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Original Contribution  |   July 2019
Comparison of Lumbar Fusion for Back Pain and Opioid Use at County and Managed Care Hospitals
Author Notes
  • From the Department of Neurosurgery at Riverside University Health System in Moreno Valley, California (Drs Ghanchi, Miulli, Kashyap, Toor, Farr, Ray, and Sweiss); the Department of Neurosurgery at Arrowhead Regional Medical Center in Colton, California (Drs Miulli and Beamer); the Department of Neurosurgery at Kaiser Permanente Medical Center in Fontana, California (Dr Rao); and the College of Pharmacy at the University of Florida in Orlando (Dr Ashraf). 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Hammad Ghanchi, DO, MSc, Riverside University Health System, Neurological Surgery Residency Program, 26520 Cactus Ave, Moreno Valley, CA 92555-3927. Email: h.ghanchi@ruhealth.org
     
Article Information
Pain Management/Palliative Care / Opioids
Original Contribution   |   July 2019
Comparison of Lumbar Fusion for Back Pain and Opioid Use at County and Managed Care Hospitals
The Journal of the American Osteopathic Association, July 2019, Vol. 119, 419-427. doi:https://doi.org/10.7556/jaoa.2019.078
The Journal of the American Osteopathic Association, July 2019, Vol. 119, 419-427. doi:https://doi.org/10.7556/jaoa.2019.078
Abstract

Context: Opioids may be prescribed for the short-term management of acute-onset back pain in the setting of trauma or for long-term management of chronic back pain. More than 50% of regular opioid users report taking them for back pain.

Objective: To investigate whether surgical intervention reduces opioid requirements by patients taking opioids for back pain and whether there is a difference between county and managed care hospitals in this postoperative reduction of opioid requirement.

Methods: A retrospective medical record review of 118 patients who underwent elective lumbar fusion at 4 hospitals (2 county hospitals and 2 managed care hospitals) was conducted. Opioid requirements before and after surgical intervention and at the 30-day outpatient follow-up were evaluated.

Results: Forty medical records were included in the study. An overall decrease in opioid use was found in the postoperative follow-up phase after lumbar fusion in both the county and managed care hospitals. This reduction was statistically significant at 3 of 4 hospitals (P<0.01). When the data were pooled by facility type, the significance remained for county facilities (P<.01) but not managed care facilities (P=.18). Moreover, there was a significant decrease in opioid use during the postoperative inpatient phase for county compared with managed care facilities (P=.0427). The pain rating reported by patients during the hospital stay was significantly higher at county compared with managed care hospitals (P=.0088); however, the difference at discharge was not significant (P=.14).

Conclusion: Our study indicates that lumbar fusion is associated with a significant decrease in opioid use (P<.05) compared with nonsurgical management. Overall, the difference in decreased opioid use between county and managed care hospitals after lumbar fusion was not significant.

