Hilary J. Mosher, MFA, MD

METHODS

RESULTS

DISCUSSION

CONCLUSION

METHODS

RESULTS

DISCUSSION

CONCLUSION

METHODS

RESULTS

DISCUSSION

CONCLUSION

In their study of goals of care (GOC) discussions and documentation, Wong et al. add to already robust evidence that communication, in this case from physicians caring for hospitalized patients back to long‐term care facilities, has room for improvement. They highlight that 37.5% of patients had documented discussions, and for cases in which these discussions resulted in changes to a patient's advance directive, only 1 in 4 were relayed in the discharge summary.[1]

As physicians caring for hospitalized patients and concerned with improving care quality and efficiency, many of us are familiar with potential systems solutions to augmenting communication: reminders in the electronic health record, checklists, multidisciplinary teams, scripts, and posthospitalization follow‐up phone calls. However, important as they are, these solutions often elide the underlying cognitive elements related to how we, as physicians, think about and engage in the diversity of cases presented to us, and to how we prioritize communication work.

Wong et al. looked at patient characteristics associated with performance of GOC discussions to understand when and why physicians might engage in GOC conversations in the hospital and to generate insights into potential targets for improvement. They found that characteristics of patients prior to hospital admission were not associated with GOC discussions; signs of acuity of illness were.[1] In other words, physicians in the hospital are pretty good at recognizing patients in extremis, and prioritize GOC discussions with these patients. What we are not good at, or might not be considering, is assessing the broader context of a patient's health.

Whether we interpret these results as appropriate prioritization, or as a sign that we are waiting too long to broach the subject of care goals, depends on how we conceptualize the hospital stay in the context of a patient's health story, and, by extension, the role of the hospitalist in this story. For some patients, an acute illness requiring hospitalization is unexpected and readily treated, and the patient rapidly returns to a prior level of health and function. The need for hospitalization represents an outlier state.

For other patients, often older, more debilitated, or with multiple and chronic medical conditions, minor changes in health or declines in mental, social, or physical function precipitate the need for hospitalization. Likewise, iatrogenic harms of hospitalizationsleeplessness, fasting, delirium, immobilitycan contribute to enduring decline.[2, 3] For these patients, the need for hospitalization is not so far from, or may be, their norm.[4]

I suspect that Wong et al.'s findings reflect a collective response to the uncertainties of prognostication, and the resultant discomfort in raising questions that are difficult to answer. How do we know it is time to start talking about the right amount of care? Some might answer, I think rightly, that it is rarely if ever too early, yet robust discussions are challenging if we are not sure of the relevance or the immediate goal. In the case of the patient who is ill, declining, yet not in extremis, many of us might conclude that raising the question would not produce actionable information; it would not change immediate in‐hospital management.

This common conclusion leads to a significant missed opportunity, both on an individual level for physicians and patients, and for hospital medicine as a specialty. Health, and the losses that come with declining health, are wrapped up with fundamental aspects of our identities, and take time and consideration to change and evolve. Decisions about our healthcare are statements about who we have been, who we are, and who we will no longer be. Especially for the second group of patients described above, each hospital stay affords a chance to assess, counsel, educate, support, and empower patients to move in the direction of their values, and to ready them for that eventuality when they or their loved ones are faced with decisions about how, and where, they will die. As specialists in hospital‐based healthcare, hospitalists have the privilege and professional duty to facilitate this journey.

However, as hospitalists, we are often meeting patients for the first time; how do we assimilate an understanding of that point in time within the context of a patient's life with enough confidence to engage discussions? As Wong et al. show, it appears that in regard to very ill patients, respiratory rate and Glasgow Coma Scale inform action.[1] What signs or observations help inform action earlier in the trajectory of decline, to allow for anticipatory guidance and discussion? Increasingly, we see evidence that measures of frailty and functional status, applied in the hospital, are associated with hospital outcomes including readmission and death.[5, 6, 7] Future work might explore if training physicians to systematically assess frailty and functional status leads to greater frequency of, and comfort with, initiating GOC discussions during hospitalization.

Moreover, an emphasis on evaluating frailty and function, and explicitly including this assessment in our clinical decision‐making might help shift our thinking toward valuing each hospitalization as an opportunity to both intervene to improve function[8, 9] and to support, educate, and prepare patients under our care for the journey aheadin other words, to fully engage with our role as specialists in the comprehensive and coordinated treatment of patients who require hospitalization.

In their study of goals of care (GOC) discussions and documentation, Wong et al. add to already robust evidence that communication, in this case from physicians caring for hospitalized patients back to long‐term care facilities, has room for improvement. They highlight that 37.5% of patients had documented discussions, and for cases in which these discussions resulted in changes to a patient's advance directive, only 1 in 4 were relayed in the discharge summary.[1]

As physicians caring for hospitalized patients and concerned with improving care quality and efficiency, many of us are familiar with potential systems solutions to augmenting communication: reminders in the electronic health record, checklists, multidisciplinary teams, scripts, and posthospitalization follow‐up phone calls. However, important as they are, these solutions often elide the underlying cognitive elements related to how we, as physicians, think about and engage in the diversity of cases presented to us, and to how we prioritize communication work.

Wong et al. looked at patient characteristics associated with performance of GOC discussions to understand when and why physicians might engage in GOC conversations in the hospital and to generate insights into potential targets for improvement. They found that characteristics of patients prior to hospital admission were not associated with GOC discussions; signs of acuity of illness were.[1] In other words, physicians in the hospital are pretty good at recognizing patients in extremis, and prioritize GOC discussions with these patients. What we are not good at, or might not be considering, is assessing the broader context of a patient's health.

