Patient and institutional factors associated with postoperative opioid prescribing after common vascular procedures

From the New England Society for Vascular Surgery

Patient and institutional factors associated with postoperative opioid prescribing after common vascular procedures Edward D. Gifford, MD,a Kristine T. Hanson, MPH,b Victor J. Davila, MD,c Warren A. Oldenburg, MD,d Jill J. Colglazier, MD,e Samuel R. Money, MD,c Albert Hakaim, MD,d William M. Stone, MD,c Houssam Farres, MD,d Elizabeth B. Habermann, PhD,b Manju Kalra, MD,e Richard J. Fowl, MD,c Gustavo S. Oderich, MD,e Fahad Shuja, MD,e Thomas C. Bower, MD,e and Randall R. DeMartino, MD, MS,e Hartford, Conn; Rochester, Minn; Phoenix, Ariz; and Jacksonville, Fla

ABSTRACT Objective: Overprescription of postoperative opioid medication is a major contributor to the opioid abuse epidemic in the United States. Research into prescribing practices has suggested that patients be limited to 7 days or <200 morphine milligram equivalents (MME) after surgical procedures. Our aim was to identify patient or institutional factors associated with increased opioid prescriptions. Methods: Opioid naive patients from an integrated health system undergoing one of nine surgical and endovascular procedures tracked within the Vascular Quality Initiative from 2015 to 2017 were identified and matched to their discharge and refill opioid prescriptions. Discharge opioid prescriptions were converted to MME. The primary outcome was discharge MME >200, and secondary outcomes were procedure-specific top-quartile opioid prescription and medication refills. Multivariable logistic regression was used to assess patient and perioperative factors associated with each outcome. Results: Among 1546 opioid naive patients, 739 (48%) received a discharge opioid prescription; median MME was 0 (interquartile range, 0-150), and 349 (23%) had >200 MME. Among those with a discharge prescription, median MME was 180 (interquartile range, 150-300). MME varied by procedure (P < .001), with highest MME after suprainguinal bypass (median, 225) and infrainguinal bypass (200) and lowest MME after carotid artery stenting, carotid endarterectomy, and percutaneous peripheral vascular intervention (all medians of 0). On multivariable analysis, factors associated with MME >200 included younger patient age (<65 vs $ 80 years; odds ratio [OR], 3.0; 95% confidence interval [CI], 1.9-4.6; P < .001), treating institution B vs A (OR, 3.50; 95% CI, 2.42-5.07; P < .001) and C vs A (OR, 3.90; 95% CI, 2.66-5.74; P < .001), procedurespecific top-quartile length of stay (OR, 1.45; 95% CI, 1.01-2.08; P ¼ .047), and prior tobacco use (OR, 1.60; 95% CI, 1.07-2.37; P ¼ .02). The same variables along with current tobacco use and lack of preoperative aspirin were associated with procedure-specific top-quartile MME at discharge. Chronic beta-blocker use was protective of top-quartile MME. Based on the observed variability, an institutional standard for opioid prescribing has been developed for standardization. Conclusions: Opioid prescriptions at discharge vary with the invasiveness of vascular surgical procedures. Less than 25% of patients receive >200 MME. Variation by center represents a lack of standardization in prescribing practices and an opportunity for further improvement based on developed guidelines. Patient factors and procedure type can alert clinicians to patients at risk of higher than recommended MME. (J Vasc Surg 2019;-:1-10.) Keywords: Opioids; Vascular Quality Initiative; Prescriptions

During the last decade, opioid abuse in the United States has grown to epidemic proportions. In 2015, there were >33,000 opioid-related deaths, and in 2016, this number grew to >42,000.1 Surgeons invariably have a

role to play in the dissemination of opioid medication. Postoperative administration of opioids by surgeons accounts for 10% of all opioid prescriptions.2 Postoperative pain is a major concern of patients. However, one study

From the Division of Vascular and Endovascular Surgery, Hartford Hospital,

Additional material for this article may be found online at www.jvascsurg.org.

Hartforda; the Robert D. and Patricia E. Kern Center for the Science of Health

Correspondence: Randall R. DeMartino, MD, MS, Division of Vascular and Endo-

Care Delivery,b and Division of Vascular and Endovascular Surgery,e Mayo

vascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (e-mail:

Clinic, Rochester; the Division of Vascular and Endovascular Surgery, Mayo Clinic, Phoenixc; and the Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville.d Author conflict of interest: E.D.G. received consulting fees for prior work for Foundry Therapeutics, Inc. G.S.O. is a consultant for Cook Medical and W. L. Gore & Associates, all fees paid to Mayo Clinic. Presented as a Rapid Fire Presentation at the Forty-fifth Annual Meeting of the

[email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214 Copyright Ó 2019 by the Society for Vascular Surgery. Published by Elsevier Inc. https://doi.org/10.1016/j.jvs.2019.05.068

New England Society for Vascular Surgery, Cape Neddick, Me, October 1214, 2018.

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found that more than two-thirds of patients have leftover opioid medication after recovery from their procedure.3 In the same patient cohort, <10% of the unused medication was disposed of properly. Unused medication increases the risk of inappropriate use by family or friends, through theft, or by the patients themselves. Indeed, one in three of these appropriately obtained narcotics are eventually diverted for inappropriate use.4 One of the issues driving the overprescription of postoperative opioids is a lack of guidelines that encompass severity of procedure, previous opioid tolerance, and other potential risk factors for abuse.3,5 To that end, regulatory bodies have recommended limiting the duration of postoperative opioid prescriptions.6-8 Multiple agencies including the Centers for Disease Control and Prevention as well as states such as Massachusetts have advocated that opioid prescriptions for acute pain be limited to 7 days.6,7 As part of a recent Medicare Part D update, the Centers for Medicare and Medicaid Services proposed limiting all postoperative opioid prescriptions among opioid naive patients to 7 days.8 A 7-day opioid prescription is considered the equivalent of 200 morphine milligram equivalents (MME), which approximates one 5-mg tablet of oxycodone every 6 hours for 7 days. In attempting to standardize postoperative opioid prescription practices, providers must look at current prescribing patterns as well as risk factors for overprescription of opioid medication. A study from our institution in the Annals of Surgery demonstrated that >80% of postoperative opioid prescriptions across a variety of surgical specialties fall above the recommended 200 MME limit.5 To date, there exists little or no information on postoperative opioid prescribing in vascular surgery patients. The aim of our study was to assess patterns of postoperative opioid prescribing after common vascular and endovascular procedures and to identify factors associated with higher opioid prescribing.

