Introduction
The opioid crisis in the United States is intimately linked to surgical care.1 Excessive opioid prescribing after surgery introduces a large quantity of leftover medication into the community.2 Opioid-naïve patients who undergo surgery are at risk of becoming new persistent opioid users after a wide variety of operations.3 This complication has been shown to affect between 4-10% of patients undergoing common general surgical procedures, 10% of patients undergoing curative intent oncologic surgery, 13% of patients undergoing cardiothoracic surgery, and 5% of pediatric surgical patients.4-7 Developing persistent opioid use after surgery results in higher healthcare spending due to increased hospital readmissions and ambulatory care visits in the immediate postoperative period.8 Moreover, chronic opioid use leads to increased morbidity and mortality and exerts billions of dollars in financial strain related to substance use disorder treatment and lost productivity.9
Although this phenomenon has been shown to impact many surgical procedures, the prevalence of new persistent opioid use after inguinal hernia repair is currently unknown. Worldwide, more than 20 million patients undergo groin hernia repair annually and it is estimated that roughly 700,000-800,000 inguinal hernias repairs are performed each year in the United States.10,11 As such a common operation, any incidence of prolonged opioid use after surgery could have significant adverse clinical and financial effects. Compared to other surgical conditions, inguinal hernia is also uniquely characterized by a high incidence of pre- and postoperative pain, which may affect both opioid prescribing and use.12 Therefore it is critical to understand the incidence of new persistent opioid use following inguinal hernia repair as well as its risk factors in order to further combat the ongoing opioid health crisis.
Within that context, we performed a retrospective cohort study of opioid-naïve patients undergoing inguinal hernia repair in the United States to determine the incidence of new persistent opioid use after surgery. In particular, we investigated the association of various risk factors with new persistent use after surgery. We hypothesized that a non-trivial number of patients will become a chronic opioid user after surgery and that risk factors such as filling larger opioid prescriptions and using opioids prior to surgery will contribute to their risk.
Methods
Data Source and Cohort Selection
The data source for this study was Optum’s de-identified Clinformatics® Data Mart Database of administrative health claims in the United States. This database contains insurance claims of 13 million annually insured patients in the United States and includes patient demographic information, medical claims data, and pharmacy claims data. This database contains patients with private insurance or Medicare Advantage plans through UnitedHealthcare. Only patients with Medicare Part A, Part B, and Part D (prescription coverage) are included in this database, therefore any prescriptions filled are included. This study of de-identified patient data was deemed to be exempt from regulation by the University of Michigan Institutional Review Board and followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.13
A retrospective review was performed to identify opioid-naïve, adult patients (18 years or older) who underwent outpatient open and laparoscopic inguinal hernia repair between January 1, 2008 and December 31, 2016 and filled an opioid prescription in the perioperative period (Figure 1). Patients undergoing inguinal hernia repair were identified using the following Current Procedure Terminology (CPT) codes: 49505, 49507, 49520, 49521, 49525, 49650, and 49651. Opioid-naïve status was determined by excluding patients who filled an opioid prescription in the 365 to 31 days prior to the date of surgery. Only patients with continuous medical insurance and pharmacy coverage in the 1 year before and 1 year after surgery were included. Patients who underwent subsequent surgery within 6 months of inguinal hernia repair were excluded. Lastly, patients were excluded if they did not fill an opioid prescription in the perioperative period (30 days prior to admission for surgery to 3 days post-discharge).
Figure 1 –
Study Cohort Selection
Outcomes
The primary outcome was new persistent opioid use after surgery. This was defined using the following 3 criteria: 1) the patient filled an opioid prescription during the perioperative period; 2) the patient filled an additional opioid prescription in post-discharge days 4-90; and 3) the patient filled another opioid prescription in post-discharge days 91-180. Put simply, the intent of this definition is to capture patients who undergo an operation, fill an initial opioid prescription that is intended to treat their surgical pain in the immediate postoperative period, and then go on to continue filling additional opioid prescriptions long after their surgical pain should have resolved.
This definition is similar to but more stringent than that used in a widely-cited study by Brummett et al., which defined new persistent opioid use as filling a prescription in the perioperative period plus filling a prescription between 90-180 days after surgery.3 The intent of making the definition of new persistent opioid use more specific was to capture continuous prescription filling from the time of surgery to beyond 3 months after surgery.