Whether we interpret these results as appropriate prioritization, or as a sign that we are waiting too long to broach the subject of care goals, depends on how we conceptualize the hospital stay in the context of a patient's health story, and, by extension, the role of the hospitalist in this story. For some patients, an acute illness requiring hospitalization is unexpected and readily treated, and the patient rapidly returns to a prior level of health and function. The need for hospitalization represents an outlier state.

For other patients, often older, more debilitated, or with multiple and chronic medical conditions, minor changes in health or declines in mental, social, or physical function precipitate the need for hospitalization. Likewise, iatrogenic harms of hospitalizationsleeplessness, fasting, delirium, immobilitycan contribute to enduring decline.[2, 3] For these patients, the need for hospitalization is not so far from, or may be, their norm.[4]

I suspect that Wong et al.'s findings reflect a collective response to the uncertainties of prognostication, and the resultant discomfort in raising questions that are difficult to answer. How do we know it is time to start talking about the right amount of care? Some might answer, I think rightly, that it is rarely if ever too early, yet robust discussions are challenging if we are not sure of the relevance or the immediate goal. In the case of the patient who is ill, declining, yet not in extremis, many of us might conclude that raising the question would not produce actionable information; it would not change immediate in‐hospital management.

This common conclusion leads to a significant missed opportunity, both on an individual level for physicians and patients, and for hospital medicine as a specialty. Health, and the losses that come with declining health, are wrapped up with fundamental aspects of our identities, and take time and consideration to change and evolve. Decisions about our healthcare are statements about who we have been, who we are, and who we will no longer be. Especially for the second group of patients described above, each hospital stay affords a chance to assess, counsel, educate, support, and empower patients to move in the direction of their values, and to ready them for that eventuality when they or their loved ones are faced with decisions about how, and where, they will die. As specialists in hospital‐based healthcare, hospitalists have the privilege and professional duty to facilitate this journey.

However, as hospitalists, we are often meeting patients for the first time; how do we assimilate an understanding of that point in time within the context of a patient's life with enough confidence to engage discussions? As Wong et al. show, it appears that in regard to very ill patients, respiratory rate and Glasgow Coma Scale inform action.[1] What signs or observations help inform action earlier in the trajectory of decline, to allow for anticipatory guidance and discussion? Increasingly, we see evidence that measures of frailty and functional status, applied in the hospital, are associated with hospital outcomes including readmission and death.[5, 6, 7] Future work might explore if training physicians to systematically assess frailty and functional status leads to greater frequency of, and comfort with, initiating GOC discussions during hospitalization.

Moreover, an emphasis on evaluating frailty and function, and explicitly including this assessment in our clinical decision‐making might help shift our thinking toward valuing each hospitalization as an opportunity to both intervene to improve function[8, 9] and to support, educate, and prepare patients under our care for the journey aheadin other words, to fully engage with our role as specialists in the comprehensive and coordinated treatment of patients who require hospitalization.

In their study of goals of care (GOC) discussions and documentation, Wong et al. add to already robust evidence that communication, in this case from physicians caring for hospitalized patients back to long‐term care facilities, has room for improvement. They highlight that 37.5% of patients had documented discussions, and for cases in which these discussions resulted in changes to a patient's advance directive, only 1 in 4 were relayed in the discharge summary.[1]

As physicians caring for hospitalized patients and concerned with improving care quality and efficiency, many of us are familiar with potential systems solutions to augmenting communication: reminders in the electronic health record, checklists, multidisciplinary teams, scripts, and posthospitalization follow‐up phone calls. However, important as they are, these solutions often elide the underlying cognitive elements related to how we, as physicians, think about and engage in the diversity of cases presented to us, and to how we prioritize communication work.

Wong et al. looked at patient characteristics associated with performance of GOC discussions to understand when and why physicians might engage in GOC conversations in the hospital and to generate insights into potential targets for improvement. They found that characteristics of patients prior to hospital admission were not associated with GOC discussions; signs of acuity of illness were.[1] In other words, physicians in the hospital are pretty good at recognizing patients in extremis, and prioritize GOC discussions with these patients. What we are not good at, or might not be considering, is assessing the broader context of a patient's health.

Whether we interpret these results as appropriate prioritization, or as a sign that we are waiting too long to broach the subject of care goals, depends on how we conceptualize the hospital stay in the context of a patient's health story, and, by extension, the role of the hospitalist in this story. For some patients, an acute illness requiring hospitalization is unexpected and readily treated, and the patient rapidly returns to a prior level of health and function. The need for hospitalization represents an outlier state.

For other patients, often older, more debilitated, or with multiple and chronic medical conditions, minor changes in health or declines in mental, social, or physical function precipitate the need for hospitalization. Likewise, iatrogenic harms of hospitalizationsleeplessness, fasting, delirium, immobilitycan contribute to enduring decline.[2, 3] For these patients, the need for hospitalization is not so far from, or may be, their norm.[4]

I suspect that Wong et al.'s findings reflect a collective response to the uncertainties of prognostication, and the resultant discomfort in raising questions that are difficult to answer. How do we know it is time to start talking about the right amount of care? Some might answer, I think rightly, that it is rarely if ever too early, yet robust discussions are challenging if we are not sure of the relevance or the immediate goal. In the case of the patient who is ill, declining, yet not in extremis, many of us might conclude that raising the question would not produce actionable information; it would not change immediate in‐hospital management.