Back pain is a major contributor to the opioid crisis; more than 50% of patients with chronic pain cite back pain as one of their reasons for starting opioid therapy.1-3 Opioids may be prescribed for the short-term management of acute-onset back pain in the setting of trauma or for long-term management of chronic back pain. 
Opioid use and abuse has been exponentially increasing in the United States since 2000.4 A Centers for Disease Control and Prevention (CDC) review of drug-related deaths and overdoses from 2000-2014 found that the death rate from all drug overdoses increased by 137% and the rate of opioid-related deaths increased by over 200%.4 By 2016, the number of opioid-related deaths was 5 times higher than it was in 2000.5 In October 2017, the United States declared the opioid epidemic a national public health emergency. 
Back pain can be stratified into acute, subacute, and chronic.6 Patients with acute and subacute back pain may benefit from short-term opioid therapy; however, patients with chronic back pain and radicular symptoms for more than 16 weeks7 may need longer-term opioid therapy. The purpose of the current study was to evaluate whether surgical intervention for chronic back pain and radicular pain can reduce opioid use and whether surgical intervention has an effect on opioid use at a county vs managed care hospital. 
Methods
Four hospitals (2 county and 2 managed care) were enrolled in this retrospective review of a prospectively collected database. Patient medical records from 2016 to 2017 were reviewed from each hospital during 2017. Authorization was obtained from the institutional review board of each hospital. Inclusion criteria were age 18 years or older and elective lumbar fusion for degenerative back and radicular pain lasting more than 16 weeks. Levels fused were defined as the number of disc spaces traversed by the surgery, eg, fusion of L4 and L5 was defined as 1 level fused. Patients who required fusions because of traumatic injuries to the spine and patients taking opioids for other causes were excluded. Patients with chronic pain conditions that affected the nonaxial skeleton, such as fibromyalgia, rheumatoid arthritis, complex regional pain syndrome, and gout, and patients with previous back operations were also excluded. 
The average daily preoperative opioid use was calculated on the basis of patient-reported opioid medication use or the prescriptions written in the medical record by the primary care or pain management physicians and further verified using the Controlled Substance Utilization Review and Evaluation System (CURES) database to ensure that no other sources of opioid medications were found. Pain medication use in the postoperative inpatient phase was retrieved using the medication administration record. An average of the daily reported pain was also assessed; the perioperative pain rating was evaluated on the 1 to 10 Numeric Pain Rating Scale from the electronic medical record. The patients’ opioid use at their initial 15- to 30-day postoperative outpatient follow-up was assessed on the basis of patient-reported pain rating, prescriptions written on hospital discharge, and patient report of medication use. 
All opioid use was converted to oral morphine milligram equivalents (MMEs)8 for data analysis and direct comparison of the various opioid medications. All patient data were stratified by hospital for initial t test analysis. Next, the 2 county hospitals and the 2 managed care hospitals were pooled and compared for differences in opioid use to assess for any socioeconomic differences. Additional factors such as nonopioid therapies, number of levels being fused, and hospital length of stay were also reviewed. 
Significant values were defined as P<.05. Our primary end point was to determine whether lumbar fusion had a positive or negative effect on opioid use. As a secondary end point, we sought to compare the similarities and differences between the 2 patient populations of county (uninsured or underinsured) and managed care (insured) patients. 
Results
A total of 118 patient records met the inclusion criteria.The 10 most recent patients from each hospital who met the enrollment criteria were selected. A post-hoc power analysis determined that 10 medical records from each hospital (N=40) yielded a sufficiently powered study (0.8) given the differences in preoperative and postoperative opioid use among all groups. Table 1 presents the patient demographics for the 4 hospitals studied. The ages ranged from 26 to 91 years. No significant difference in age was found among the 4 hospitals. The sex of the patients was also not significantly different. Therefore, data were noted to be homogenous between the hospitals in terms of patient age and sex. County hospitals fused statistically significant more levels than managed care hospitals. Therefore, the levels fused did not correlate directly with pain reported (P=.0415). 
Table 1.
Demographics of Patients Who Underwent Elective Lumbar Fusion for Pain Management of Degenerative Disease in Different Hospitals (N=40)
County Hospital Managed Care Hospital
Characteristic A (n=10) B (n=10) A (n=10) B (n=10)
Age, y, range 34-79 26-75 37-91 35-88
 Mean 66.2 65.6 67.1 69.4
 Median 56 53 65 62
Sex  
 Male 6 7 5 4
 Female 4 3 5 6
Levels Fused 2.4 2.1 1.3 1.2
Table 1.
Demographics of Patients Who Underwent Elective Lumbar Fusion for Pain Management of Degenerative Disease in Different Hospitals (N=40)
County Hospital Managed Care Hospital
Characteristic A (n=10) B (n=10) A (n=10) B (n=10)
Age, y, range 34-79 26-75 37-91 35-88
 Mean 66.2 65.6 67.1 69.4
 Median 56 53 65 62
Sex  
 Male 6 7 5 4
 Female 4 3 5 6
Levels Fused 2.4 2.1 1.3 1.2
×
Our results demonstrated an 8% to 51.9% reduction in opioid use in the postoperative outpatient period among all hospitals when compared with the preoperative phase (Table 2). This result was statistically significance at 3 of the 4 hospitals studied. County hospital A and B both reached significance (P<.01); moreover, when these data were pooled together, this significance was maintained (P=.003). Managed care hospital A demonstrated a 36.3% reduction in opioid use in the postoperative phase (P=.0027); however, managed care hospital B demonstrated only an 8% reduction and did not reach significance (P=.28). When the 2 managed care hospitals were pooled together, the data demonstrated a reduction that did not reach statistical significance (P=.18). 
Table 2.
Pain Management of Patients Who Underwent Elective Lumbar Fusion for Degenerative Disease (N=40)
Hospital Type Mean Preoperative Daily MME Mean Postoperative Daily Inpatient MME Mean Postoperative Daily Outpatient MME Pre- to Postoperative Reduction in MME P Value
County Hospital
 A 48.23 60.26 23.20 25.03 .0005
 B 43.00 48.62 30.50 12.50 .0035
 Combined 45.62 54.44 26.85 18.77 .0034
Managed Care Hospital
 A 40.00 64.89 25.50 14.50 .0027
 B 88.00 142.97 81.00 7.00 .2819
 Combined 64.00 103.93 53.25 10.75 .1803
County vs Managed Care Hospital  NA NA NA NA .1605