Patient and Clinical Covariates
In order to evaluate the association of patient and clinical factors on new persistent opioid use, we included a number of demographic and clinical variables. Demographic information such as age, sex, race and ethnicity, education, and geographic region of residence were included. Missing demographic data were coded as unknown. Patient comorbidities were included using the Charlson Comorbidity Index. History of tobacco use, determined by International Classification of Diseases (ICD) version 9 (305.1; V15.82) and ICD version 10 (Z72.0; F17.2; Z87.891) diagnosis codes, was also included since it is a known risk factor for developing an opioid use disorder.14 Clinical variables included year of surgery, surgical approach, mental health disorders, pain disorders, and major postoperative complications. Mental health disorders were determined based on the Agency of Healthcare Research and Quality Clinical Classification System (CCS).15 Pain disorders and major postoperative complications were assessed using ICD-9 and ICD-10 codes. Claims from the 12 months prior to admission for surgery were used to determine comorbidities, tobacco use, mental health disorders, pain disorders and major postoperative complications. Lastly, prescription-specific covariates were initial prescription size in oral morphine equivalents (OME) and filling a preoperative prescription, defined as filling an opioid prescription within the 30 days prior to surgery. Opioid prescriptions were identified from pharmacy claims using AHFS Pharmacologic-Therapeutic Classification from pharmacy claims and NDC codes. Prescriber specialty was determined for all prescriptions filled in the 30 days prior to surgery using a taxonomy which is linked with the encrypted national provider identifier.
Statistical Analysis
Descriptive statistics were calculated to characterize basic demographics and characteristics of patients with persistent use and patients without persistent use. Variables were compared using Student’s t-test or Chi-squared analysis, as appropriate.
A multivariable logistic regression model was used to estimate the risk-adjusted likelihood of new persistent opioid use, adjusted for the demographic, comorbidities and clinical variables mentioned above, except for physician specialty. For patients who filled an opioid prescription in the 30 days prior to surgery, we determined the proportion of prescriptions by prescriber specialty. All analyses were performed using Stata version 15.1 (StataCorp). Hypotheses were two-sided and significance was set at α = 0.05.
Results
During the study period, 59,795 patients underwent inguinal hernia repair and met inclusion criteria (Figure 1). Cohort demographics and characteristics are listed in Table 1. Mean (SD) age was 57.8 (16.1) years old and 55,014 (92%) patients were male. The majority of patients were Caucasian (40,187, 67%), geographically located in the South Atlantic region (14,055, 23.5%), and had less than a bachelor’s degree (45,333, 76%).
Table 1 –
Baseline demographic characteristics and univariate analysis.
| Characteristic | No New Persistent Opioid Use (N=58,873) (%) |
New Persistent Opioid Use (N=922) (%) |
Overall (N=59,795) |
P value |
|---|---|---|---|---|
| Age (years) | 0.137 | |||
| < 45 | 12409 (21.1) | 184 (20) | 12593 (21.1) | |
| 45 - 64 | 24718 (42.0) | 368 (39.9) | 25086 (42.0) | |
| >= 65 | 21746 (36.9) | 370 (40.1) | 22116 (37.0) | |
| Male | 54873 (92.0) | 841 (91.2) | 55014 (92.0) | 0.373 |
| Race/ethnicity | 0.003 | |||
| Caucasian | 39586 (67.2) | 601 (65.2) | 40187 (67.2) | |
| African-American | 3172 (5.4) | 65 (7.1) | 3237 (5.4) | |