This common conclusion leads to a significant missed opportunity, both on an individual level for physicians and patients, and for hospital medicine as a specialty. Health, and the losses that come with declining health, are wrapped up with fundamental aspects of our identities, and take time and consideration to change and evolve. Decisions about our healthcare are statements about who we have been, who we are, and who we will no longer be. Especially for the second group of patients described above, each hospital stay affords a chance to assess, counsel, educate, support, and empower patients to move in the direction of their values, and to ready them for that eventuality when they or their loved ones are faced with decisions about how, and where, they will die. As specialists in hospital‐based healthcare, hospitalists have the privilege and professional duty to facilitate this journey.

However, as hospitalists, we are often meeting patients for the first time; how do we assimilate an understanding of that point in time within the context of a patient's life with enough confidence to engage discussions? As Wong et al. show, it appears that in regard to very ill patients, respiratory rate and Glasgow Coma Scale inform action.[1] What signs or observations help inform action earlier in the trajectory of decline, to allow for anticipatory guidance and discussion? Increasingly, we see evidence that measures of frailty and functional status, applied in the hospital, are associated with hospital outcomes including readmission and death.[5, 6, 7] Future work might explore if training physicians to systematically assess frailty and functional status leads to greater frequency of, and comfort with, initiating GOC discussions during hospitalization.

Moreover, an emphasis on evaluating frailty and function, and explicitly including this assessment in our clinical decision‐making might help shift our thinking toward valuing each hospitalization as an opportunity to both intervene to improve function[8, 9] and to support, educate, and prepare patients under our care for the journey aheadin other words, to fully engage with our role as specialists in the comprehensive and coordinated treatment of patients who require hospitalization.

Recent trends show a marked increase in outpatient use of chronic opioid therapy (COT) for chronic noncancer pain (CNCP)[1, 2] without decreases in reported CNCP,[3] raising concerns about the efficacy and risk‐to‐benefit ratio of opioids in this population.[4, 5, 6, 7, 8] Increasing rates of outpatient use likely are accompanied by increasing rates of opioid exposure among patients admitted to the hospital. To our knowledge there are no published data regarding the prevalence of COT during the months preceding hospitalization.

Opioid use has been linked to increased emergency room utilization[9, 10] and emergency hospitalization,[11] but associations between opioid use and inpatient metrics (eg, mortality, readmission) have not been explored. Furthermore, lack of knowledge about the prevalence of opioid use prior to hospitalization may impede efforts to improve inpatient pain management and satisfaction with care. Although there is reason to expect that strategies to safely and effectively treat acute pain during the inpatient stay differ between opioid‐nave patients and opioid‐exposed patients, evidence regarding treatment strategies is limited.[12, 13, 14] Opioid pain medications are associated with hospital adverse events, with both prior opioid exposure and lack of opioid use as proposed risk factors.[15] A better understanding of the prevalence and characteristics of hospitalized COT patients is fundamental to future work to achieve safer and more effective inpatient pain management.

The primary purpose of this study was to determine the prevalence of prior COT among hospitalized medical patients. Additionally, we aimed to characterize inpatients with occasional and chronic opioid therapy prior to admission in comparison to opioid‐nave inpatients, as differences between these groups may suggest directions for further investigation into the distinct needs or challenges of hospitalized opioid‐exposed patients.

METHODS

We used inpatient and outpatient administrative data from the Department of Veterans Affairs (VA) Healthcare System. The primary data source to identify acute medical admissions was the VA Patient Treatment File, a national administrative database of all inpatient admissions, including patient demographic characteristics, primary and secondary diagnoses (using International Classification of Diseases, 9th Revision, Clinical Modification [ICD‐9‐CM], codes), and hospitalization characteristics. Outpatient pharmacy data were from the VA Pharmacy Prescription Data Files. The VA Vital Status Files provided dates of death.

We identified all first acute medical admissions to 129 VA hospitals during fiscal years (FYs) 2009 to 2011 (October 2009September 2011). We defined first admissions as the initial medical hospitalization occurring following a minimum 365‐day hospitalization‐free period. Patients were required to demonstrate pharmacy use by receipt of any outpatient medication from the VA on 2 separate occasions within 270 days preceding the first admission, to avoid misclassification of patients who routinely obtained medications only from a non‐VA provider. Patients admitted from extended care facilities were excluded.

We grouped patients by opioid‐use status based on outpatient prescription records: (1) no opioid use, defined as no opioid prescriptions in the 6 months prior to hospitalization; (2) occasional opioid use, defined as patients who received any opioid prescription during the 6 months prior but did not meet definition of chronic use; and (3) chronic opioid therapy, defined as 90 or more days' supply of opioids received within 6 months preceding hospitalization. We did not specify continuous prescribing. Opioids included in the definition were codeine, dihydrocodeine, fentanyl (mucosal and topical), hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, oxymorphone, pentazocine, propoxyphene, tapentadol, and tramadol.[16, 17]

We compared groups by demographic variables including age, sex, race, income, rural vs urban residence (determined from Rural‐Urban Commuting Area codes), region based on hospital location; overall comorbidity using the Charlson Comorbidity Index (CCI);[18] and 10 selected conditions to characterize comorbidity (see Supporting Information, Appendix A, in the online version of this article). These 10 conditions were chosen based on probable associations with chronic opioid use or high prevalence among hospitalized veterans.[9, 19, 20]

We used a CNCP definition based on ICD‐9‐CM codes.[9] This definition did not include episodic conditions such as migraine[2] or a measure of pain intensity.[21] All conditions were determined from diagnoses coded during any encounter in the year prior to hospitalization, exclusive of the first (ie, index) admission. We also determined the frequency of palliative care use, defined as presence of ICD‐9‐CM code V667 during index hospitalization or within the past year. Patients with palliative care use (n=3070) were excluded from further analyses.