METHODS The Vascular Quality Initiative (VQI) database was queried for all patients aged 18 years or older who underwent one of nine open and endovascular vascular procedures (carotid artery stenting [CAS], carotid endarterectomy [CEA], open abdominal aortic aneurysm [AAA] repair, endovascular aneurysm repair [EVAR], suprainguinal bypass, infrainguinal bypass, thoracic and complex EVAR, and open and percutaneous peripheral vascular intervention [PVI]) from January 1, 2015 to August 23, 2017 across an integrated health care system composed of three academic medical centers and one regional affiliated medical center in Minnesota, Florida, Arizona, and Wisconsin. A total of 2256 patients were identified within the VQI data set during the study period. Of these, 213 (9.4%) had undergone a VQI-recorded procedure within the preceding 12 months and were excluded. Ninety-five

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ARTICLE HIGHLIGHTS d

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d

Type of Research: Retrospective multicenter analysis of prospectively collected Vascular Quality Initiative data Key Findings: Factors most commonly associated with increased opioid prescribing in 1546 opioid naive patients included younger age, prolonged length of stay, tobacco use, and treating institution. Take Home Message: Standardization of prescribing patterns for common vascular procedures across institutions can help to decrease inappropriate dissemination of postoperative opioid medication.

patients (4.2%) refused Minnesota research authorization, and 23 (1.0%) patients died in the hospital and were excluded. Finally, two patients (0.1%) did not have a valid patient identifier in VQI and could not be matched to clinical and prescribing data (Fig 1). The Mayo Clinic Institutional Review Board approved this minimal risk study and waived the need for consent. Patient data. Patient data in VQI included demographics, comorbidities, and prior vascular history. Patients were identified as admissions from home or from a nursing facility. Postoperative complications were identified using the available in-hospital complications collected in each module (Appendix, online only). Given the low frequency and breadth of complications across the nine modules, the presence of a complication was noted and collectively examined as “any in-hospital complication.” Patients with multiple missing data entries within the complication fields were excluded from the analysis of any in-hospital complication. Relevant hospital data also included length of stay (LOS); prolonged LOS was defined as those within the procedure-specific top quartile for LOS. Discharge status was dichotomized into home or not home. At included institutions, midlevel providers and surgical trainees write the majority of postoperative prescriptions. Given possible prescribing differences among providers, we included variables to assess opioid prescribing by month (ie, new trainees in summer) and day of the week (cross cover trainees vs midlevel provider). Opioid data. Outpatient opioid prescriptions written between 90 days before the procedure through 30 days after discharge were abstracted from the electronic medical record. Postoperative pain prescriptions that fall under the Drug Enforcement Administration schedule II or III classification were included in our analysis. These included opioid agonists (eg, oxycodone), opioid partial agonists (eg, tramadol), and combinations (ie, oxycodone-acetaminophen). Fentanyl patches were included, whereas methadone was excluded.

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Total patients: 2256

Available for analysis: 1923

Exclusions: • VQI procedure < 1 year (213) • Died in hospital (23) • Refused research authorization (95) • Inaccurate patient identifier (2)

Documented preoperative opioid use (377)

Opioid naïve patients: 1546

MME > 200 349 (23%)

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MME ≤ 200 1197 (77%)

Fig 1. Patient exclusions. MME, Morphine milligram equivalents; VQI, Vascular Quality Initiative.

Preoperative opioid use was defined as prescription of opioid medication between 90 days and 8 days before the procedure or documented history of opioid use up to 90 days before the procedure. As some providers issue postoperative prescriptions during the immediate preoperative visit, patients with new opioid prescriptions within 7 days before the procedure who were not otherwise identified as preoperative opioid users were considered opioid naive. Preoperative opioid users were excluded from further analysis. If a patient’s chart suggested chronic opioid use (ie, a prior but not current opioid prescription), the medical record was scrutinized for a 90-day period before the index procedure to identify any potential opioid use. Discharge prescriptions were defined as new opioid prescriptions between 7 days before the procedure through the date of discharge. Refill prescriptions were defined as opioids prescribed from 1 day to 30 days after discharge regardless of the provider who originated the prescription (surgeon, primary care provider, emergency department provider). Patients who underwent additional surgery within 30 days after discharge, died within 30 days after discharge, or were discharged to a rehabilitation unit, a nursing home, or a transitional care unit were excluded from the refill analysis. Discharge opioid prescriptions were converted into MME. Total MME at discharge was calculated and categorized using the threshold of MME >200 vs #200 as a surrogate for excessive quantity of opioids based on recommendations of current regulatory bodies.6-8 Patients were identified as receiving a discharge MME in the top-quartile MME (Q4) within each procedure compared

with the lower three quartiles (Q1-Q3). This allowed us to account for the fact that many vascular surgical procedures are of different magnitudes and recovery lengths. Therefore, they will vary in the amount of postoperative opioids prescribed. This analysis permitted us to focus on the highest level prescriptions regardless of procedure type. Statistical analysis. The primary outcome was MME >200, and secondary analysis assessed procedurespecific top-quartile (Q4) vs lower three-quartile (Q1-Q3) MME at discharge and opioid refills. Univariate analyses assessed associations of procedure type, demographics and comorbid conditions, time of procedure and discharge (year, month, day of week), postoperative LOS, presence of any postoperative complication, and ambulatory status at discharge with the primary and secondary end points. Continuous variables were compared with the Wilcoxon rank sum and KruskalWallis tests, and categorical variables were compared with c2 and Fisher exact tests. Multivariable logistic regression analysis was performed with outcomes of MME >200, top-quartile MME, and refills. Variables that were significantly associated with outcomes on univariate analysis (P < .10) or that had been found in previous studies to be associated with a discrepancy in opioid prescribing patterns were included in the multivariable analysis. Models assessing MME >200 and top-quartile prescriptions included sex, age category, body mass index (BMI) category, discharge day of week, institution, prolonged LOS, discharge status, smoking status, American Society of Anesthesiologists (ASA) class, prior amputation, and preoperative aspirin and beta-blocker use; procedure type was also included in the model of MME >200 to assess variation in high prescribing by procedure. The multivariable model assessing refills included procedure type, year of procedure, sex, age category, BMI category, discharge day of week, institution, prolonged LOS, dialysis, ASA class, prior amputation, prior arterial revascularization, preoperative aspirin use, and MME >200 at discharge; as one of the four sites did not have any refills, the multivariable model assessing refills was limited to the remaining three sites (Minnesota, Arizona, and Florida). Prescribing guidelines were developed from data targeting the mean of the second quartile within each procedure type based on previous work at our institution.9 A P value of <.05 was considered significant. All analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC).

RESULTS Of 1923 patients, 377 (19.6%) had documented preoperative opioid use within 90 days to 8 days before the procedure or history of opioid use within 90 days before the procedure vs 1546 (80.4%) who were considered opioid naive (Fig 1). Analysis was limited to patients

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Table I. Demographics of opioid naive patients Total (N ¼ 1546) Procedure type CAS

128 (8.3)

CEA

333 (21.5)

Open AAA repair EVAR Suprainguinal bypass

69 (4.5) 262 (16.9) 54 (3.5)

Infrainguinal bypass

105 (6.8)

TEVAR

188 (12.2)

Open PVI Percutaneous PVI

79 (5.1) 328 (21.2)

Female sex

406 (26.3)

Age, years

72.0 (9.5)

Hispanic or Latino BMI, kg/m2

20 (1.3) 28.0 (24.8-31.6)

Site Hospital A

1081 (69.9)

Hospital B

219 (14.2)

Hospital C

216 (14.0)

Hospital D

30 (1.9)

Transferred from hospital or rehabilitation unit LOS, days Prolonged LOS

90 (6.5) 2 (1-4) 300 (19.4)

Discharge status “not home”

143 (9.2)

Smoking (never)

291 (18.8)

Hypertension

1327 (85.8)

Diabetes

447 (28.9)

CAD

566 (36.7)

Dialysis

56 (3.6)

Preadmission nursing home

11 (0.7)

Assistance with ambulationa

133 (12.1)

ASA classb 1 and 2 3 4 and 5 Prior arterial revascularization Prior amputation

89 (8.1) 846 (77.2) 161 (14.7) 357 (23.1) 28 (1.8)