| Hispanic | 4313 (7.3) | 79 (8.6) | 4392 (7.4) | |
| Asian | 1326 (2.3) | 7 (0.8) | 1333 (2.2) | |
| Unknown | 10476 (17.8) | 170 (18.4) | 10646 (17.8) | |
| Education | <0.001 | |||
| Less than high school | 262 (0.5) | 7 (0.8) | 269 (0.5) | |
| High school diploma | 12421 (21.1) | 276 (29.9) | 12697 (21.2) | |
| Less than bachelor degree | 31892 (54.2) | 475 (51.5) | 32367 (54.1) | |
| College degree or more | 13115 (22.3) | 148 (16.1) | 13263 (22.2) | |
| Unknown | 1183 (2.0) | 16 (1.7) | 1199 (2.0) | |
| Geographic region | <0.001 | |||
| East North Central | 9408 (16.0) | 136 (14.8) | 9544 (16) | |
| East South Central | 1661 (2.8) | 33 (3.6) | 1694 (2.8) | |
| Middle Atlantic | 3793 (6.4) | 37 (4) | 3830 (6.4) | |
| Mountain | 6747 (11.5) | 117 (12.7) | 6864 (11.5) | |
| New England | 2332 (4) | 23 (2.5) | 2355 (3.9) | |
| Pacific | 8137 (13.8) | 132 (14.3) | 8269 (13.8) | |
| South Atlantic | 13842 (23.5) | 213 (23.1) | 14055 (23.5) | |
| West North Central | 5755 (9.8) | 56 (6.1) | 5811 (9.7) | |
| West South Central | 6914 (11.7) | 168 (18.2) | 7082 (11.8) | |
| Unknown | 284 (0.5) | 7 (0.8) | 291 (0.5) | |
| Charlson comorbidity Index, mean (SD) | 0.8 (1.43) | 1.0 (1.53) | 0.8 (1.44) | <0.001 |
| History of tobacco use | 4975 (8.5) | 140 (15.2) | 5115 (8.6) | <0.001 |
| Year of surgery | <0.001 | |||
| 2008 | 6273 (10.7) | 119 (12.9) | 6392 (10.7) | |
| 2009 | 6429 (10.9) | 148 (16.1) | 6577 (11) | |
| 2010 | 6761 (11.5) | 118 (12.8) | 6879 (11.5) | |
| 2011 | 6706 (11.4) | 120 (13) | 6826 (11.4) | |
| 2012 | 6941 (11.8) | 97 (10.5) | 7038 (11.8) | |
| 2013 | 6401 (10.9) | 85 (9.2) | 6486 (10.9) | |
| 2014 | 6133 (10.4) | 89 (9.7) | 6222 (10.4) | |
| 2015 | 6444 (11) | 84 (9.1) | 6528 (10.9) | |
| 2016 | 6785 (11.5) | 62 (6.7) | 6847 (11.5) | |
| Surgical approach | <0.001 | |||
| Laparoscopic | 19279 (32.8) | 251 (27.2) | 19530 (32.7) | |
| Open | 39594 (67.3) | 671 (72.8) | 40265 (67.3) | |
| Mental health disorders | ||||
| Adjustment | 903 (1.5) | 15 (1.6) | 918 (1.5) | 0.820 |
| Anxiety | 3190 (5.4) | 88 (9.5) | 3278 (5.5) | <0.001 |
| Mood | 3118 (5.3) | 86 (9.3) | 3204 (5.4) | <0.001 |
| Disruptive | 549 (0.9) | 16 (1.7) | 565 (0.9) | 0.012 |
| Personality | 53 (0.1) | 2 (0.2) | 55 )0.1) | 0.208 |
| Psychosis | 240 (0.4) | 9 (1.0) | 249 (0.4) | 0.008 |
| Alcohol or substance abuse disorders | 1229 (2.1) | 40 (4.3) | 1269 (2.1) | <0.001 |
| Suicide or self-harm | 55 (0.1) | 4 (0.4) | 59 (0.1) | 0.013 |
| Other | 1104 (1.9) | 24 (2.6) | 1128 (1.9) | 0.107 |
| Pain disorders | ||||
| Arthritis | 20410 (34.7) | 399 (43.3) | 20809 (34.8) | <0.001 |
| Back | 8630 (14.7) | 208 (22.6) | 8838 (14.8) | <0.001 |
| Neck | 3497 (5.9) | 90 (9.8) | 3587 (6.0) | <0.001 |
| Other pain conditions | 9813 (16.7) | 216 (23.4) | 10029 (16.8) | <0.001 |
| Major postoperative complications | 777 (1.3) | 26 (2.8) | 803 (1.3) | <0.001 |
| Opioid prescriptions | ||||
| Preoperative opioid prescription (30d before procedure) | 5424 (9.2) | 292 (31.7) | 5716 (9.6) | <0.001 |
| Initial prescription size (OME), median (IQR) | 210 (150) | 225 (150) | 210 (150) | 0.005 |
A total of 922 (1.5%) patients developed new persistent opioid use during the study period. Risk-adjusted likelihood of new persistent opioid use for patient and clinical factors is listed in Table 2. Among the included demographic variables, having a high school diploma was associated with an increased risk of new persistent use (OR 1.405, 95% CI 1.201-1.644). Charlson Comorbidity Index and tobacco use were also associated with increased risk of new persistent use (OR 1.058, 95% CI 1.013-1.105 and OR 1.545, 95% 1.270-1.879, respectively).