We compared opioid use groups by baseline characteristics using the [2] statistic to determine if the distribution was nonrandom. We used analysis of variance to compare hospital length of stay between groups. We used the [2] statistic to compare rates of 4 outcomes of interest: intensive care unit (ICU) admission during the index hospitalization, discharge disposition other than home, 30‐day readmission rate, and in‐hospital or 30‐day mortality.

To assess the association between opioid‐use status and the 4 outcomes of interest, we constructed 2 multivariable regression models; the first was adjusted only for admission diagnosis using the Clinical Classification Software (CCS),[22] and the second was adjusted for demographics, CCI, and the 10 selected comorbidities in addition to admission diagnosis.

The authors had full access to and take full responsibility for the integrity of the data. All analyses were conducted using SAS statistical software version 9.2 (SAS Institute, Cary, NC). The study was approved by the University of Iowa institutional review board and the Iowa City VA Health Care System Research and Development Committee.

RESULTS

DISCUSSION

This observational study is, to our knowledge, the first to report prevalence of and characteristics associated with prior opioid use among hospitalized medical patients. The prevalence of any opioid use and of COT was substantially higher in this hospitalized cohort than reported in outpatient settings. The prevalence of any opioid use during 1 year (FY 2009) among all veterans with VA primary care use was 26.1%.[23] A study of incident prescribing rates among veterans with new diagnoses of noncancer‐related pain demonstrated 11% received an opioid prescription within 1 year.[24] Using a definition of 90 consecutive prescription days to define COT, Dobscha et al.[25] found that 5% of veterans with persistent elevated pain intensity and no previous opioid prescriptions subsequently received COT within 12 months. The high prevalence we found likely reflects cumulative effects of incident use as well as an increased symptom burden in a population defined by need for medical hospitalization.

Although a veteran population may not be generalizable to a nonveteran setting, we do note prior studies reporting prevalence of any opioid use in outpatient cohorts (in 2000 and 2005) of between 18% and 30%, with higher rates among women and patients over 65 years of age.[1, 2]

Our work was purposefully inclusive of cancer patients so that we might assess the degree to which cancer diagnoses accounted for prior opioid use in hospitalized patients. Surprisingly, the rate of COT for patients with cancer was lower than that for patients with CNCP, perhaps reflecting that a cancer condition defined in administrative data may not constitute a pain‐causing disease.

Recognition of the prevalence of opioid therapy is important as we work to understand and improve safety, satisfaction, utilization, and long‐term health outcomes associated with hospitalization. Our finding that over half of medical inpatients have preexisting CNCP diagnoses, and a not entirely overlapping proportion has prior opioid exposure, implies a need for future work to refine expectations and strategies for inpatient management, potentially tailored to prior opioid use and presence of CNCP.

A recent Joint Commission sentinel event alert[26] highlights opioid adverse events in the hospital and identifies both lack of previous opioid therapy and prior opioid therapy as factors increasing risk. ICU admission during the hospital stay may reflect adverse events such as opioid‐induced respiratory depression; in our study, patients with no opioid use prior to admission were more likely to have an ICU stay, although the effect was small. One might speculate that clinicians, accustomed to treating pain in opioid‐exposed patients, are using inappropriately large starting dosages of narcotics for inpatients without first assessing prior opioid exposure. Another possible explanation is that patients on COT are admitted to the hospital with less severe illness, potentially reflecting functional, social, or access limitations that compromise ability to manage illness in the outpatient setting. More detailed comparison of illness severity is beyond the scope of the present work.

Patient satisfaction with pain management is reflected in 2 of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) questions, and is publically reported.[27] HCAHPS results also figure in the formula for the Centers for Medicare and Medicaid Services value‐based purchasing.[28] Preadmission pain is predictive of postoperative pain[29, 30] and may shape patient expectations; how preadmission opioid use modulates nonsurgical pain and satisfaction with management in the medical inpatient remains to be studied. The high prevalence of prior COT underscores the importance of understanding characteristics of patients on COT, and potential differences and disparities in pain management, when designing interventions to augment patient satisfaction with pain management.

Although the age distribution and patterns of comorbidities differed between the opioid‐use groups, opioid therapy remained a small but significant predictor of hospital readmission; this association was independent of CNCP diagnosis. Functional outcomes are recognized as important measures of efficacy of outpatient pain management strategies,[31] with some evidence that opioids are associated with worse functioning.[32, 33] Functional limitations, as well as inadequately or inappropriately treated pain, may drive both admissions and readmissions. Alternately, COT may be a marker for unmeasured factors that increase a patient's risk of returning to the hospital. Further work is needed to elucidate the relationship between COT and healthcare utilization associated with the inpatient stay.

Our finding that patients on COT have an increased mortality risk is concerning, given the rapid expansion in use of these medications. Although pain is increasingly prevalent toward end of life,[34] we did not observe an association between either CNCP (data not shown) or occasional opioid use and mortality. COT may complicate chronic disease through adverse drug effects including respiratory depression, apnea, or endocrine or immune alteration. Complex chronically ill patients with conditions such as COPD, HF, or diabetes may be particularly susceptible to these effects. Incident use of morphine is associated with increased mortality in acute coronary syndrome and HF[35, 36]: we are not aware of any work describing the relationship between prior opioid use and incident use during hospitalization in medical patients.