Abbreviations: MME, morphine milligram equivalent; NA, not applicable.

Table 2.
Pain Management of Patients Who Underwent Elective Lumbar Fusion for Degenerative Disease (N=40)
Hospital Type Mean Preoperative Daily MME Mean Postoperative Daily Inpatient MME Mean Postoperative Daily Outpatient MME Pre- to Postoperative Reduction in MME P Value
County Hospital
 A 48.23 60.26 23.20 25.03 .0005
 B 43.00 48.62 30.50 12.50 .0035
 Combined 45.62 54.44 26.85 18.77 .0034
Managed Care Hospital
 A 40.00 64.89 25.50 14.50 .0027
 B 88.00 142.97 81.00 7.00 .2819
 Combined 64.00 103.93 53.25 10.75 .1803
County vs Managed Care Hospital  NA NA NA NA .1605

Abbreviations: MME, morphine milligram equivalent; NA, not applicable.

×
The number of opioids (different formulations) being taken by patients preoperatively ranged from 1 to 3, with a mean of 1.03 at county and 1.1 at managed care hospitals (Table 3). The mean daily preoperative MMEs were similar at county A (48.23), county B (43), and managed care A (40) hospitals, but the MME was significantly higher at managed care B hospital (88). When reviewing the postoperative inpatient MME, a similar finding was noted, with the former 3 hospitals having a similar range of values of mean daily MME (60, 49, 65, respectively) and the latter hospital having almost double the value (143) (Table 3). The pooled values of county vs managed care for this variable was also 91% higher in the managed care setting (54 vs 104). 
Table 3.
Pain Management of Patients Who Underwent Elective Lumbar Fusion for Degenerative Disease by Hospital Type: Preoperative vs Postoperative Detailed (N=40)
County Hospital Managed Care Hospital
Variable A B A B County Hospital Total Managed Care Hospital Total
Preoperative
 No. opioid prescriptions,  mean 1.27 0.8 1 1.2 1.03 1.1
 Daily MME, mean (range) 48.23 (0-110) 43
(30-60)
40
(20-60)
88
(60-150)
45.62 64
 Daily MME, median 60 40 35 80 NA NA
Operative
 Mean No. levels fused 2.4 2.1 1.3 1.2 2.25 1.25
Postoperative
 Total inpatient MME 327.17 248.90 237.70 605.60 288.03 421.65
 No. inpatient days, mean 5 5 3.4 4.2 5 3.8
 Inpatient daily MME, mean 60.26 48.62 64.89 142.97 54.44 103.93
 Follow-up daily MME, mean (range) 23.20
(0-60)
30.50
(0-60)
25.50
(5-50)
81.00
(30-150)
26.85 53.25
 Follow-up daily MME, median 20 30 25 75 NA NA

Abbreviations: MME, morphine milligram equivalent; NA, not applicable.

