10-PR codes. Confounders (patient demographic and hospital characteristics) were adjusted for using multivariable regression analysis models.

Results: After controlling for potentially confounding variables such as primary payer, Charlson comorbidity index, Gustillo type, and bone density, we found that patients with OUD had greater odds of readmission after open lower extremity fractures (adjusted OR 1.45 [95% confidence interval (CI) 1.0 to 2.0]; p = 0.03). The 90-day infection occurrence was higher in patients with OUD (adjusted OR 1.96 [95% CI 1.0 to 3.8]; p = 0.049) and was the primary reason for readmission in both groups. Moreover, 11% (11 of 103) of patients with OUD were readmitted with opioid-induced complications, which was exclusively observed in this cohort. Patients with OUD also had longer hospital stays (adjusted mean difference 2.2 days [95% CI 0.5 to 3.8]; p = 0.01) and higher hospitalization charges (adjusted mean difference in USD 34,000 [95% CI 1000 to 66,000]; p = 0.04) and costs (adjusted mean difference in USD 7000 [95% CI 2000 to 13,000]; p = 0.007) than those without OUD.

Conclusion: These findings suggest that mitigating infection and opioid overdose, addiction, and constipation in patients with OUD could reduce readmissions in lower extremity fracture patients. Future research should focus on antibiotic and wound care compliance and the early and frequent engagement of postoperative opioid addiction support services.

Level of evidence: Level III, therapeutic study.