AAA, Abdominal aortic aneurysm; ASA, American Society of Anesthesiologists; BMI, body mass index; CAD, coronary artery disease; CAS, carotid artery stent; CEA, carotid endarterectomy; EVAR, endovascular aneurysm repair; LOS, length of stay; PVI, peripheral vascular intervention; TEVAR, thoracic endovascular aortic repair. Categorical variables are presented as number (%). Continuous variables are presented as mean (standard deviation) or median (interquartile range). a Data point missing for 451 patients. b ASA class unknown for 450 patients.

who were opioid naive. The most common procedures were CEA, percutaneous PVI, and EVAR (Table I). Among the 1546 opioid naive patients, 739 (47.8%) received an opioid prescription at discharge. Among all

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postoperative vascular patients, median MME at discharge was thus 0 (interquartile range [IQR], 0-150). Among patients who received an opioid prescription at discharge, median MME was 180 (IQR, 150-300). MME prescribed at discharge varied by procedure type (Fig 2). Only one procedure type, suprainguinal bypass, had median MME >200 at discharge (median, 225; IQR, 75-300), whereas the median was 200 MME at discharge (IQR, 50-300) among patients who underwent infrainguinal bypass. Conversely, among patients who underwent CAS, CEA, and percutaneous PVI, median discharge MME was 0 (Fig 2). Hospital D had no patients within the CAS, open AAA repair, suprainguinal bypass, thoracic endovascular aortic repair, and open PVI modules. MME >200. Overall, 349 patients received >200 MME at discharge. This represents 22.6% of all patients and 47.2% of patients who received an opioid prescription. On univariate analysis, the following factors were significantly associated with receiving MME >200 at discharge: procedure type, younger patient age, discharge day of week, weekend vs weekday discharge, treating hospital, longer surgical and overall LOS, prior and current smoking status, and others (Supplementary Table I, online only). Sex, race and ethnicity, BMI, and additional factors were not significantly different between the two groups (Supplementary Table I, online only). Among patients who underwent open AAA repair, conversion from endovascular AAA repair and operative approach were not associated with MME >200. The grouped end point of any in-hospital complication was not significantly associated with higher prescribing, with 25.1% of patients with a complication receiving MME >200 compared with 21.9% of patients without a complication (P ¼ .31). In our multivariable logistic regression analysis, procedures with significantly lower odds of MME >200 included CAS, CEA, and percutaneous PVI compared with open PVI (Fig 3). Suprainguinal bypass and infrainguinal bypass were both associated with a significantly higher likelihood of MME >200. Other factors associated with MME >200 included younger age, weekend vs weekday discharge, treating hospital, prolonged LOS, prior tobacco use, and prior amputation (Fig 3). Patient sex, BMI, discharge to other than home, current tobacco use, ASA class, preoperative aspirin use, and preoperative beta-blocker use were not associated with MME >200 (Fig 3). Top-quartile MME. On univariate analysis, factors associated with the top quartile of MME prescription included younger age, Hispanic/Latino ethnicity, treating hospital, and procedure-specific prolonged LOS (Supplementary Table II, online only). On multivariable analysis, factors associated with top-quartile MME included younger age, treating hospital, prolonged LOS,

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Fig 2. Morphine milligram equivalents (MME) prescribed at discharge by procedure type. AAA, Abdominal aortic aneurysm; CAS, carotid artery stenting; CEA, carotid endarterectomy; EVAR, endovascular aneurysm repair; IQR, interquartile range; PVI, peripheral vascular intervention; TEVAR, thoracic endovascular aortic repair.

and both prior and current tobacco use, whereas preoperative aspirin use and chronic beta-blocker use (>30 days) were associated with lower odds of topquartile MME (Fig 4). Sex, BMI, discharge day of week, discharge to other than home, ASA class, prior amputation, and perioperative or unknown beta-blocker use were not associated with top-quartile MME at discharge (Fig 4). Opioid refills. Of 1546 opioid naive patients, patients who had additional surgery, died within 30 days of discharge, or were discharged to a rehabilitation unit, nursing home, or other hospital were excluded (n ¼ 164). Of the 1382 remaining patients, 117 received an opioid refill within 30 days of discharge (8.5%). Median discharge MME in the no-refill group was 0 (IQR, 0-150) vs 150 for those requiring refill (IQR, 0-225; P ¼ .002). Factors associated with increased opioid refill on multivariable analysis included later year of procedure (2017 vs 2015), age <65 years (vs $80 years), dialysis dependency, prolonged LOS, and lower ASA class (Fig 5). Patients with CAS and CEA refilled at significantly lower rates compared with reference of open PVI. Sex, BMI, weekend vs weekday discharge, hospital site, prior arterial revascularization, prior amputation, and preoperative aspirin use were not associated with differences in refill rate. Patients discharged with <200 MME did not receive opioid refills at a higher rate than patients with MME >200 at discharge (Fig 5).

DISCUSSION Surgeons prescribe a significant amount of opioid medication.2 Overprescription of opioid medication to postoperative patients occurs in >80% of common surgical procedures across specialties and represents a source of excess dissemination of opioids into the general

population.5 In our multi-institutional study of postoperative opioid prescribing practices, the majority of patients undergoing standard vascular operations received less than the maximum recommended dose of discharge opioid medication (MME >200). Often, for common procedures such as CEA and percutaneous PVI, no opioids were prescribed. These patients probably instead received acetaminophen (Tylenol) or ibuprofen as needed, as is standard in our practice. Conversely, patients undergoing infrainguinal and suprainguinal bypass were more likely to go home with higher quantities of opioid medication. Factors associated with the highest opioid discharge prescriptions overall (MME >200) and within each procedure (top quartile) included younger age, treating hospital, prolonged LOS, and tobacco use. Patients receiving preoperative aspirin or chronic beta blockade were less likely to be among the top-quartile MME, perhaps reflecting a protective effect of chronic preventive health care on higher postoperative opioid prescriptions. Patients who refilled their opioid medication at higher rates were younger (<65 years), on dialysis, and in better health by ASA class (1 or 2). Taken together, clinicians should be keenly aware that younger patients, smokers, and those with longer LOS are at risk of higher prescribing, whereas patient care systems are also associated with opioid prescribing practices. Controlling for multiple variables, one of our strongest findings was the variability in prescribing practices across different institutions. This observation, in both overall and procedure-specific prescribing, represents a target for early quality improvement to standardize and to decrease postoperative opioid prescriptions. The escalating importance of standardizing opioid prescription for surgical procedures reflects the magnitude of the problem of opioid addiction and abuse in the United States. During the last 20 years, loose regulations on opioid prescriptions, mandates from regulatory bodies about postoperative pain control, and marketing of short- and long-term opioids by pharmaceutical companies have contributed to an epidemic of opioid misuse and abuse.4,10 The dissemination of opioids has resulted in >42,000 opioid-related deaths in the last year, with an economic burden of more than $78 billion in 2013.1,11 A study in 2009 identified that 21% of short-term opioid users progressed to episodic use after initial prescription and that 6% ultimately became chronic users.12 Chronic opioid use in the postoperative populations can range from 4.4% to 23.8% and is associated with higher rates of readmission after elective surgical procedures.3,13,14 This emphasizes the importance of limiting the duration and the amount of prescribed opioids to minimize leftover medication, which may not be disposed of properly. Decreasing the potential for misuse of these medications may subsequently reduce the risk of chronic opioid use in postoperative populations. A number of studies have examined the role of the surgeon in the administration of postoperative opioids.