Table 3.
Pain Management of Patients Who Underwent Elective Lumbar Fusion for Degenerative Disease by Hospital Type: Preoperative vs Postoperative Detailed (N=40)
County Hospital Managed Care Hospital
Variable A B A B County Hospital Total Managed Care Hospital Total
Preoperative
 No. opioid prescriptions,  mean 1.27 0.8 1 1.2 1.03 1.1
 Daily MME, mean (range) 48.23 (0-110) 43
(30-60)
40
(20-60)
88
(60-150)
45.62 64
 Daily MME, median 60 40 35 80 NA NA
Operative
 Mean No. levels fused 2.4 2.1 1.3 1.2 2.25 1.25
Postoperative
 Total inpatient MME 327.17 248.90 237.70 605.60 288.03 421.65
 No. inpatient days, mean 5 5 3.4 4.2 5 3.8
 Inpatient daily MME, mean 60.26 48.62 64.89 142.97 54.44 103.93
 Follow-up daily MME, mean (range) 23.20
(0-60)
30.50
(0-60)
25.50
(5-50)
81.00
(30-150)
26.85 53.25
 Follow-up daily MME, median 20 30 25 75 NA NA

Abbreviations: MME, morphine milligram equivalent; NA, not applicable.

×
Table 4 presents the Numeric Pain Rating Scale ratings reported by the patients in the preoperative phase and on the day of discharge from the hospital. The mean pain score reported by patients during the inpatient phase was also recorded and was found to be similar at county (7.75) and managed care (6.77) hospitals. Moreover, the difference between preoperative pain and pain on day of discharge was noted to be 2.3 points lower at county hospitals and 4.3 points lower at managed care hospitals. 
Table 4.
Pain Management of Patients Who Underwent Elective Lumbar Fusion for Degenerative Disease by Hospital Type: Patient Pain Scalesa (N=40)
County Hospital Managed Care Hospital Combined
Scale Item A (n=10) B (n=10) A (n=10) B (n=10) County Hospital Managed Care Hospital
Mean preoperative pain 9.07 8.60 9.20 8.40 8.84 8.80
Mean postoperative pain 8.06 7.45 7.11 6.43 7.75 6.77
Discharge pain 7.27 5.80 5.60 3.40 6.53 4.50
Difference 1.80 2.80 3.60 5.00 2.30 4.30

a Pain was assessed using the Numeric Pain Rating Scale (0 [no pain at all] to 10 [worst imaginable pain]).

Table 4.
Pain Management of Patients Who Underwent Elective Lumbar Fusion for Degenerative Disease by Hospital Type: Patient Pain Scalesa (N=40)
County Hospital Managed Care Hospital Combined
Scale Item A (n=10) B (n=10) A (n=10) B (n=10) County Hospital Managed Care Hospital
Mean preoperative pain 9.07 8.60 9.20 8.40 8.84 8.80
Mean postoperative pain 8.06 7.45 7.11 6.43 7.75 6.77
Discharge pain 7.27 5.80 5.60 3.40 6.53 4.50
Difference 1.80 2.80 3.60 5.00 2.30 4.30

a Pain was assessed using the Numeric Pain Rating Scale (0 [no pain at all] to 10 [worst imaginable pain]).

×
Furthermore, the reduction in MME when comparing daily MME use during the inpatient setting with the postoperative outpatient follow-up visit (Table 3) was 27.59 MME (51%) at county hospitals (54.44-26.85; 95% CI, 27.09-28.08) and 50.68 MME (52%) at managed care hospitals (103.93-53.25; 95% CI, 45.84-55.51). The reduction from preoperative MME use to postoperative MME use at outpatient follow-up was 18.77 MME (42%) at county hospitals (45.62-26.85; 95% CI, 26.41-27.28) and 10.75 MME (20%) at managed care hospitals (64-53.25; 95% CI, 5.92-15.58). 
The average number of inpatient days (Table 3) was 5 at county hospitals and 3.8 at the managed care hospitals. The number of levels fused was also higher at county (2.25) vs managed care (1.25) hospitals. 
The difference in reduction in opioid use for pooled cohorts of both county and managed care hospitals were analyzed (Table 5; P=.16). The difference between the 2 hospitals when analyzing the inpatient use of opioids was significant (P=.0427). Moreover, when comparing the patient-reported pain during this inpatient phase, a significant difference was found (P=.0088), with managed care patients reporting less pain during their hospital stay than county patients. However, no significant difference was found in the pain reported by patients on the day of discharge (P=.1455). 
Table 5.
Pain Management of Patients Who Underwent Elective Lumbar Fusion for Degenerative Disease: Comparison Between Pooled Cohorts of County and Managed Care Patients (N=40)
County vs Managed Care Hospitals P Value
Preoperative MME vs postoperative MME .1605
Inpatient postoperative MME dosage levels .0427
Mean inpatient pain rating .0088
Mean pain rating at discharge .1455