Table 2 –
Multivariate logistic regression of risk factors for new persistent opioid use after inguinal hernia repair.
| Odds Ratio |
P value | 95% Confidence Interval |
||
|---|---|---|---|---|
| Age (ref group: <45) | ||||
| 45-64 | 0.992 | 0.933 | 0.827 | 1.191 |
| >=65 | 1.076 | 0.475 | 0.880 | 1.316 |
| Male | 1.092 | 0.467 | 0.862 | 1.384 |
| Race (ref group: Caucasian) | ||||
| African American | 1.145 | 0.323 | 0.875 | 1.497 |
| Hispanic | 1.001 | 0.996 | 0.780 | 1.284 |
| Asian | 0.381 | 0.012* | 0.180 | 0.808 |
| Unknown | 1.116 | 0.236 | 0.931 | 1.337 |
| Education (ref group: Less than bachelor degree) | ||||
| Less than high school | 1.381 | 0.422 | 0.628 | 3.035 |
| High school diploma | 1.405 | <0.001* | 1.201 | 1.644 |
| College degree or more | 0.822 | 0.042* | 0.680 | 0.993 |
| Unknown | 0.811 | 0.436 | 0.480 | 1.373 |
| Geographic region (ref group: South Atlantic) | ||||
| East North Central | 1.086 | 0.466 | 0.870 | 1.355 |
| East South Central | 1.326 | 0.142 | 0.910 | 1.932 |
| Middle Atlantic | 0.741 | 0.099 | 0.519 | 1.058 |
| Mountain | 1.182 | 0.164 | 0.934 | 1.495 |
| New England | 0.777 | 0.258 | 0.502 | 1.203 |
| Pacific | 1.044 | 0.712 | 0.829 | 1.316 |
| West North Central | 0.765 | 0.081 | 0.566 | 1.034 |
| West South Central | 1.653 | <0.001* | 1.340 | 2.038 |
| UNKNOWN | 1.447 | 0.351 | 0.666 | 3.144 |
| Charlson comorbidity index | 1.058 | 0.011* | 1.013 | 1.105 |
| Tobacco use | 1.545 | <0.001* | 1.270 | 1.879 |
| Year of surgery (ref group:2008) | ||||
| 2009 | 1.160 | 0.238 | 0.906 | 1.485 |
| 2010 | 0.856 | 0.243 | 0.660 | 1.111 |
| 2011 | 0.893 | 0.391 | 0.689 | 1.157 |
| 2012 | 0.660 | 0.003* | 0.502 | 0.869 |
| 2013 | 0.639 | 0.002* | 0.480 | 0.851 |
| 2014 | 0.679 | 0.007* | 0.512 | 0.901 |
| 2015 | 0.606 | 0.001* | 0.454 | 0.809 |
| 2016 | 0.404 | <0.001* | 0.293 | 0.556 |
| Surgical approach (ref group: Open) | ||||
| Laparoscopic | 0.893 | 0.142 | 0.767 | 1.039 |
| Mental health disorders | ||||
| Adjustment | 1.023 | 0.933 | 0.605 | 1.731 |
| Anxiety | 1.424 | 0.005* | 1.114 | 1.820 |
| Mood | 1.279 | 0.057 | 0.993 | 1.647 |
| Disruptive | 1.694 | 0.048* | 1.005 | 2.856 |
| Personality | 0.901 | 0.898 | 0.182 | 4.453 |
| Psychosis | 1.146 | 0.705 | 0.566 | 2.322 |
| Alcohol or substance abuse disorders | 1.526 | 0.019* | 1.071 | 2.174 |
| Suicide or self-harm | 1.651 | 0.387 | 0.530 | 5.143 |
| Other | 1.114 | 0.614 | 0.733 | 1.694 |
| Pain disorders | ||||
| Arthritis | 1.147 | 0.069 | 0.989 | 1.329 |
| Back | 1.366 | 0.001* | 1.145 | 1.629 |
| Neck | 1.320 | 0.024* | 1.038 | 1.679 |
| Other pain conditions | 1.211 | 0.022* | 1.028 | 1.426 |
| Major postoperative complication | 1.704 | 0.011* | 1.132 | 2.563 |
| Opioid prescriptions | ||||
| Preoperative opioid prescription (30d before procedure) | 4.335 | <0.001* | 3.750 | 5.010 |
| Initial prescription size >=75th percentile (>=300 OME) | 1.361 | <0.001* | 1.180 | 1.570 |
Patients who underwent surgery from 2012-2016 had a lower risk of developing new persistent use compared to patient who underwent surgery in 2008, with this effect becoming stronger each year except for 2014.
