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Background Opioid use has increased to epidemic levels over the past decade within the United States, particularly among vulnerable populations. This retrospective study aimed to evaluate rates of prolonged opioid use in the Veteran population after thoracic surgery and identify specific risk clusters. Methods Veterans Administration data on patients who underwent thoracic surgery between January 1, 2006 and September 30, 2015 included preoperative opioid use information for stratification of patients to preoperative chronic opioid use (PCOU; nPCOU = 16,612) versus patients without preoperative chronic opioid use (WPCOU; nWPCOU = 2,328). A Poisson regression model and prior literature were used to identify variables for use in a Latent Class Analysis (LCA) model for each stratum. Three-cluster models were selected, and identified as 'low-', 'intermediate-' and 'high-' risk groups. Results Cluster interpretations included: (a) Low risk: no psychiatric diagnoses, preoperative medication use, or preoperative chronic pain, (b) Intermediate risk: no psychiatric diagnoses, but had preoperative medication use and some preoperative chronic pain and (c) High risk: psychiatric diagnoses, preoperative medication use and preoperative chronic pain. For the PCOU stratum, rates of prolonged opioid use 1 year after surgery were as follows: 46.3%, 61.9% and 66.0%. For the WPCOU stratum, the observed rates were 4.7%, 8.3% and 9.2%. Conclusions Prolonged opioid use trajectories obviously differ by PCOU status, as well as preoperative psychosocial diagnoses, medication use and chronic pain. This is a first step in population-level research to curb the rate of prolonged opioid use in Veterans following thoracic surgery. Significance This article presents population-level chronic opioid use trajectories after thoracic surgery, using latent class structures. Demographics, preoperative psychological diagnoses, medication usage and chronic pain variables were utilized to identify population-level clusters. The cluster identified as highest risk had preoperative chronic opioid use, psychological diagnoses, other medication prescriptions and chronic pain.

Background The goal of surgical education is to prepare the trainee for independent practice; however, the relevance of the current residency experience to practice remains uncertain. The purpose of this study was to identify the surgical procedures most frequently performed in orthopaedic residency and in early surgical practice and to identify surgical procedures performed more often or less often in orthopaedic residency compared with early surgical practice. Methods This retrospective cohort study included American Medical Association (AMA) Current Procedural Terminology (CPT) codes (n = 4,329,561 procedures) reported by all U.S. orthopaedic surgery residents completing residency between 2010 and 2012 (n = 1,978) and AMA CPT codes for all procedures (n = 413,370) reported by U.S. orthopaedic surgeons who took the American Board of Orthopaedic Surgery Part II certifying examination between 2013 and 2015 (n = 2,205). Relative rates were determined for AMA CPT codes and AMA CPT code categories for adult and pediatric surgeries that had frequencies of ≥0.1% for both practitioners and residents. Results The top 25 adult AMA CPT code categories contributed 82.1% of the total case volume for residents and 82.4% for practitioners. Knee and shoulder arthroscopy were the most frequently performed procedures in adults in both residency and early practice. Humerus/elbow fracture and/or dislocation procedures and "other musculoskeletal-introduction or removal" procedures were the most frequently performed procedures in pediatric cases in both residency and early practice. Of the total 78 adult and 82 pediatric code categories included in our analysis that had a frequency of >1% in residency or early practice, there were 4 adult and 6 pediatric code categories demonstrating 44% to 1,164% greater frequency in residency than in early practice, and there were 8 adult and 7 pediatric code categories demonstrating 26% to 73% less frequency in residency than in early practice. Conclusions Similarity between residency and early practice experience is generally strong. However, we identified several AMA CPT code categories and individual CPT codes for which the level of exposure during residency varied substantially from early practice experience. These findings can help residencies ensure adequate trainee exposure to procedures performed commonly in early practice.

The incidence of chronic pain following thoracic surgery (∼50%) is greater than most other surgeries. The goal of this retrospective study was to detect the incidence of prolonged opioid use at 1 year after surgery among those veterans who were chronic opioid users versus not chronic users during the one year prior to their thoracic surgery, separately. In addition, predictors of prolonged opioid use at 1 year after surgery from demographic, surgical, and comorbid medical and psychiatric factors were assessed for each of the two groups separately. Veterans Health Administration sample of 19,240 patients who had thoracotomy or video assisted thoracoscopy between 2006 and 2015 and were alive at one year after surgery were included. “Chronic opioid use” was defined as consistent opioid prescription for more than 90 days during the year (1). Veterans’ opioid use during the 1-year prior to surgery was used to determine whether they were “preoperative chronic opioid users” at the time of surgery. Similarly, the opioid use information during the first year after the surgery was used to determine whether they become “prolonged opioid users” during the 1-year following surgery. Out of 2,370 preoperative opioid users at the time of surgery, 61% (95% CI: 59% to 63%) continued prolonged opioid use at 1 year after their thoracic surgery. Only younger age and the presence of pre-existing chronic pain were associated with the prolonged opioid use at 1 year after surgery. Out of 16,870 patients who were not preoperative chronic opioid users during the year prior to their surgery, 6.8% (95% CI: 6.4% to 7.2%) became prolonged opioid users. At the 0.01 type I error level, the presence of pre-existing chronic pain, longer duration of hospital stay, antidepressant use and benzodiazepine use were associated with prolonged opioid use at one year after thoracic surgery.