CONCLUSION

Nearly 1 in 4 hospitalized veterans has current or recent COT at the time of hospital admission for nonsurgical conditions; nearly half have been prescribed any opioids. Practitioners designing interventions to improve pain management in the inpatient setting should account for prior opioid use. Patients who are on COT prior to hospitalization differ in age and comorbidities from their counterparts who are not on COT. Further elucidation of differences between opioid‐use groups may help providers address care needs during the transition to posthospitalization care. CNCP diagnoses and chronic opioid exposure are different entities and cannot serve as proxies in administrative data. Additional work on utilization and outcomes in specific patient populations may improve our understanding of the long‐term health effects of chronic opioid therapy.

Disclosures: Dr. Mosher is supported by the Veterans Administration (VA) Quality Scholars Fellowship, Office of Academic Affiliations, Department of Veterans Affairs. Dr. Cram is supported by a K24 award from NIAMS (AR062133) at the National Institutes of Health. The preliminary results of this article were presented at the Society of General Internal Medicine Annual Meeting in Denver, Colordao, April 2013. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. Data are available to researchers with VA accreditation, the statistical code and the protocol are available to interested readers by contacting Dr. Mosher. The authors report no conflict of interest in regard to this study.

Recent trends show a marked increase in outpatient use of chronic opioid therapy (COT) for chronic noncancer pain (CNCP)[1, 2] without decreases in reported CNCP,[3] raising concerns about the efficacy and risk‐to‐benefit ratio of opioids in this population.[4, 5, 6, 7, 8] Increasing rates of outpatient use likely are accompanied by increasing rates of opioid exposure among patients admitted to the hospital. To our knowledge there are no published data regarding the prevalence of COT during the months preceding hospitalization.

Opioid use has been linked to increased emergency room utilization[9, 10] and emergency hospitalization,[11] but associations between opioid use and inpatient metrics (eg, mortality, readmission) have not been explored. Furthermore, lack of knowledge about the prevalence of opioid use prior to hospitalization may impede efforts to improve inpatient pain management and satisfaction with care. Although there is reason to expect that strategies to safely and effectively treat acute pain during the inpatient stay differ between opioid‐nave patients and opioid‐exposed patients, evidence regarding treatment strategies is limited.[12, 13, 14] Opioid pain medications are associated with hospital adverse events, with both prior opioid exposure and lack of opioid use as proposed risk factors.[15] A better understanding of the prevalence and characteristics of hospitalized COT patients is fundamental to future work to achieve safer and more effective inpatient pain management.

The primary purpose of this study was to determine the prevalence of prior COT among hospitalized medical patients. Additionally, we aimed to characterize inpatients with occasional and chronic opioid therapy prior to admission in comparison to opioid‐nave inpatients, as differences between these groups may suggest directions for further investigation into the distinct needs or challenges of hospitalized opioid‐exposed patients.

METHODS

We used inpatient and outpatient administrative data from the Department of Veterans Affairs (VA) Healthcare System. The primary data source to identify acute medical admissions was the VA Patient Treatment File, a national administrative database of all inpatient admissions, including patient demographic characteristics, primary and secondary diagnoses (using International Classification of Diseases, 9th Revision, Clinical Modification [ICD‐9‐CM], codes), and hospitalization characteristics. Outpatient pharmacy data were from the VA Pharmacy Prescription Data Files. The VA Vital Status Files provided dates of death.

We identified all first acute medical admissions to 129 VA hospitals during fiscal years (FYs) 2009 to 2011 (October 2009September 2011). We defined first admissions as the initial medical hospitalization occurring following a minimum 365‐day hospitalization‐free period. Patients were required to demonstrate pharmacy use by receipt of any outpatient medication from the VA on 2 separate occasions within 270 days preceding the first admission, to avoid misclassification of patients who routinely obtained medications only from a non‐VA provider. Patients admitted from extended care facilities were excluded.

We grouped patients by opioid‐use status based on outpatient prescription records: (1) no opioid use, defined as no opioid prescriptions in the 6 months prior to hospitalization; (2) occasional opioid use, defined as patients who received any opioid prescription during the 6 months prior but did not meet definition of chronic use; and (3) chronic opioid therapy, defined as 90 or more days' supply of opioids received within 6 months preceding hospitalization. We did not specify continuous prescribing. Opioids included in the definition were codeine, dihydrocodeine, fentanyl (mucosal and topical), hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, oxymorphone, pentazocine, propoxyphene, tapentadol, and tramadol.[16, 17]

We compared groups by demographic variables including age, sex, race, income, rural vs urban residence (determined from Rural‐Urban Commuting Area codes), region based on hospital location; overall comorbidity using the Charlson Comorbidity Index (CCI);[18] and 10 selected conditions to characterize comorbidity (see Supporting Information, Appendix A, in the online version of this article). These 10 conditions were chosen based on probable associations with chronic opioid use or high prevalence among hospitalized veterans.[9, 19, 20]

We used a CNCP definition based on ICD‐9‐CM codes.[9] This definition did not include episodic conditions such as migraine[2] or a measure of pain intensity.[21] All conditions were determined from diagnoses coded during any encounter in the year prior to hospitalization, exclusive of the first (ie, index) admission. We also determined the frequency of palliative care use, defined as presence of ICD‐9‐CM code V667 during index hospitalization or within the past year. Patients with palliative care use (n=3070) were excluded from further analyses.

We compared opioid use groups by baseline characteristics using the [2] statistic to determine if the distribution was nonrandom. We used analysis of variance to compare hospital length of stay between groups. We used the [2] statistic to compare rates of 4 outcomes of interest: intensive care unit (ICU) admission during the index hospitalization, discharge disposition other than home, 30‐day readmission rate, and in‐hospital or 30‐day mortality.

