Open AccessComorbid Insomnia and Sleep Apnea are Associated with Greater Downstream Health Care Utilization and Chronic Opioid Use after Arthroscopic Hip Surgery
Author(s) -
Daniel I. Rhon,
Suzanne J. Snodgrass,
Joshua A. Cleland,
Chad Cook
Publication year - 2019
Publication title -
pain physician
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.31
H-Index - 99
eISSN - 2150-1149
pISSN - 1533-3159
DOI - 10.36076/ppj/2019.22.e351
Subject(s) - medicine , sleep apnea , insomnia , obstructive sleep apnea , retrospective cohort study , diagnosis code , logistic regression , physical therapy , cohort , opioid , emergency medicine , psychiatry , population , receptor , environmental health
Background: There is a relationship between sleep, pain, and chronic opioid utilization. Thishas been poorly explored in general, and especially in patients undergoing orthopaedic surgery.Fewer studies have investigated this relationship based on a sleep diagnosis present both beforeand after surgery.Objectives: To identify the association between insomnia and sleep apnea and downstreamopioid use and medical utilization (visits and cost) in the 2 years following arthroscopic hip surgery.Study Design: A retrospective cohort.Setting: The US Military Health System.Methods: This was a consecutive cohort of individuals undergoing hip arthroscopy in the MilitaryHealth System (MHS). Medical utilization data were abstracted from the MHS Data Repositorybetween 2003 and 2015, representing 1 year prior and 2 years after surgery for every individual.Sleep disorder diagnoses (insomnia and sleep apnea) were identified using International Classificationof Disease codes, and opioid utilization was determined from pharmacy data based on AmericanHospital Formulary Service codes 280808 and 280812. Sleep disorders present before surgery wereused as predictors in multivariate logistic regression, and sleep disorders present after surgery wereexamined for associations with the outcomes using the Chi-square tests. The dependent variables inboth cases were downstream medical utilization (costs, visits, and opioid use).Results: Of 1870 eligible patients (mean age 32.3 years; 44.5% women), 165 (8.8%) had a diagnosisof insomnia before surgery and 333 (17.8%) after surgery; whereas 93 (5.0%) had a diagnosis of apneabefore surgery and 268 (14.3%) after surgery. A diagnosis of insomnia before surgery predicted havingat least 3+ opioids prescriptions after surgery (adjusted odds ratio, 1.97 [95% confidence interval, 1.39,2.79]) and greater downstream total medical visits and costs in the 2 years after surgery. However, thenumber of individuals with a diagnosis of insomnia or apnea after surgery more than doubled, andwas significantly associated with chronic opioid use, all-cause medical and all hip-related medicaldownstream visits and costs in the 2 years after surgery.Limitations: The use of observational data and claims data are only as good as how it was entered.Conclusions: Sleep disorders prior to surgery predicted chronic opioid use and medical utilizationafter surgery. However, a much higher rate of individuals had sleep apnea and insomnia presentafter surgery, which were significantly associated with chronic opioid use and greater total andhip-related medical utilization (visits and costs). Screening for sleep disorders prior to surgery maybe important, but an even higher rate of sleep disorders may be developed after surgery, andcontinued screening after surgery may have greater clinical merit. Assessing quality of sleep duringperioperative management may provide a unique opportunity to decrease pain and chronic opioiduse after surgery.Key words: Pain, opioid use, insomnia, sleep apnea, orthopaedic surgery, military medicine,health care utilizationPain Physician 2019