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Fig 3. Multivariable analysis of factors associated with morphine milligram equivalents (MME) >200 at discharge. AAA, Abdominal aortic aneurysm; ASA, American Society of Anesthesiologists; BMI, body mass index; CAS, carotid artery stenting; CEA, carotid endarterectomy; CI, confidence interval; EVAR, endovascular aneurysm repair; LOS, length of stay; OR, odds ratio; PVI, peripheral vascular intervention; TEVAR, thoracic endovascular aortic repair. 1 Procedure-specific top-quartile LOS.

Pharmacy data from the national prescription audit suggest that surgeons account for almost 10% of all opioid prescriptions.2 However, prescribing practices differ among surgical providers and procedures. A study using National Surgical Quality Improvement Program data across Mayo Clinic institutions by Thiels et al5 demonstrated that 93.7% of patients received an opioid prescription when undergoing one of 25 common elective surgical procedures and that 80.9% of opioid naive patients received more than the recommended maximum of 200 MME at time of discharge compared with only 22.6% of patients in our series of solely vascular patients. Variation in prescribing practices and

overprescription are problems even within the same specialty and procedure. A single-center study found that the number of opioid pills prescribed after partial mastectomy repair varied from 0 to 50 pills, and overall only 15% of patients took the prescribed medication.15 A recent study in Michigan found that among 2392 patients, the amount of opioids required for pain control amounted to only 27% of the prescribed amount.16 Furthermore, overall prescription size was the strongest associated factor with opioid consumption after surgery. Overall, variability in prescribing practices is an area for quality improvement and standardization in the discharge process.

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Fig 4. Multivariable analysis, procedure-specific top-quartile morphine milligram equivalents (MME). ASA, American Society of Anesthesiologists; BMI, body mass index; CI, confidence interval; LOS, length of stay; OR, odds ratio. 1Procedure-specific top-quartile LOS.

Vascular surgery patients may have a broad variety of postoperative pain requirements. Although chronic pain is a common problem in patients with peripheral artery disease, there are sparse data on postoperative opioid needs or risk factors of high opioid prescribing within this population. In a cohort of patients with peripheral artery disease, 61% reported chronic regional pain and 29% chronic widespread pain, with no pain difference between patients with intermittent claudication and patients with critical limb ischemia.17 Similarly, in our study, suprainguinal bypass patients (peripheral artery disease, including axillofemoral bypass) had a significantly higher median MME than the open AAA repair cohort. Active tobacco use has been associated with higher doses of postoperative opioid medication compared with nonsmokers.18 In our analysis, prior tobacco users received a higher opioid prescription compared with patients who never used tobacco, but

never users and current users had similar prescription amounts. This could be attributed to a lower pain threshold in abstinent smokers compared with either ongoing tobacco users or nonsmokers, as seen in a study of postoperative pain in patients undergoing hepatic resection.19 There have been ongoing regulatory and institutionbased policies to improve opioid prescribing practices. A primary goal has been to identify the optimal length and amount for postoperative opioid prescriptions. Along with regulatory efforts to limit prescriptions to 7 days, a database study used median opioids prescribed at discharge in combination with the early nadir of opioid refills to identify optimum duration of postoperative medication, typically 4 to 9 days for common general surgery procedures.20 Other methods include using a threshold that meets 80% of a patient’s opioid needs to drive future prescription recommendations, a tactic

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Fig 5. Multivariable analysis, opioid refills. AAA, Abdominal aortic aneurysm; ASA, American Society of Anesthesiologists; BMI, body mass index; CAS, carotid artery stenting; CEA, carotid endarterectomy; CI, confidence interval; EVAR, endovascular aneurysm repair; LOS, length of stay; MME, morphine milligram equivalents; OR, odds ratio; PVI, peripheral vascular intervention; TEVAR, thoracic endovascular aortic repair. 1Hospital D excluded, given lack of refill events. 2Procedure-specific top-quartile LOS.

that in practice significantly reduced the amount of prescribed opioids.21 Based on the results of our study as well as the previous study of prescribing patterns among multiple surgical specialties by Thiels et al,5,9 we have implemented system-wide recommendations for opioid prescribing after common vascular surgery procedures (Table II). Guidelines were rolled out in 2018 as a mandatory education module for all attending surgeons, midlevel providers, and surgical trainees. Our recommendations reflect the median opioid prescription of the second quartile. Additional measures to curtail and to track postoperative opioid prescriptions include

more widespread adoption of electronic opioid prescribing, an approach that only 8% of physicians use but that is available to >80% of pharmacies.22 Our study has several limitations. This is a retrospective database study that has heterogeneity among procedure types, and complications can vary in magnitude. Non-narcotic medication for postoperative pain, such as Tylenol and ibuprofen, was not tracked in our study. In addition, although the institutions in the study exist in an integrated health care delivery system, not all care is received within the same system. Thus, some patients may receive refill prescriptions outside our system

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Table II. Recommended postoperative opioid prescription for common vascular and endovascular procedures Procedure CAS (transfemoral)

Low dose

Standard dose

NSAIDs/Tylenol only

NSAIDs/Tylenol only

High dose 5 tabs oxycodone/10 tabs tramadol

Percutaneous PVI or fistulography CAS (TCAR) Carotid endarterectomy Dialysis access (AVF, excludes transposition) EVAR (percutaneous) Femoral endarterectomy or open PVI, EVAR or TEVAR (open access)

10 tabs oxycodone/15 tabs tramadol

TEVAR percutaneous Open AAA repair

NSAIDs/Tylenol only

15 tabs oxycodone/25 tabs tramadol

25 tabs oxycodone/40 tabs tramadol

Infrainguinal bypass

20 tabs oxycodone/30 tabs tramadol

35 tabs oxycodone/50 tabs tramadol

Suprainguinal bypass

25 tabs oxycodone/40 tabs tramadol

35 tabs oxycodone/50 tabs tramadol

AAA, Abdominal aortic aneurysm; AVF, arteriovenous fistula; CAS, carotid artery stenting; EVAR, endovascular aortic repair; NSAIDs, nonsteroidal antiinflammatory drugs; PVI, peripheral vascular intervention; TCAR, transcarotid arterial revascularization; TEVAR, thoracic endovascular aortic repair.

that we cannot track. Data limited to VQI modules may not identify all reasons for the variability noted among treating institutions. Although we based our recommendations on the findings of our study as well as of similar studies, our guidelines for opioid prescribing may not be applicable to all populations of patients (such as chronic users) and health care models. They may require further refinement as we move forward with implementation. Last, we used prescribing patterns only and not opioid prescriptions filled. Thus, some medications prescribed may not have been used. We therefore limit our interpretation of these data only to prescribing patterns and not the amount taken. We do know through a follow-up study by Thiels et al9 across surgical specialties that in CEA patients, 90% consumed <50 MME and 80% consumed 0 MME.

CONCLUSIONS The majority of patients undergoing common vascular and endovascular procedures receive no opioids, and of those who do, most receive less than the maximum recommended amount of opioid medications at discharge. Patients undergoing suprainguinal and infrainguinal bypass, younger patients, and tobacco users are all more likely to require higher amounts of opioids at discharge. Although these findings may seem logical, we still encountered patients in each of the minimally invasive categories who received excess opioid medication at discharge. By highlighting these risk factors, we hope to reassure providers in the community that many patients do not require an opioid prescription at discharge. As treating hospital was one of the strongest

factors associated with variability in our study, we think this represents one of the earliest targets for quality improvement and have provided prescribing recommendations based on these data to help guide providers. Ideally, our work aims to define procedure- and patienttailored practices to decrease the incidence of new episodic and chronic opioid use.