There was no difference in risk of new persistent opioid use between open and laparoscopic surgery, however having a major postoperative complication was associated with prolonged use (OR 1.704, 95% CI 1.132-2.563).
Anxiety, disruptive mood disorder, and alcohol or substance abuse disorders were associated with increased risk of new persistent opioid use. Similarly, pain disorders such as back, neck, and other pain conditions were associated with increased risk.
Larger initial prescription size was also associated with increased risk of new persistent opioid use. The strongest risk factor for new persistent opioid use was filling a preoperative opioid prescription in the 30 days before surgery (OR 4.335, 95% CI 3.750-5.010). In total, 5716 (9.6%) patients filled an opioid prescription within 30 days prior to surgery. These prescriptions were provided by surgeons (3228, 51.5%), primary care physicians (975, 15.6%), emergency medicine physicians (503, 8.0%), pain specialists (23, 0.4%), other subspecialties (1005, 16.0%), and unknown providers (535, 8.5%) (Table 3).
Table 3 –
Source of preoperative (30d) and late postoperative opioid prescriptions.
| Prescriber Specialty | Preoperative Prescriptions (%) |
Postoperative Days 4-90 |
Postoperative Days 91-180 |
|---|---|---|---|
| Surgery | 3228 (51.5%) | ||
| Primary Care | 975 (15.6%) | ||
| Emergency Medicine | 503 (8.0%) | ||
| Physical Medicine and Rehabilitation; Pain Specialists | 23 (0.4%) | ||
| Other | 1005 (16.0%) | ||
| Unknown/Missing | 535 (8.5%) |
Discussion
In this large national cohort of opioid-naïve patients undergoing elective inguinal hernia repair, 1.5% of patients continued to fill opioid prescriptions more than 3 months after surgery. Risk factors for persistent opioid use included patient comorbidities, tobacco use, mental health and pain disorders, and filling a larger initial opioid prescription. The most significant risk factor for prolonged use was filling an opioid prescription in the month before surgery. Given that recent literature has suggested that the incidence of perioperative complications in inguinal hernia repair is generally less than 1%, new persistent opioid use may represent one of the most significant adverse outcomes of this procedure.16 In the context of roughly 700,000 inguinal hernia repairs being performed annually in the United States, this study suggests that some 10,000 of these patients will become new persistent opioid users every year.
To our knowledge, this is the first study to describe the incidence and risk factors for new persistent opioid use following inguinal hernia repair. In recent years, there has been a preponderance research dedicated to understanding the effect that opioid exposure at the time of surgery has on patients. New persistent opioid use has been shown to affect virtually every surgical subspecialty.17 Although the current study suggests that the incidence of this phenomenon is lower following inguinal hernia repair compared to other common surgical procedures, where average incidence is around 6%, it is important to note that these results may actually underestimate a more accurate rate of new persistent opioid use.3 While it’s possible that differences in surgical factors may explain this lower incidence (elective inguinal hernia repair is a relatively straightforward, outpatient procedure), it is also known that the prevalence of opioid use disorder is higher in uninsured and unemployed patients, who would be excluded from our analysis.18,19 A higher prevalence of new persistent opioid use in these populations is doubly important, given the barriers to treatment faced by these patients. Difference in methodology may also explain this difference, given that the current study specifically employed a more stringent definition of persistent opioid use. Compared to the most well-known definition utilized by Brummett et al. of filling one perioperative prescription plus filling an additional prescription beyond 90 days, the current definition requires continuous prolonged opioid use from the time of surgery by requiring two additional prescription fills (from days 4-90 and days 91-180) in addition to the perioperative prescription.3 This definition has been used elsewhere, such as in describing new persistent opioid use in pediatric patients.5 Methodologic differences aside, this analysis nevertheless uncovers some important trends in new persistent use which may help providers and policymakers make practice changes to reduce opioid-related risks.
