Background

Whether a particular surgeon’s opioid prescribing behavior is associated with prolonged postoperative opioid use is unknown. This study tested the hypothesis that the patients of surgeons with a higher propensity to prescribe opioids are more likely to utilize opioids long-term postoperatively.

Methods

The study identified 612,378 Medicare fee-for-service patients undergoing total knee arthroplasty between January 1, 2011, and December 31, 2016. “High-intensity” surgeons were defined as those whose patients were, on average, in the upper quartile of opioid utilization in the immediate perioperative period (preoperative day 7 to postoperative day 7). The study then estimated whether patients of high-intensity surgeons had higher opioid utilization in the midterm (postoperative days 8 to 90) and long-term (postoperative days 91 to 365), utilizing an instrumental variable approach to minimize confounding from unobservable factors.

Results

In the final sample of 604,093 patients, the average age was 74 yr (SD 5), and there were 413,121 (68.4%) females. A total of 180,926 patients (30%) were treated by high-intensity surgeons. On average, patients receiving treatment from a high-intensity surgeon received 36.1 (SD 35.0) oral morphine equivalent (morphine milligram equivalents) per day during the immediate perioperative period compared to 17.3 morphine milligram equivalents (SD 23.1) per day for all other patients (+18.9 morphine milligram equivalents per day difference; 95% CI, 18.7 to 19.0; P < 0.001). After adjusting for confounders, receiving treatment from a high-intensity surgeon was associated with higher opioid utilization in the midterm opioid postoperative period (+2.4 morphine milligram equivalents per day difference; 95% CI, 1.7 to 3.2; P < 0.001 [11.4 morphine milligram equivalents per day vs. 9.0]) and lower opioid utilization in the long-term postoperative period (–1.0 morphine milligram equivalents per day difference; 95% CI, –1.4 to –0.6; P < 0.001 [2.8 morphine milligram equivalents per day vs. 3.8]). While statistically significant, these differences are clinically small.

Conclusions

Among Medicare fee-for-service patients undergoing total knee arthroplasty, surgeon-level variation in opioid utilization in the immediate perioperative period was associated with statistically significant but clinically insignificant differences in opioid utilization in the medium- and long-term postoperative periods.

Editor’s Perspective
What We Already Know about This Topic
  • National efforts to rationalize postoperative opioid prescribing are widespread
  • It remains unclear whether early perioperative surgeon prescribing behaviors are associated with long-term opioid utilization
What This Article Tells Us That Is New
  • Among 604,093 Medicare beneficiaries undergoing total knee arthroplasty between 2011 and 2016, patients receiving treatment from surgeons in the top quartile of opioid prescribing (“high-intensity”) received 36.1 oral morphine milliequivalent per day in the first week after surgery, while the remaining patients received only 17.3 oral morphine milliequivalent per day
  • Receiving treatment from a high-intensity opioid-prescribing surgeon was associated with slightly higher opioid utilization between postoperative days 8 and 90 (+2.4 [11.4 vs. 9.0] oral morphine milliequivalent per day) and slightly lower opioid utilization between postoperative days 91 and 365 (–1.0 [2.8 vs. 3.8] oral morphine milliequivalent per day)
  • These differences were clinically small although statistically significant
  • Among Medicare beneficiaries undergoing total knee arthroplasty, variations in surgeon early postoperative prescribing is not associated with meaningful differences in medium- or long-term postoperative opioid utilization