Abbreviation: MME, morphine milligram equivalent.

Table 5.
Pain Management of Patients Who Underwent Elective Lumbar Fusion for Degenerative Disease: Comparison Between Pooled Cohorts of County and Managed Care Patients (N=40)
County vs Managed Care Hospitals P Value
Preoperative MME vs postoperative MME .1605
Inpatient postoperative MME dosage levels .0427
Mean inpatient pain rating .0088
Mean pain rating at discharge .1455

Abbreviation: MME, morphine milligram equivalent.

×
Discussion
Back and radicular pain are multifaceted, and an appropriate workup needs to be completed to determine whether a patient is an appropriate surgical candidate. When patients initially present with back pain, a detailed history and physical examination should be completed to assess for possible causes. If anatomical injury to the spine is suspected, computed tomographic imaging can be used to assess for bony pathologic changes or magnetic resonance imaging for compression of neural elements. In many cases, conservative care in the form of anti-inflammatory analgesics, physical therapy, and bracing are sufficient.6,9,10 However, if a patient does not respond to conservative treatments or begins to demonstrate signs of neurologic deficits, surgical consultation should be sought. 
Our retrospective dataset consisted of all patients undergoing elective lumbar fusion for back and radicular pain with symptoms lasting greater than 16 weeks. Contrary to the belief that surgical procedures can increase pain medication requirements, our study demonstrates that surgical intervention can play a crucial role in reducing the level of opioid use for degenerative disease of the lumbar spine. While opioid requirements, measured in MME, increased in the acute postoperative phase at all hospitals as expected, they tapered down to below preoperative requirements at outpatient follow-up, between 14 and 30 days postoperatively. 
Our primary end point was to determine whether surgery had a positive or negative effect on opioid use. The use of opioid medication decreased at all 4 hospitals (Figure) and was statistically significant at 3 of the 4 hospitals. Our secondary end point was to compare the socioeconomic differences between county and managed care populations. In a pooled data analysis comparing opioid use by hospital type—county vs managed care—the county hospitals maintained a statistically significant reduction in opioid requirements in the outpatient postoperative phase compared with the managed care hospitals (Table 2). Multiple factors may have influenced this finding; increased preoperative opioid use and dose in managed care patients may have been related to prolonged conservative management. Most patients in a managed care setting have easier access to health care and are given a protocol-driven treatment regimen. The initial pain improvement with conservative treatment, often due to opioid use, may delay surgical referrals—a study11 of total knee replacements found that 54% of patients delayed surgical intervention by 2 years secondary to opioid use. Similar findings may be seen in patients with back pain who may opt to postpone spine surgery; long-term nonsurgical management can lead to opioid tolerance and dependence.12 
Figure.
Daily opioid use by patients undergoing lumbar fusion for back pain indicated by mean morphine milligram equivalent (MME).
Figure.
Daily opioid use by patients undergoing lumbar fusion for back pain indicated by mean morphine milligram equivalent (MME).
The statistically significant difference (P=.0427) in opioid use during the postoperative inpatient phase (Table 5) between county and managed care hospitals may have been related to patient satisfaction ratings.13-15 These hospital ratings based on patient satisfaction scores, although subjective, affect reimbursement rates15,16; private insurers are adopting such policies.14,15 The increased use of opioids in the managed care hospitals can likely be explained by the hospitals’ aim to make patients happier through treating postoperative pain more aggressively with opioid medication rather than nonopioid alternatives. The added benefit of opioid-induced euphoria may serve as a secondary bonus for higher patient satisfactory scores. This area needs further study, but a health care system driven by patient satisfaction may be putting patients at increased risk for opioid addiction. 
The average number of vertebrae fused at each hospital was similar, ranging from 1.2 to 2.4 (Table 3). The difference was not substantial but was approximately 1 level greater at the county hospitals. The addition of a fusion level leads to a larger incision and may explain the increase in average number of inpatient days as well as increased pain reported by patients at the county compared with the managed care hospitals. Given a larger number of levels fused at the county hospitals, one would expect an increased use of pain medications in the acute inpatient postoperative phase. However, the contrary was found. Another confounding factor that could have contributed to length of stay, particularly in the county hospitals, is the difficulty with disposition in those who may require rehabilitation services. 