AUTHOR CONTRIBUTIONS Conception and design: EG, KH, VD, WO, JC, SM, AH, WS, HF, EH, MK, RF, GO, FS, TB, RD Analysis and interpretation: EG, KH, VD, WO, JC, SM, AH, WS, HF, EH, MK, RF, GO, FS, TB, RD Data collection: EG, KH, RD Writing the article: EG, KH Critical revision of the article: EG, KH, VD, WO, JC, SM, AH, WS, HF, EH, MK, RF, GO, FS, TB, RD Final approval of the article: EG, KH, VD, WO, JC, SM, AH, WS, HF, EH, MK, RF, GO, FS, TB, RD Statistical analysis: KH Obtained funding: Not applicable Overall responsibility: EG

REFERENCES 1. Seth P, Scholl L, Rudd RA, Bacon S. Overdose deaths involving opioids, cocaine, and psychostimulantsdUnited States, 2015-2016. MMWR Morb Mortal Wkly Rep 2018;67: 349-58. 2. Levy B, Paulozzi L, Mack KA, Jones CM. Trends in opioid analgesic-prescribing rates by specialty, U.S., 2007-2012. Am J Prev Med 2015;49:409-13. 3. Bates C, Laciak R, Southwick A, Bishoff J. Overprescription of postoperative narcotics: a look at postoperative pain

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5.

6.

7.

8.

9.

10.

11.

12.

13.

medication delivery, consumption and disposal in urological practice. J Urol 2011;185:551-5. Paulozzi LJ, Jones CM, Mack KA, Rudd RA. Vital signs: overdoses of prescription opioid pain relieversdUnited States, 1999-2008. MMWR Morb Mortal Wkly Rep 2011;60:1487-92. Thiels CA, Anderson SS, Ubl DS, Hanson KT, Bergquist WJ, Gray RJ, et al. Wide variation and overprescription of opioids after elective surgery. Ann Surg 2017;266:564-73. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic paindUnited States, 2016. MMWR Recomm Rep 2016;65:1-49. Meier B, Tavernise S. States move to control how painkillers are prescribed. Available at: https://www.nytimes.com/2016/ 03/12/business/states-move-to-control-how-painkillers-areprescribed.html. Accessed June 21, 2018. 2019 Medicare Advantage and Part D rate announcement and call letter, https://www.cms.gov/Newsroom/Media ReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/201804-02-2.html. Accessed January 10, 2019. Thiels CA, Ubl DS, Yost KJ, Dowdy SC, Mabry TM, Gazelka HM, et al. Results of a prospective, multicenter initiative aimed at developing opioid-prescribing guidelines after surgery. Ann Surg 2018;268:457-68. Manchikanti L, Helm S, Fellows B, Janata JW, Pampati V, Grider JS, et al. Opioid epidemic in the United States. Pain Physician 2012;15(Suppl):ES9-38. Florence CS, Zhou C, Luo F, Xu L. The economic burden of prescription opioid overdose, abuse, and dependence in the United States, 2013. Med Care 2016;54:901-6. Hooten WM, St Sauver JL, McGree ME, Jacobson DJ, Warner DO. Incidence and risk factors for progression from short-term to episodic or long-term opioid prescribing: a population-based study. Mayo Clin Proc 2015;90:850-6. Gupta A, Nizamuddin J, Elmofty D, Nizamuddin SL, Tung A, Minhaj M, et al. Opioid abuse or dependence increases 30-day readmission rates after major operating room procedures: a national readmissions database study. Anesthesiology 2018;128:880-90.

2019

14. Jiang X, Orton M, Feng R, Hossain E, Malhotra NR, Zager EL, et al. Chronic opioid usage in surgical patients in a large academic center. Ann Surg 2017;265:722-7. 15. Hill MV, McMahon ML, Stucke RS, Barth RJ. Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures. Ann Surg 2017;265:709-14. 16. Howard R, Fry B, Gunaseelan V, Lee J, Waljee J, Brummett C, et al. Association of opioid prescribing with opioid consumption after surgery in Michigan. JAMA Surg 2019;154: e184234. 17. Lindgren H, Gottsäter A, Qvarfordt P, Bergman S. All cause chronic widespread pain is common in patients with symptomatic peripheral arterial disease and is associated with reduced health related quality of life. Eur J Vasc Endovasc Surg 2016;52:205-10. 18. Chiang HL, Chia YY, Lin HS, Chen CH. The implications of tobacco smoking on acute postoperative pain: a prospective observational study. Pain Res Manag 2016;2016: 9432493. 19. Shen L, Wei K, Chen Q, Qiu H, Tao Y, Yao Q, et al. Decreased pain tolerance before surgery and increased postoperative narcotic requirements in abstinent tobacco smokers. Addict Behav 2018;78:9-14. 20. Scully RE, Schoenfeld AJ, Jiang W, Lipsitz S, Chaudhary MA, Learn PA, et al. Defining optimal length of opioid pain medication prescription after common surgical procedures. JAMA Surg 2018;153:37-43. 21. Hill MV, Stucke RS, McMahon ML, Beeman JL, Barth RJ. An educational intervention decreases opioid prescribing after general surgical operations. Ann Surg 2018;267:468-72. 22. Gawande AA. It’s time to adopt electronic prescriptions for opioids. Ann Surg 2017;265:693-4. Submitted Jan 21, 2019; accepted May 18, 2019.

Additional material for this article may be found online at www.jvascsurg.org.

Journal of Vascular Surgery Volume

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APPENDIX (online only).

Continued. Open abdominal aortic aneurysm repair

Any complication across Vascular Quality Initiative modules

Prolonged intubation Myocardial infarction Respiratory complication Renal dysfunction

Carotid artery stenting Ipsilateral neurologic event

Leg ischemia

Contralateral neurologic event

Bowel ischemia

Myocardial infarction

Wound complication

Access site complication

Return to operating room Stroke

Carotid endarterectomy

Congestive heart failure

Cranial nerve injury at discharge

Dysrhythmia

New neurologic event

Peripheral vascular intervention

Postoperative complication

Surgery before September 20, 2016

Myocardial infarction Wound infection

Puncture site hematoma

Reperfusion symptoms

Access site stenosis/occlusion

Return to operating room

Complication requiring admission Surgery after September 20, 2016

Congestive heart failure

Any postprocedure complication

Dysrhythmia

Cardiac complication

Endovascular aneurysm repair Any postoperative complication

Myocardial infarction

Prolonged intubation

Pulmonary complication

Evacuate abdominal hematoma

Renal complication

Puncture site hematoma

Access site complication

Access site occlusion

Hematoma

Infection

Stenosis/occlusion

Myocardial infarction

Infection

Respiratory

Pseudoaneurysm Amputation during admission

Leg ischemia

Suprainguinal bypass

Intestinal ischemia Stroke

Prolonged intubation

Dialysis

Myocardial infarction

Reoperation

Respiratory complication

Congestive heart failure

Renal dysfunction

Dysrhythmia

Wound complication

Infrainguinal bypass

Graft infection

Wound infection

Leg ischemia

Graft infection

Return to operating room

Myocardial infarction

Right amputation

Respiratory complication

Left amputation

Renal dysfunction

Intervention for patency/failed patency

Stroke

Congestive heart failure

Amputation

Dysrhythmia Thoracic endovascular aortic repair

Intervention for patency/failed patency Return to operating room

Any complication

Congestive heart failure

Prolonged intubation

Dysrhythmia

Puncture site hematoma

(Continued)