One in ten patients filled an opioid prescription in the 30 days prior to their surgery. This more than quadrupled their odds of persistent use. This prescription was provided by surgeons in more than 50% of cases, with primary care physicians and emergency medicine physicians providing another 25% of these prescriptions. This finding likely reflects the fact that patients commonly present with hernia-associated pain prior to surgery and desire relief while waiting for their operation. This finding also may also represent a practice of providing “convenience prescriptions” for patients, so that they already have their opioid prescription filled and available at the time of surgery. Some outpatient surgical and dental clinics even advise patients to be sure to fill their opioid prescription before their surgery. However, this practice clearly stands out in significantly increasing a patient’s risk for opioid dependence. Whether prescribed for pain or convenience, these data suggest that the risks of preoperative prescriptions far outweigh the benefit of simple convenience to patients.
Another important finding of this study is that a large initial opioid prescription (≥ 300 mg OME) was a risk factor for prolonged opioid use after surgery. For context, a prescription of more than 300 mg OME is equivalent to 40 tablets of oxycodone 5 mg or 60 tablets of hydrocodone/acetaminophen 5/325 mg. Others have demonstrated a similar association between prescription size and both the amount of opioids patients report using after surgery as well as the incidence of new persistent use.6,20-22 Excessive opioid prescribing is a significant issue after hernia repair, with patients often receiving 3-4 times more pills than they report using.23,24 A number of initiatives to reduce excessive prescribing have successfully decreased the size of postoperative opioid prescriptions without adversely affecting patient pain or satisfaction.25,26 In fact, in a study of opioid-sparing pain management in patients specifically undergoing laparoscopic inguinal hernia repair, median prescription size was only 6 pills, patients reported a median satisfaction of 10 on a 10-point scale, and 100% of patients agreed their pain was manageable with the prescription they were provided.27 In the current cohort, it’s worth noting that 31,486 (15%) patients in the initial 207,383 patients did not fill an opioid prescription after surgery, consistent with other studies examining opioid use following this and other procedures.23 Therefore, not only is reducing opioid prescribing after inguinal hernia repair feasible, but these efforts may directly reduce the incidence of new persistent opioid use as well. Current widely-available prescribing guidelines based on patient-reported opioid use after hernia repair suggest between 0-10 tablets of oxycodone 5 mg.28
This study has several limitations, the most important of which is that these results represent only a selective group of commercially insured adults who did not have a lapse in insurance status for 24 consecutive months. It is well-known that the prevalence of opioid use disorder is higher among un-, underinsured, and unemployed individuals. Therefore, these results may significantly underestimate the rate of new persistent opioid use after inguinal hernia repair in the general population. Another way in which this study may also underestimate the incidence of developing clinically significant prolonged opioid use after surgery is by requiring two additional opioid refills after the initial postoperative opioid prescription. Other studies have demonstrated that even intermittent prolonged opioid use can lead to adverse patient outcomes.29 This study may also fail to account for prescriptions that are filled outside of a patient’s insurance plan (for example, by self-pay), however this number is likely small in a cohort of patients with continuous insurance for 2 years. This study also excludes patients who did not fill an opioid prescription, which limits our ability to draw conclusions about an equally important group of inguinal hernia patients. Gleaning information specific to patients who undergo hernia repair without utilizing opioids will be critical to further refining policies to encourage opioid stewardship. Our analysis also does not include actual opioid consumption, however, there is a strong association with filling an opioid prescription and using opioids. Lastly, the retrospective nature of this analysis introduces the issue of selection bias, however these results are in line with studies conducted of similar surgical procedures.3
Conclusion
Following inguinal hernia repair, 1.5% of previously opioid-naïve patients will continue to use opioids for months after surgery. Given the ubiquity of inguinal hernia repair, this represents a significant source of opioid dependence in the United States. Filling an opioid prescription in the 30 days prior to surgery quadruples a patient’s odds of new persistent opioid use after surgery, and therefore we recommend that providers abandon this practice.
Disclosures
RH receives funding from the Blue Cross Blue Shield Foundation of Michigan. VG has no disclosures. CB, JW, and ME receive funding from the Michigan Department of Health and Human Services and the National Institute on Drug Abuse (R01DA042859). DT receives funding from AHRQ (K08 - HS025778) and Medtronic. No funder or sponsor had any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. RH and VG had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
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