Another factor to be cognizant of is the use of nonopioid medications as adjuvant therapy for pain control. There were a variety of muscle relaxers and anti-inflammatory medications used in the postoperative phase; these medications varied to a slight degree among our patients and was dependent on the hospitals’ formulary and surgeon preference. Future studies may be done to monitor and standardize these medications and find optimal combinations that may work better than others. Many surgeons are cautious to use certain nonsteroidal anti-inflammatory drugs (NSAIDs) because of their antiplatelet effects, which can cause postoperative hematomas; furthermore, their anti-inflammatory properties can inhibit bony fusion.17 At county hospital A, all patients were receiving a continuous infusion of ketorolac tromethamine (120 mg at 10 mL/hour for 50 hours) in the immediate postoperative phase. This hospital also had the greatest reduction in opioid use of the 4 hospitals studied. Although the data for NSAID use in the immediate postoperative phase is controversial,17-19 our data show that NSAIDs may limit opioid use and therefore can be considered in the immediate postoperative period when excessive bleeding is not an issue. Icing, manipulation, and early mobilization have also been shown to be effective for managing low back pain.9 
The differences in opioid use between the county and managed care hospital patients studied highlights an important difference in the access to appropriate management of back pain. From this perspective, patients in a county hospital system seemingly are at a disadvantage because of the limited resources and availability for specialty care at county facilities. However, our data appear to support a more conservative approach to opioid use in the management of back pain vs the current approach used by managed care hospitals. The nonopioid medications used before and after an operation seem to have contributed a significant positive effect in reducing opioid use and should be further studied to replicate this finding. 
Limitations
A limiting factor in this study is the patients’ self-reporting of preoperative and outpatient postoperative pain medication use. We used data from the prescriptions given to the patients and their reported medication use to gather these data, and the data were confirmed using the CURES database to ensure that no other opioid prescriptions had been written. Opioid use was strictly monitored during the inpatient phase using the medication administration record; however, this information was not available in the outpatient phases of this study given its retrospective nature. In future studies, a stricter regimen may be formulated for a prospective trial so that this information can be kept in a medication administration record. Moreover, the possibility of patients using unprescribed opioid medications or recreational drugs during the outpatient phases of this study was unable to be regulated. 
Another limiting factor was the use of various nonopioid medications. Given that multiple hospitals were involved and that this was a retrospective study, we were unable to ensure that all patients received the same adjuvant therapies. In future studies, we hope to standardize the adjuvant medications so that any potential synergistic analgesic effects can be standardized. 
In addition, the opioids used in this study were varied; we attempted to rectify this factor by converting all of the medications to oral MMEs. However, the quality of the opioids used and the possibility that some formulations were combined with acetaminophen may have affected their analgesic effects. A related confounding variable was the lack of information with regard to the duration of opioid therapy before the operation. A longer duration of therapy may make it more difficult to wean patients off opioids. Given that this was a retrospective medical record review, we were unable to ascertain this variable. 
Conclusion
The present study demonstrated a significant reduction in opioid use in the postoperative phase independent of socioeconomic status. Overall, selected patients in both county and managed care systems may benefit from early identification of spine disease to decrease opioid use. A prospective study is needed. We hope that our preliminary data offer other researchers a chance to replicate or build on our efforts. 
Author Contributions
All authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; all authors drafted the article or revised it critically for important intellectual content; all authors gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. 
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Figure.
Daily opioid use by patients undergoing lumbar fusion for back pain indicated by mean morphine milligram equivalent (MME).
Figure.
Daily opioid use by patients undergoing lumbar fusion for back pain indicated by mean morphine milligram equivalent (MME).
Table 1.
Demographics of Patients Who Underwent Elective Lumbar Fusion for Pain Management of Degenerative Disease in Different Hospitals (N=40)
County Hospital Managed Care Hospital
Characteristic A (n=10) B (n=10) A (n=10) B (n=10)
Age, y, range 34-79 26-75 37-91 35-88
 Mean 66.2 65.6 67.1 69.4
 Median 56 53 65 62
Sex  
 Male 6 7 5 4
 Female 4 3 5 6
Levels Fused 2.4 2.1 1.3 1.2
Table 1.
Demographics of Patients Who Underwent Elective Lumbar Fusion for Pain Management of Degenerative Disease in Different Hospitals (N=40)
County Hospital Managed Care Hospital
Characteristic A (n=10) B (n=10) A (n=10) B (n=10)
Age, y, range 34-79 26-75 37-91 35-88
 Mean 66.2 65.6 67.1 69.4
 Median 56 53 65 62
Sex  
 Male 6 7 5 4
 Female 4 3 5 6
Levels Fused 2.4 2.1 1.3 1.2
×
Table 2.
Pain Management of Patients Who Underwent Elective Lumbar Fusion for Degenerative Disease (N=40)
Hospital Type Mean Preoperative Daily MME Mean Postoperative Daily Inpatient MME Mean Postoperative Daily Outpatient MME Pre- to Postoperative Reduction in MME P Value
County Hospital
 A 48.23 60.26 23.20 25.03 .0005
 B 43.00 48.62 30.50 12.50 .0035
 Combined 45.62 54.44 26.85 18.77 .0034
Managed Care Hospital
 A 40.00 64.89 25.50 14.50 .0027
 B 88.00 142.97 81.00 7.00 .2819
 Combined 64.00 103.93 53.25 10.75 .1803
County vs Managed Care Hospital  NA NA NA NA .1605