(Continued on next page)

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Journal of Vascular Surgery ---

Continued. Access site occlusion Myocardial infarction Stroke Respiratory complication Dialysis Arm ischemia Leg ischemia Compartment syndrome Intestinal ischemia Renal ischemia Surgical site infection Spinal cord ischemia Reintervention Congestive heart failure Dysrhythmia

2019

Journal of Vascular Surgery Volume

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Number

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Supplementary Table I (online only). Univariate analysis of morphine milligram equivalents (MME) > 200 MME #200 (n ¼ 1197)

Variable

MME >200 (n ¼ 349)

P value

Procedure type CAS

118 (92.2)

CEA

270 (81.1)

Open AAA repair EVAR Suprainguinal bypass Infrainguinal bypass TEVAR Open PVI Percutaneous PVI

<.001

10 (7.8) 63 (18.9)

42 (60.9)

27 (39.1)

212 (80.9)

50 (19.1)

23 (42.6)

31 (57.4)

53 (50.5)

52 (49.5)

137 (72.9)

51 (27.1)

57 (72.2)

22 (27.8)

285 (86.9)

43 (13.1)

884 (77.5)

256 (22.5)

313 (77.1)

93 (22.9)

Sex Male Female Age at surgery, years

72.7 (9.4)

.85 <.001

69.7 (9.6)

Age category, years <65

218 (67.5)

105 (32.5)

65-69

190 (75.1)

63 (24.9)

70-74

257 (78.6)

70 (21.4)

75-79

233 (79.8)

59 (20.2)

80þ

299 (85.2)

52 (14.8)

1144 (77.5)

332 (22.5)

53 (75.7)

17 (24.3)

<.001

Race White Other/unknown

.73

Hispanic or Latino Missing Hispanic or Latino Not Hispanic or Latino 2

BMI, kg/m

1

0

13 (65.0)

7 (35.0)

.18

1183 (77.6)

342 (22.4)

28.1 (24.8-31.6)

27.4 (24.3-31.6)

.09

Year of surgery 2015

341 (78.6)

93 (21.4)

2016

483 (76.1)

152 (23.9)

.56

2017

373 (78.2)

104 (21.8)

Month of discharge July-September

249 (77.6)

72 (22.4)

October-June

948 (77.4)

277 (22.6)

Weekday (Monday-Friday)

1017 (78.8)

273 (21.2)

Weekend (Saturday-Sunday)

180 (70.3)

76 (29.7)

Hospital A

887 (82.1)

194 (17.9)

Hospital B

140 (63.9)

79 (36.1)

Hospital C

142 (65.7)

74 (34.3)

Hospital D

28 (93.3)

2 (6.7)

.95

Discharge day of week .003

Site <.001

Transferred from hospital or rehabilitation unita No

993 (76.7)

302 (23.3)

Yes

66 (73.3)

24 (26.7)

Missing

138

.47

23

(Continued on next page)

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Supplementary Table I (online only). Continued. Variable LOS (admission to discharge), days

MME #200 (n ¼ 1197) 1 (1-4)

MME >200 (n ¼ 349)

P value

3 (1-6)

<.001 .26

Prolonged LOS (procedure-specific top quartile) No

972 (78.0)

274 (22.0)

Yes

225 (75.0)

75 (25.0)

1 (1-3)

2 (1-5)

<.001

1089 (77.6)

314 (22.4)

.57

108 (75.5)

35 (24.5)

Never

246 (84.5)

45 (15.5)

Prior

687 (76.3)

213 (23.7)

Current

264 (74.4)

91 (25.6)

No

160 (73.1)

59 (26.9)

Yes

1037 (78.1)

290 (21.9)

837 (76.2)

262 (23.8)

67 (78.8)

18 (21.2)

Surgical LOS (surgery to discharge), days Discharge status Home Not home Smoking

.004

Hypertension .10

Diabetes None Diet Non-insulin medication

167 (81.1)

39 (18.9)

Insulin

126 (80.8)

30 (19.2)

.30

CAD symptoms Missing

2

0

None

749 (76.6)

History of MI but no symptoms

186 (75.3)

61 (24.7)

Stable angina

248 (81.6)

56 (18.4)

Unstable angina/MI <6 months

.25

229 (23.4)

12 (80.0)

3 (20.0)

Prior CABG No

978 (77.6)

283 (22.4)

Yes, <5 years

58 (73.4)

21 (26.6)

Yes, $5 years

161 (78.2)

45 (21.8)

.67

Prior PCI None

912 (77.0)

272 (23.0)

Yes, <5 years

111 (77.6)

32 (22.4)

Yes, $5 years

174 (79.5)

45 (20.5)

.73

CHF Missing None

1

0

1025 (77.2)

303 (22.8)

Asymptomatic, history of CHF

60 (73.2)

22 (26.8)

Mild

69 (79.3)

18 (20.7)

Moderate

36 (90.0)

4 (10.0)

6 (75.0)

2 (25.0)

Severe

.32

COPD Missing None Not treated On medication On home oxygen

1

0

920 (76.7)

279 (23.3)

92 (76.0)

29 (24.0)

159 (82.0)

35 (18.0)

25 (80.6)

6 (19.4)

.40

Journal of Vascular Surgery Volume

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Gifford et al

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Supplementary Table I (online only). Continued. Variable

MME #200 (n ¼ 1197)

MME >200 (n ¼ 349)

P value

0

.50

Dialysis Missing No

1 1151 (77.3)

338 (22.7)

Functioning transplant

16 (88.9)

2 (11.1)

On dialysis

29 (76.3)

9 (23.7)

Creatinine, mg/dL

1 (0.9-1.3)

1 (0.9-1.2)

.02

Stress test Missing

1

0

.61

Not done

567 (78.5)

155 (21.5)

Normal

487 (76.3)

151 (23.7)

142 (76.8)

43 (23.2)

1186 (77.3)

349 (22.7)

MI or ischemia Preadmission living Home Nursing home

11 (100.0)

.07

0 (0.0)

Ambulatory statusb Missing Ambulatory

350

101

.10

736 (76.5)

226 (23.5)

Ambulatory with assistance

94 (81.7)

21 (18.3)

Wheelchair or bedridden

17 (94.4)

1 (5.6)

ASA classc Missing 1-2, normal-with mild disease 3, with severe disease 4-5, constant threat-moribund Preoperative hemoglobin, g/dL

372

78

.25

61 (68.5)

28 (31.5)

645 (76.2)

201 (23.8)

119 (73.9) 13.7 (12.4-14.7)

42 (26.1) 13.4 (12.3-14.8)

.68 .23

Prior CEA or CAS No

1075 (77.0)

321 (23.0)

Yes

122 (81.3)

28 (18.7)

No

1097 (77.9)

312 (22.1)

Yes

100 (73.0)

37 (27.0)

Prior aneurysm repair .19

Prior arterial revascularization No

931 (78.3)

258 (21.7)

Yes

266 (74.5)

91 (25.5)

.13

No

1177 (77.5)

341 (22.5)

Yes

20 (71.4)

8 (28.6)

No

213 (72.4)

81 (27.6)

Yes

972 (78.9)

