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Original Investigation
Association of VA Surgeons
December 5, 2018

Trends and Outcomes of Cardiovascular Surgery in Patients With Opioid Use Disorders

Author Affiliations
  • 1Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
  • 2Department of Population and Quantitative Health Sciences, Population Health and Outcomes Research Core, Case Western Reserve University School of Medicine, Cleveland, Ohio
JAMA Surg. Published online December 5, 2018. doi:10.1001/jamasurg.2018.4608
Key Points

Question  What are the associations of opioid use disorder (OUD) with outcomes of cardiovascular surgery?

Findings  In this US nationwide cohort study of 5 718 552 cardiac surgery patients, compared with patients without OUD, there was no significant difference in mortality among patients with OUD, although they had a higher number of complications overall (67.6% vs 59.2%).

Meaning  Cardiac surgery in patients with OUD is safe, but it is associated with higher complications and resource utilization.

Abstract

Importance  Persistent opioid use is currently a major health care crisis. There is a lack of knowledge regarding its prevalence and effect among patients undergoing cardiac surgery.

Objective  To characterize the national population of cardiac surgery patients with opioid use disorder (OUD) and compare outcomes with the cardiac surgery population without OUD.

Design, Setting, and Participants  In this retrospective population-based cohort study, more than 5.7 million adult patients who underwent cardiac surgery (ie, coronary artery bypass graft, valve surgery, or aortic surgery) in the United States were included. Pregnant patients were excluded. Propensity matching was performed to compare outcomes between cardiac surgery patients with OUD (n = 11 359) and without OUD (n = 5 707 193). The Nationwide Inpatient Sample database was queried from January 1998 to December 2013. Data were analyzed in January 2018.

Exposures  Persistent opioid use and/or dependence.

Main Outcomes and Measures  In-hospital mortality, complications, length of stay, costs, and discharge disposition.

Results  Among the 5 718 552 included patients, 3 887 097 (68.0%) were male; the mean (SD) age of patients with OUD was 47.67 (13.03) years and of patients without OUD was 65.53 (26.14) years. The prevalence of OUD among cardiac surgery patients was 0.2% (n = 11 359), with an 8-fold increase over 15 years (0.06% [262 of 437 641] in 1998 vs 0.54% [1425 of 263 930] in 2013; difference, 0.48%; 95% CI of difference, 0.45-0.51; P < .001). Compared with patients without OUD, patients with OUD were younger (mean [SD] age, 48 [0.30] years vs 66 [0.05] years; P < .001) and more often male (70.8% vs 68.0%; P < .001), black (13.7% vs 4.8%), or Hispanic (9.1% vs 4.8%). Patients with OUD more commonly fell in the first quartile of median income (30.7% vs 17.1%; P < .001) and were more likely to be uninsured or Medicaid beneficiaries (48.6% vs 7.7%; P < .001). Valve and aortic operations were more commonly performed among patients with OUD (49.8% vs 16.4%; P < .001). Among propensity-matched pairs, the mortality was similar between patients with vs without OUD (3.1% vs 4.0%; P = .12), but cardiac surgery patients with OUD had an overall higher incidence of major complications (67.6% vs 59.2%; P < .001). Specifically, the risks of blood transfusion (30.4% vs 25.9%; P = .002), pulmonary embolism (7.3% vs 3.8%; P < .001), mechanical ventilation (18.4% vs 15.7%; P = .02), and prolonged postoperative pain (2.0% vs 1.2%; P = .048) were significantly higher. Patients with OUD also had a significantly longer length of stay (median [SE], 11 [0.30] vs 10 [0.22] days; P < .001) and cost significantly more per patient (median [SE], $49 790 [1059] vs $45 216 [732]; P < .001).

Conclusions and Relevance  The population of patients with persistent opioid use or opioid dependency undergoing cardiac surgery has increased over the past decade. Cardiac surgery in patients with OUD is safe but is associated with higher complications and cost. Patients should not be denied surgery because of OUD status but should be carefully monitored postoperatively for complications.

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