To assess the association between opioid‐use status and the 4 outcomes of interest, we constructed 2 multivariable regression models; the first was adjusted only for admission diagnosis using the Clinical Classification Software (CCS),[22] and the second was adjusted for demographics, CCI, and the 10 selected comorbidities in addition to admission diagnosis.

The authors had full access to and take full responsibility for the integrity of the data. All analyses were conducted using SAS statistical software version 9.2 (SAS Institute, Cary, NC). The study was approved by the University of Iowa institutional review board and the Iowa City VA Health Care System Research and Development Committee.

RESULTS

DISCUSSION

This observational study is, to our knowledge, the first to report prevalence of and characteristics associated with prior opioid use among hospitalized medical patients. The prevalence of any opioid use and of COT was substantially higher in this hospitalized cohort than reported in outpatient settings. The prevalence of any opioid use during 1 year (FY 2009) among all veterans with VA primary care use was 26.1%.[23] A study of incident prescribing rates among veterans with new diagnoses of noncancer‐related pain demonstrated 11% received an opioid prescription within 1 year.[24] Using a definition of 90 consecutive prescription days to define COT, Dobscha et al.[25] found that 5% of veterans with persistent elevated pain intensity and no previous opioid prescriptions subsequently received COT within 12 months. The high prevalence we found likely reflects cumulative effects of incident use as well as an increased symptom burden in a population defined by need for medical hospitalization.

Although a veteran population may not be generalizable to a nonveteran setting, we do note prior studies reporting prevalence of any opioid use in outpatient cohorts (in 2000 and 2005) of between 18% and 30%, with higher rates among women and patients over 65 years of age.[1, 2]

Our work was purposefully inclusive of cancer patients so that we might assess the degree to which cancer diagnoses accounted for prior opioid use in hospitalized patients. Surprisingly, the rate of COT for patients with cancer was lower than that for patients with CNCP, perhaps reflecting that a cancer condition defined in administrative data may not constitute a pain‐causing disease.

Recognition of the prevalence of opioid therapy is important as we work to understand and improve safety, satisfaction, utilization, and long‐term health outcomes associated with hospitalization. Our finding that over half of medical inpatients have preexisting CNCP diagnoses, and a not entirely overlapping proportion has prior opioid exposure, implies a need for future work to refine expectations and strategies for inpatient management, potentially tailored to prior opioid use and presence of CNCP.

A recent Joint Commission sentinel event alert[26] highlights opioid adverse events in the hospital and identifies both lack of previous opioid therapy and prior opioid therapy as factors increasing risk. ICU admission during the hospital stay may reflect adverse events such as opioid‐induced respiratory depression; in our study, patients with no opioid use prior to admission were more likely to have an ICU stay, although the effect was small. One might speculate that clinicians, accustomed to treating pain in opioid‐exposed patients, are using inappropriately large starting dosages of narcotics for inpatients without first assessing prior opioid exposure. Another possible explanation is that patients on COT are admitted to the hospital with less severe illness, potentially reflecting functional, social, or access limitations that compromise ability to manage illness in the outpatient setting. More detailed comparison of illness severity is beyond the scope of the present work.

Patient satisfaction with pain management is reflected in 2 of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) questions, and is publically reported.[27] HCAHPS results also figure in the formula for the Centers for Medicare and Medicaid Services value‐based purchasing.[28] Preadmission pain is predictive of postoperative pain[29, 30] and may shape patient expectations; how preadmission opioid use modulates nonsurgical pain and satisfaction with management in the medical inpatient remains to be studied. The high prevalence of prior COT underscores the importance of understanding characteristics of patients on COT, and potential differences and disparities in pain management, when designing interventions to augment patient satisfaction with pain management.

Although the age distribution and patterns of comorbidities differed between the opioid‐use groups, opioid therapy remained a small but significant predictor of hospital readmission; this association was independent of CNCP diagnosis. Functional outcomes are recognized as important measures of efficacy of outpatient pain management strategies,[31] with some evidence that opioids are associated with worse functioning.[32, 33] Functional limitations, as well as inadequately or inappropriately treated pain, may drive both admissions and readmissions. Alternately, COT may be a marker for unmeasured factors that increase a patient's risk of returning to the hospital. Further work is needed to elucidate the relationship between COT and healthcare utilization associated with the inpatient stay.

Our finding that patients on COT have an increased mortality risk is concerning, given the rapid expansion in use of these medications. Although pain is increasingly prevalent toward end of life,[34] we did not observe an association between either CNCP (data not shown) or occasional opioid use and mortality. COT may complicate chronic disease through adverse drug effects including respiratory depression, apnea, or endocrine or immune alteration. Complex chronically ill patients with conditions such as COPD, HF, or diabetes may be particularly susceptible to these effects. Incident use of morphine is associated with increased mortality in acute coronary syndrome and HF[35, 36]: we are not aware of any work describing the relationship between prior opioid use and incident use during hospitalization in medical patients.

CONCLUSION

Nearly 1 in 4 hospitalized veterans has current or recent COT at the time of hospital admission for nonsurgical conditions; nearly half have been prescribed any opioids. Practitioners designing interventions to improve pain management in the inpatient setting should account for prior opioid use. Patients who are on COT prior to hospitalization differ in age and comorbidities from their counterparts who are not on COT. Further elucidation of differences between opioid‐use groups may help providers address care needs during the transition to posthospitalization care. CNCP diagnoses and chronic opioid exposure are different entities and cannot serve as proxies in administrative data. Additional work on utilization and outcomes in specific patient populations may improve our understanding of the long‐term health effects of chronic opioid therapy.

