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THA with liposomal bupivacaine linked with decreased opioid use, shorter hospital stay
At 10 hospitals, total hip arthroplasty with liposomal bupivacaine correlated with decreased postoperative inpatient opioid consumption, shorter hospital length of stay, increased chance of home discharge and lower hospitalization costs in Medicare patients, according to recently published results.
Researchers used the Premier Healthcare Database from 10 hospitals to identify 12,589 patients who underwent THA and were insured through Medicare or commercial insurance. Of the 7,232 Medicare patients, 3,622 patients underwent surgery with liposomal bupivacaine (Exparel; Pacira BioSciences Inc.) and 3,610 patients underwent surgery without the medication. There were 5,357 commercial insurance patients, of which 2,648 received liposomal bupivacaine and 2,709 patients did not receive liposomal bupivacaine.
Inpatient opioid consumption, hospital length of stay, discharge status, same-hospital readmissions and total hospitalization costs were compared with descriptive, univariate and multivariable analyses.
Results showed the use of liposomal bupivacaine correlated with lower postoperative inpatient opioid consumption, a 0.7-day shorter length of stay, a 1.6- to 1.7-fold increased likelihood of home discharge and no increased readmissions in patients with either Medicare or commercial insurance. Total hospitalization costs in Medicare patients were $561 lower with liposomal bupivacaine and were $41 higher with liposomal bupivacaine in commercial insurance patients. – by Monica Jaramillo
Disclosures: Asche reports he is a member of the Health Outcomes and Economics Advisory Board for Pacira BioSciences Inc. Please see the full study for a list of all other authors’ relevant financial disclosures.
Perspective
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This retrospective comparative cohort study uses the Premier hospital database to compare primary total hips where liposomal bupivacaine was used against a group where this injectable medication was not used. The article concludes that the liposomal bupivacaine group had lower opioid use, lower length of stay and higher percent discharge to home. While this study represents a significant work effort from a large database, there are several points that should be noted.
Several prospective, randomized studies have examined the effectiveness of liposomal bupivacaine in hip and knee arthroplasty, and most have concluded that while it does work to reduce postoperative pain as part of a periarticular injection, it does not outperform more affordable, generic local anesthetics. This study compares a large group of patients where liposomal bupivacaine was used compared to a group where it was not, and it is unclear if this control group had any periarticular injection used, a potentially unfair comparison. It’s also conceivable that those surgeons who were informed enough to use liposomal bupivacaine were also savvy enough to employ the full range of perioperative techniques know to enhance early recovery, including multimodal pain control, anesthetic choices and surgical techniques. The liposomal bupivacaine may not have been the single factor that led to these outcomes (if we are to believe the well-designed studies that addressed this question), rather it may serve as a marker for the use of a comprehensive rapid recovery program.
Furthermore, it should be noted that four of the five authors have relevant conflicts of interest with the study drug, including two employees of Pacira, one consultant and one advisory board member. Conflicts akin to this do not negate the results, and our orthopedic literature is full of such relationships, but it makes one question the results when better designed studies from non-conflicted researchers have come to different conclusions.
In this era of value-based care, surgeons long for methods to improve surgical outcomes. To that end, we should rely on the well-designed studies to give us guidance, and this study falls short of that goal.