Prior amputation .44

Preoperative aspirin .008

260 (21.1)

No for medical reason

12 (63.2)

7 (36.8)

Noncompliant

0 (0.0)

1 (100.0)

Preoperative P2Y12 antagonist Missing

1

0

.28

None

838 (77.2)

247 (22.8)

Any P2Y12 antagonist

307 (79.3)

80 (20.7)

50 (69.4)

22 (30.6)

No, for medical reason Noncompliant

1 (100.0)

0 (0.0)

(Continued on next page)

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Supplementary Table I (online only). Continued. MME #200 (n ¼ 1197)

Variable

MME >200 (n ¼ 349)

P value

0

.89

Preoperative statin Missing

1

No

250 (77.2)

74 (22.8)

Yes

917 (77.3)

269 (22.7)

24 (82.8)

5 (17.2)

5 (83.3)

1 (16.7)

No for medical reason Noncompliant d

Preoperative beta blockers Missing No Preoperative 1-30 days Chronic >30 days

138

23

450 (75.1)

149 (24.9)

20 (55.6)

16 (44.4)

576 (78.6)

157 (21.4)

No, for medical reason

7 (70.0)

Operation day only

5 (83.3)

Noncompliant

1 (100.0)

.03

3 (30.0) 1 (16.7) 0 (0.0)

Preoperative ACE inhibitor or ARB No

575 (77.5)

167 (22.5)

Yes

617 (78.0)

174 (22.0)

No for medical reason

5 (38.5)

.003

8 (61.5)

Preoperative chronic anticoagulant Missing

1

0

None

999 (77.4)

292 (22.6)

Any anticoagulation

165 (78.2)

46 (21.8)

32 (74.4)

11 (25.6)

No, for medical reason

.86

Postoperative MIe Missing No

210

43

967 (76.1)

303 (23.9)

Troponin only

5 (83.3)

1 (16.7)

ECG or clinical

15 (88.2)

2 (11.8)

.47

Postoperative dysrhythmiaf Missing

343

66

No

814 (74.7)

275 (25.3)

Yes

40 (83.3)

8 (16.7)

.18

Postoperative CHFg Missing No Yes

343 850 (75.0) 4 (100.0)

66

.58

283 (25.0) 0 (0.0)

Conversion from endovascular AAAg No

33 (57.9)

24 (42.1)

Early

1 (100.0)

0 (0.0)

Late

8 (72.7)

3 (27.3)

37 (61.7)

23 (38.3)

5 (55.6)

4 (44.4)

.70

Exposureg Anterior Retroperitoneal

.73

Postoperative pneumonia or reintubationh No

454 (68.9)

Yes

13 (72.2)

205 (31.1) 5 (27.8)

No

704 (73.5)

254 (26.5)

Yes

32 (64.0)

18 (36.0)

.76

Return to OR, reoperation, or reinterventioni .14

Journal of Vascular Surgery Volume

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Number

Gifford et al

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Supplementary Table I (online only). Continued. Variable

MME #200 (n ¼ 1197)

MME >200 (n ¼ 349)

P value

Any in-hospital complication Missing

8

8

No

1046 (78.1)

293 (21.9)

Yes

143 (74.9)

48 (25.1)

.31

AAA, Abdominal aortic aneurysm; ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; ASA, American Society of Anesthesiologists; BMI, body mass index; CABG, coronary artery bypass grafting; CAD, coronary artery disease; CAS, carotid artery stent; CEA, carotid endarterectomy; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; ECG, electrocardiography; EVAR, endovascular aneurysm repair; LOS, length of stay; MI, myocardial infarction; OR, operating room; PCI, percutaneous coronary intervention; PVI, peripheral vascular intervention; TEVAR, thoracic endovascular aortic repair. Categorical variables are presented as number (%). Continuous variables are presented as mean (standard deviation) or median (interquartile range). a Not available in updated VQI modules. b Not available in EVAR and TEVAR modules. c Not available in EVAR and updated PVI modules. d Not available in updated PVI module. e Not available in old PVI module. f Not available in PVI module. g Open AAA repair module only. h Available only in open AAA repair, EVAR, suprainguinal bypass, infrainguinal bypass, and TEVAR modules. i Available only in CEA, open AAA repair, suprainguinal bypass, and infrainguinal bypass modules.

10.e8

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Supplementary Table II (online only). Univariate analysis of top-quartile morphine milligram equivalents (MME) Variable

Lower quartiles, Q1-Q3 (n ¼ 1227) Top quartile, Q4 (n ¼ 319) P value

Sex Male Female

901 (79.0) 326 (80.3)

239 (21.0)

.59

80 (19.7)

72.6 (9.4)

69.6 (9.6)

<.001

<65

223 (69.0)

100 (31.0)

<.001

65-69

206 (81.4)

47 (18.6)

70-74

258 (78.9)

69 (21.1)

75-79

236 (80.8)

56 (19.2)

80þ

304 (86.6)

47 (13.4)

1171 (79.3)

305 (20.7)

Age at surgery, years Age category, years

Race White Other/unknown

56 (80.0)

.89

14 (20.0)

Hispanic or Latino Missing Not Hispanic or Latino Hispanic or Latino BMI, kg/m2

1 1214 (79.6) 12 (60.0) 28.1 (24.8-31.6)

0

.047

311 (20.4) 8 (40.0) 27.7 (24.6-31.9)

.76

1

.88

BMI category Missing

4

<25.0 kg/m2

330 (78.8)

89 (21.2)

25.0-29.9 kg/m2

472 (80.0)

118 (20.0)

30.0þ kg/m2

421 (79.1)

111 (20.9)

Year of surgery 2015

356 (82.0)

78 (18.0)

2016

486 (76.5)

149 (23.5)

2017

385 (80.7)

92 (19.3)

.06

Month of discharge July-September

253 (78.8)

68 (21.2)

October-June

974 (79.5)

251 (20.5)

1029 (79.8)

261 (20.2)

198 (77.3)

58 (22.7)

.78

Discharge day of week Weekday (Monday-Friday) Weekend (Saturday-Sunday)

.38

Site Hospital A

914 (84.6)

167 (15.4)

Hospital B

148 (67.6)

71 (32.4)

Hospital C

136 (63.0)

80 (37.0)

Hospital D

29 (96.7)

1 (3.3)

<.001

Transferred from hospital or rehabilitation unita Missing

124

37

No

1031 (79.6)

264 (20.4)

Yes

72 (80.0)

18 (20.0)

1 (1-4)

2 (1-5)

LOS (admission to discharge), days

.93

.03

Prolonged LOS (procedure-specific top quartile) No

1002 (80.4)

244 (19.6)

Yes

225 (75.0)

75 (25.0)

1110 (79.1)

293 (20.9)

117 (81.8)

26 (18.2)

.04

Discharge status Home Not home

.45

Journal of Vascular Surgery Volume

-,

Number

Gifford et al

10.e9

-

Supplementary Table II (online only). Continued. Variable

Lower quartiles, Q1-Q3 (n ¼ 1227) Top quartile, Q4 (n ¼ 319) P value

Smoking Never

251 (86.3)

40 (13.7)

Prior

701 (77.9)

199 (22.1)

Current

275 (77.5)

80 (22.5)

No

168 (76.7)

51 (23.3)

Yes

1059 (79.8)

268 (20.2)

870 (79.2)

229 (20.8)

68 (80.0)

17 (20.0)