Abbreviations: MME, morphine milligram equivalent; NA, not applicable.

Table 2.
Pain Management of Patients Who Underwent Elective Lumbar Fusion for Degenerative Disease (N=40)
Hospital Type Mean Preoperative Daily MME Mean Postoperative Daily Inpatient MME Mean Postoperative Daily Outpatient MME Pre- to Postoperative Reduction in MME P Value
County Hospital
 A 48.23 60.26 23.20 25.03 .0005
 B 43.00 48.62 30.50 12.50 .0035
 Combined 45.62 54.44 26.85 18.77 .0034
Managed Care Hospital
 A 40.00 64.89 25.50 14.50 .0027
 B 88.00 142.97 81.00 7.00 .2819
 Combined 64.00 103.93 53.25 10.75 .1803
County vs Managed Care Hospital  NA NA NA NA .1605

Abbreviations: MME, morphine milligram equivalent; NA, not applicable.

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Table 3.
Pain Management of Patients Who Underwent Elective Lumbar Fusion for Degenerative Disease by Hospital Type: Preoperative vs Postoperative Detailed (N=40)
County Hospital Managed Care Hospital
Variable A B A B County Hospital Total Managed Care Hospital Total
Preoperative
 No. opioid prescriptions,  mean 1.27 0.8 1 1.2 1.03 1.1
 Daily MME, mean (range) 48.23 (0-110) 43
(30-60)
40
(20-60)
88
(60-150)
45.62 64
 Daily MME, median 60 40 35 80 NA NA
Operative
 Mean No. levels fused 2.4 2.1 1.3 1.2 2.25 1.25
Postoperative
 Total inpatient MME 327.17 248.90 237.70 605.60 288.03 421.65
 No. inpatient days, mean 5 5 3.4 4.2 5 3.8
 Inpatient daily MME, mean 60.26 48.62 64.89 142.97 54.44 103.93
 Follow-up daily MME, mean (range) 23.20
(0-60)
30.50
(0-60)
25.50
(5-50)
81.00
(30-150)
26.85 53.25
 Follow-up daily MME, median 20 30 25 75 NA NA

Abbreviations: MME, morphine milligram equivalent; NA, not applicable.