Disclosures: Dr. Mosher is supported by the Veterans Administration (VA) Quality Scholars Fellowship, Office of Academic Affiliations, Department of Veterans Affairs. Dr. Cram is supported by a K24 award from NIAMS (AR062133) at the National Institutes of Health. The preliminary results of this article were presented at the Society of General Internal Medicine Annual Meeting in Denver, Colordao, April 2013. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. Data are available to researchers with VA accreditation, the statistical code and the protocol are available to interested readers by contacting Dr. Mosher. The authors report no conflict of interest in regard to this study.

Recent trends show a marked increase in outpatient use of chronic opioid therapy (COT) for chronic noncancer pain (CNCP)[1, 2] without decreases in reported CNCP,[3] raising concerns about the efficacy and risk‐to‐benefit ratio of opioids in this population.[4, 5, 6, 7, 8] Increasing rates of outpatient use likely are accompanied by increasing rates of opioid exposure among patients admitted to the hospital. To our knowledge there are no published data regarding the prevalence of COT during the months preceding hospitalization.

Opioid use has been linked to increased emergency room utilization[9, 10] and emergency hospitalization,[11] but associations between opioid use and inpatient metrics (eg, mortality, readmission) have not been explored. Furthermore, lack of knowledge about the prevalence of opioid use prior to hospitalization may impede efforts to improve inpatient pain management and satisfaction with care. Although there is reason to expect that strategies to safely and effectively treat acute pain during the inpatient stay differ between opioid‐nave patients and opioid‐exposed patients, evidence regarding treatment strategies is limited.[12, 13, 14] Opioid pain medications are associated with hospital adverse events, with both prior opioid exposure and lack of opioid use as proposed risk factors.[15] A better understanding of the prevalence and characteristics of hospitalized COT patients is fundamental to future work to achieve safer and more effective inpatient pain management.

The primary purpose of this study was to determine the prevalence of prior COT among hospitalized medical patients. Additionally, we aimed to characterize inpatients with occasional and chronic opioid therapy prior to admission in comparison to opioid‐nave inpatients, as differences between these groups may suggest directions for further investigation into the distinct needs or challenges of hospitalized opioid‐exposed patients.

METHODS

We used inpatient and outpatient administrative data from the Department of Veterans Affairs (VA) Healthcare System. The primary data source to identify acute medical admissions was the VA Patient Treatment File, a national administrative database of all inpatient admissions, including patient demographic characteristics, primary and secondary diagnoses (using International Classification of Diseases, 9th Revision, Clinical Modification [ICD‐9‐CM], codes), and hospitalization characteristics. Outpatient pharmacy data were from the VA Pharmacy Prescription Data Files. The VA Vital Status Files provided dates of death.

We identified all first acute medical admissions to 129 VA hospitals during fiscal years (FYs) 2009 to 2011 (October 2009September 2011). We defined first admissions as the initial medical hospitalization occurring following a minimum 365‐day hospitalization‐free period. Patients were required to demonstrate pharmacy use by receipt of any outpatient medication from the VA on 2 separate occasions within 270 days preceding the first admission, to avoid misclassification of patients who routinely obtained medications only from a non‐VA provider. Patients admitted from extended care facilities were excluded.

We grouped patients by opioid‐use status based on outpatient prescription records: (1) no opioid use, defined as no opioid prescriptions in the 6 months prior to hospitalization; (2) occasional opioid use, defined as patients who received any opioid prescription during the 6 months prior but did not meet definition of chronic use; and (3) chronic opioid therapy, defined as 90 or more days' supply of opioids received within 6 months preceding hospitalization. We did not specify continuous prescribing. Opioids included in the definition were codeine, dihydrocodeine, fentanyl (mucosal and topical), hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, oxymorphone, pentazocine, propoxyphene, tapentadol, and tramadol.[16, 17]

We compared groups by demographic variables including age, sex, race, income, rural vs urban residence (determined from Rural‐Urban Commuting Area codes), region based on hospital location; overall comorbidity using the Charlson Comorbidity Index (CCI);[18] and 10 selected conditions to characterize comorbidity (see Supporting Information, Appendix A, in the online version of this article). These 10 conditions were chosen based on probable associations with chronic opioid use or high prevalence among hospitalized veterans.[9, 19, 20]

We used a CNCP definition based on ICD‐9‐CM codes.[9] This definition did not include episodic conditions such as migraine[2] or a measure of pain intensity.[21] All conditions were determined from diagnoses coded during any encounter in the year prior to hospitalization, exclusive of the first (ie, index) admission. We also determined the frequency of palliative care use, defined as presence of ICD‐9‐CM code V667 during index hospitalization or within the past year. Patients with palliative care use (n=3070) were excluded from further analyses.

We compared opioid use groups by baseline characteristics using the [2] statistic to determine if the distribution was nonrandom. We used analysis of variance to compare hospital length of stay between groups. We used the [2] statistic to compare rates of 4 outcomes of interest: intensive care unit (ICU) admission during the index hospitalization, discharge disposition other than home, 30‐day readmission rate, and in‐hospital or 30‐day mortality.

To assess the association between opioid‐use status and the 4 outcomes of interest, we constructed 2 multivariable regression models; the first was adjusted only for admission diagnosis using the Clinical Classification Software (CCS),[22] and the second was adjusted for demographics, CCI, and the 10 selected comorbidities in addition to admission diagnosis.

The authors had full access to and take full responsibility for the integrity of the data. All analyses were conducted using SAS statistical software version 9.2 (SAS Institute, Cary, NC). The study was approved by the University of Iowa institutional review board and the Iowa City VA Health Care System Research and Development Committee.