.005

Hypertension .30

Diabetes None Diet Non-insulin medication

168 (81.6)

38 (18.4)

Insulin

121 (77.6)

35 (22.4)

.81

CAD symptoms Missing

2

0

None

762 (77.9)

History of MI but no symptoms

194 (78.5)

53 (21.5)

Stable Angina

258 (84.9)

46 (15.1)

Unstable angina/MI <6 months

.06

216 (22.1)

11 (73.3)

4 (26.7)

Prior CABG None

996 (79.0)

265 (21.0)

<5 years

61 (77.2)

18 (22.8)

$5 years

170 (82.5)

36 (17.5)

.45

Prior PCI None

937 (79.1)

247 (20.9)

<5 years

116 (81.1)

27 (18.9)

$5 years

174 (79.5)

45 (20.5)

.86

CHF Missing None

1

0

1055 (79.4)

273 (20.6)

Asymptomatic, history of CHF

59 (72.0)

23 (28.0)

Mild

68 (78.2)

19 (21.8)

Moderate

38 (95.0)

2 (5.0)

6 (75.0)

2 (25.0)

1

0

Severe

.06

COPD Missing None Not treated On medication On home oxygen

943 (78.6)

256 (21.4)

99 (81.8)

22 (18.2)

160 (82.5)

34 (17.5)

24 (77.4)

7 (22.6)

.57

Dialysis Missing No

1 1183 (79.4)

0

Functioning transplant

16 (88.9)

2 (11.1)

On dialysis

27 (71.1)

11 (28.9)

Creatinine, mg/dL

1 (0.9-1.3)

.27

306 (20.6)

1 (0.9-1.2)

.10

Stress test Missing

1

0

Not done

550 (76.2)

172 (23.8)

Normal

519 (81.3)

119 (18.7)

MI or ischemia

157 (84.9)

28 (15.1)

.009

(Continued on next page)

10.e10

Journal of Vascular Surgery

Gifford et al

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2019

Supplementary Table II (online only). Continued. Variable

Lower quartiles, Q1-Q3 (n ¼ 1227) Top quartile, Q4 (n ¼ 319) P value

Preadmission living Home Nursing home

1216 (79.2) 11 (100.0)

319 (20.8)

.13

0 (0.0)

Ambulatory statusb Missing Ambulatory

366 755 (78.5)

85

.88

207 (21.5)

Ambulatory with assistance

91 (79.1)

24 (20.9)

Wheelchair or bedridden

15 (83.3)

3 (16.7)

ASA classc Missing 1-2, normal-with mild disease 3, with severe disease 4-5, constant threat-moribund Preoperative hemoglobin, g/dL

353

97

67 (75.3)

22 (24.7)

681 (80.5)

165 (19.5)

126 (78.3)

.45

35 (21.7)

13.6 (12.4-14.7)

13.6 (12.3-14.9)

.50

No

1103 (79.0)

293 (21.0)

.29

Yes

124 (82.7)

26 (17.3)

No

1121 (79.6)

288 (20.4)

Yes

106 (77.4)

31 (22.6)

No

946 (79.6)

243 (20.4)

Yes

281 (78.7)

76 (21.3)

Prior CEA or CAS

Prior aneurysm repair .55

Prior arterial revascularization .73

Prior amputation No

1207 (79.5)

311 (20.5)

Yes

20 (71.4)

8 (28.6)

.30

Preoperative aspirin No

220 (74.8)

74 (25.2)

Yes

995 (80.8)

237 (19.2)

No for medical reason

12 (63.2)

7 (36.8)

Noncompliant

0 (0.0)

1 (100.0)

.006

Preoperative P2Y12 antagonist Missing

1

0

None

877 (80.8)

208 (19.2)

Any P2Y12 antagonist

297 (76.7)

90 (23.3)

51 (70.8)

21 (29.2)

No, for medical reason Noncompliant

1 (100.0)

.07

0 (0.0)

Preoperative statin Missing

1

0

No

249 (76.9)

75 (23.1)

Yes

948 (79.9)

238 (20.1)

No for medical reason Noncompliant

23 (79.3) 6 (100.0)

.46

6 (20.7) 0 (0.0)

Preoperative beta blockersd Missing No Preoperative 1-30 days Chronic >30 days

124 454 (75.8)

37 145 (24.2)

28 (77.8)

8 (22.2)

609 (83.1)

124 (16.9)

.009

Journal of Vascular Surgery Volume

-,

Number

Gifford et al

10.e11

-

Supplementary Table II (online only). Continued. Variable

Lower quartiles, Q1-Q3 (n ¼ 1227) Top quartile, Q4 (n ¼ 319) P value

No, for medical reason

6 (60.0)

Operation day only

5 (83.3)

Noncompliant

1 (100.0)

4 (40.0) 1 (16.7) 0 (0.0)

Preoperative ACE inhibitor or ARB No

589 (79.4)

153 (20.6)

Yes

630 (79.6)

161 (20.4)

8 (61.5)

5 (38.5)

No for medical reason

.28

Preoperative chronic anticoagulant Missing None Any anticoagulation No, for medical reason

1

0

1023 (79.2)

268 (20.8)

168 (79.6)

43 (20.4)

35 (81.4)

8 (18.6)

.94

Postoperative MIe Missing No

192 1013 (79.8)

61

.08

257 (20.2)

Troponin only

5 (83.3)

1 (16.7)

ECG or clinical

17 (100.0)

0 (0.0)

Postoperative dysrhythmiaf Missing

311

98

No

873 (80.2)

216 (19.8)

Yes

43 (89.6)

5 (10.4)

.11

Postoperative CHFf Missing No Yes

311 912 (80.5) 4 (100.0)

98

1.00

221 (19.5) 0 (0.0)

Conversion from endovascular AAA (open AAA repair only) No

42 (73.7)

15 (26.3)

Early

1 (100.0)

0 (0.0)

Late

9 (81.8)

2 (18.2)

44 (73.3)

16 (26.7)

.79

Exposure (open AAA repair only) Anterior Retroperitoneal

8 (88.9)

.44

1 (11.1)

Postoperative pneumonia or reintubationg No

529 (80.3)

130 (19.7)

Yes

14 (77.8)

4 (22.2)

No

766 (80.0)

192 (20.0)

Yes

40 (80.0)

10 (20.0)

.77

Return to OR, reoperation, or reinterventionh .99

Any in-hospital complication No

1062 (79.3)

277 (20.7)

Yes

153 (80.1)

38 (19.9)

.8

AAA, Abdominal aortic aneurysm; ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; ASA, American Society of Anesthesiologists; BMI, body mass index; CABG, coronary artery bypass grafting; CAD, coronary artery disease; CAS, carotid artery stent; CEA, carotid endarterectomy; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; ECG, electrocardiography; LOS, length of stay; MI, myocardial infarction; OR, operating room; PCI, percutaneous coronary intervention. Categorical variables are presented as number (%). Continuous variables are presented as mean (standard deviation) or median (interquartile range). a Not available in updated peripheral vascular intervention (PVI) module. b Not available in endovascular aneurysm repair (EVAR) and thoracic endovascular aortic repair (TEVAR) modules. c Not available in EVAR and updated PVI modules. d Not available in updated PVI module. e Not available in original PVI module. f Not available in PVI modules. g Open AAA repair, EVAR, suprainguinal bypass, infrainguinal bypass, and TEVAR modules only. h CEA, open AAA repair, suprainguinal bypass, and infrainguinal bypass modules only.