Table 3.
Pain Management of Patients Who Underwent Elective Lumbar Fusion for Degenerative Disease by Hospital Type: Preoperative vs Postoperative Detailed (N=40)
County Hospital Managed Care Hospital
Variable A B A B County Hospital Total Managed Care Hospital Total
Preoperative
 No. opioid prescriptions,  mean 1.27 0.8 1 1.2 1.03 1.1
 Daily MME, mean (range) 48.23 (0-110) 43
(30-60)
40
(20-60)
88
(60-150)
45.62 64
 Daily MME, median 60 40 35 80 NA NA
Operative
 Mean No. levels fused 2.4 2.1 1.3 1.2 2.25 1.25
Postoperative
 Total inpatient MME 327.17 248.90 237.70 605.60 288.03 421.65
 No. inpatient days, mean 5 5 3.4 4.2 5 3.8
 Inpatient daily MME, mean 60.26 48.62 64.89 142.97 54.44 103.93
 Follow-up daily MME, mean (range) 23.20
(0-60)
30.50
(0-60)
25.50
(5-50)
81.00
(30-150)
26.85 53.25
 Follow-up daily MME, median 20 30 25 75 NA NA

Abbreviations: MME, morphine milligram equivalent; NA, not applicable.

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Table 4.
Pain Management of Patients Who Underwent Elective Lumbar Fusion for Degenerative Disease by Hospital Type: Patient Pain Scalesa (N=40)
County Hospital Managed Care Hospital Combined
Scale Item A (n=10) B (n=10) A (n=10) B (n=10) County Hospital Managed Care Hospital
Mean preoperative pain 9.07 8.60 9.20 8.40 8.84 8.80
Mean postoperative pain 8.06 7.45 7.11 6.43 7.75 6.77
Discharge pain 7.27 5.80 5.60 3.40 6.53 4.50
Difference 1.80 2.80 3.60 5.00 2.30 4.30

a Pain was assessed using the Numeric Pain Rating Scale (0 [no pain at all] to 10 [worst imaginable pain]).

Table 4.
Pain Management of Patients Who Underwent Elective Lumbar Fusion for Degenerative Disease by Hospital Type: Patient Pain Scalesa (N=40)
County Hospital Managed Care Hospital Combined
Scale Item A (n=10) B (n=10) A (n=10) B (n=10) County Hospital Managed Care Hospital
Mean preoperative pain 9.07 8.60 9.20 8.40 8.84 8.80
Mean postoperative pain 8.06 7.45 7.11 6.43 7.75 6.77
Discharge pain 7.27 5.80 5.60 3.40 6.53 4.50
Difference 1.80 2.80 3.60 5.00 2.30 4.30

a Pain was assessed using the Numeric Pain Rating Scale (0 [no pain at all] to 10 [worst imaginable pain]).

×
Table 5.
Pain Management of Patients Who Underwent Elective Lumbar Fusion for Degenerative Disease: Comparison Between Pooled Cohorts of County and Managed Care Patients (N=40)
County vs Managed Care Hospitals P Value
Preoperative MME vs postoperative MME .1605
Inpatient postoperative MME dosage levels .0427
Mean inpatient pain rating .0088
Mean pain rating at discharge .1455

Abbreviation: MME, morphine milligram equivalent.

Table 5.
Pain Management of Patients Who Underwent Elective Lumbar Fusion for Degenerative Disease: Comparison Between Pooled Cohorts of County and Managed Care Patients (N=40)
County vs Managed Care Hospitals P Value
Preoperative MME vs postoperative MME .1605
Inpatient postoperative MME dosage levels .0427
Mean inpatient pain rating .0088
Mean pain rating at discharge .1455

Abbreviation: MME, morphine milligram equivalent.

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