RESULTS

DISCUSSION

This observational study is, to our knowledge, the first to report prevalence of and characteristics associated with prior opioid use among hospitalized medical patients. The prevalence of any opioid use and of COT was substantially higher in this hospitalized cohort than reported in outpatient settings. The prevalence of any opioid use during 1 year (FY 2009) among all veterans with VA primary care use was 26.1%.[23] A study of incident prescribing rates among veterans with new diagnoses of noncancer‐related pain demonstrated 11% received an opioid prescription within 1 year.[24] Using a definition of 90 consecutive prescription days to define COT, Dobscha et al.[25] found that 5% of veterans with persistent elevated pain intensity and no previous opioid prescriptions subsequently received COT within 12 months. The high prevalence we found likely reflects cumulative effects of incident use as well as an increased symptom burden in a population defined by need for medical hospitalization.

Although a veteran population may not be generalizable to a nonveteran setting, we do note prior studies reporting prevalence of any opioid use in outpatient cohorts (in 2000 and 2005) of between 18% and 30%, with higher rates among women and patients over 65 years of age.[1, 2]

Our work was purposefully inclusive of cancer patients so that we might assess the degree to which cancer diagnoses accounted for prior opioid use in hospitalized patients. Surprisingly, the rate of COT for patients with cancer was lower than that for patients with CNCP, perhaps reflecting that a cancer condition defined in administrative data may not constitute a pain‐causing disease.

Recognition of the prevalence of opioid therapy is important as we work to understand and improve safety, satisfaction, utilization, and long‐term health outcomes associated with hospitalization. Our finding that over half of medical inpatients have preexisting CNCP diagnoses, and a not entirely overlapping proportion has prior opioid exposure, implies a need for future work to refine expectations and strategies for inpatient management, potentially tailored to prior opioid use and presence of CNCP.

A recent Joint Commission sentinel event alert[26] highlights opioid adverse events in the hospital and identifies both lack of previous opioid therapy and prior opioid therapy as factors increasing risk. ICU admission during the hospital stay may reflect adverse events such as opioid‐induced respiratory depression; in our study, patients with no opioid use prior to admission were more likely to have an ICU stay, although the effect was small. One might speculate that clinicians, accustomed to treating pain in opioid‐exposed patients, are using inappropriately large starting dosages of narcotics for inpatients without first assessing prior opioid exposure. Another possible explanation is that patients on COT are admitted to the hospital with less severe illness, potentially reflecting functional, social, or access limitations that compromise ability to manage illness in the outpatient setting. More detailed comparison of illness severity is beyond the scope of the present work.

Patient satisfaction with pain management is reflected in 2 of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) questions, and is publically reported.[27] HCAHPS results also figure in the formula for the Centers for Medicare and Medicaid Services value‐based purchasing.[28] Preadmission pain is predictive of postoperative pain[29, 30] and may shape patient expectations; how preadmission opioid use modulates nonsurgical pain and satisfaction with management in the medical inpatient remains to be studied. The high prevalence of prior COT underscores the importance of understanding characteristics of patients on COT, and potential differences and disparities in pain management, when designing interventions to augment patient satisfaction with pain management.

Although the age distribution and patterns of comorbidities differed between the opioid‐use groups, opioid therapy remained a small but significant predictor of hospital readmission; this association was independent of CNCP diagnosis. Functional outcomes are recognized as important measures of efficacy of outpatient pain management strategies,[31] with some evidence that opioids are associated with worse functioning.[32, 33] Functional limitations, as well as inadequately or inappropriately treated pain, may drive both admissions and readmissions. Alternately, COT may be a marker for unmeasured factors that increase a patient's risk of returning to the hospital. Further work is needed to elucidate the relationship between COT and healthcare utilization associated with the inpatient stay.

Our finding that patients on COT have an increased mortality risk is concerning, given the rapid expansion in use of these medications. Although pain is increasingly prevalent toward end of life,[34] we did not observe an association between either CNCP (data not shown) or occasional opioid use and mortality. COT may complicate chronic disease through adverse drug effects including respiratory depression, apnea, or endocrine or immune alteration. Complex chronically ill patients with conditions such as COPD, HF, or diabetes may be particularly susceptible to these effects. Incident use of morphine is associated with increased mortality in acute coronary syndrome and HF[35, 36]: we are not aware of any work describing the relationship between prior opioid use and incident use during hospitalization in medical patients.

CONCLUSION

Nearly 1 in 4 hospitalized veterans has current or recent COT at the time of hospital admission for nonsurgical conditions; nearly half have been prescribed any opioids. Practitioners designing interventions to improve pain management in the inpatient setting should account for prior opioid use. Patients who are on COT prior to hospitalization differ in age and comorbidities from their counterparts who are not on COT. Further elucidation of differences between opioid‐use groups may help providers address care needs during the transition to posthospitalization care. CNCP diagnoses and chronic opioid exposure are different entities and cannot serve as proxies in administrative data. Additional work on utilization and outcomes in specific patient populations may improve our understanding of the long‐term health effects of chronic opioid therapy.

Disclosures: Dr. Mosher is supported by the Veterans Administration (VA) Quality Scholars Fellowship, Office of Academic Affiliations, Department of Veterans Affairs. Dr. Cram is supported by a K24 award from NIAMS (AR062133) at the National Institutes of Health. The preliminary results of this article were presented at the Society of General Internal Medicine Annual Meeting in Denver, Colordao, April 2013. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. Data are available to researchers with VA accreditation, the statistical code and the protocol are available to interested readers by contacting Dr. Mosher. The authors report no conflict of interest in regard to this study.