Analgesic Use Among Adults with a Trauma-Related Emergency Department Visit: A Retrospective Cohort Study from Alberta, Canada

Study Design

This retrospective cohort study used administrative health data without any intervention and was reported according to the strengthening of the reporting of observational studies in epidemiology (STROBE) guidelines [8]. Ethics approval for this study was received from the University of Alberta institutional review board (Pro00096969). No participants were placed at risk as a result of the study, and informed consent was not required.

Data Source

Data from the National Ambulatory Care Reporting System (NACRS), Discharge Abstract Database (DAD), Practitioner Claims, Pharmaceutical Information Network (PIN), and the Drug Optimization, Sustainability, and Evaluation (DOSE) database were linked to the Population Registry that contains demographic information for all Albertans with Alberta Health Care Insurance Plan (AHCIP) coverage; all Alberta residents are eligible and over 99% participate. NACRS and DAD include information on all individuals discharged from facility-based ambulatory care clinics including EDs and hospitals, respectively; a most responsible diagnosis code and secondary codes are included. Practitioner Claims includes information on physician billing; up to three diagnostic codes can be listed per visit. PIN contains information on dispensed prescription medications from all community pharmacies. DOSE houses medication information from all hospital pharmacies and nine select ED sites located within the Edmonton area.

Cohort Selection

Eligibility criteria for the event-defined cohort included: (1) all ED visits by adults (≥ 18 years) in Alberta between April 1, 2017 and March 31, 2018 (inclusion period) that contained a trauma diagnosis code in the primary diagnostic field and did not contain any exclusionary trauma diagnostic codes in any diagnostic field (see Table S1 in the electronic supplementary material), and (2) information from the ED site that the visit occurred was linkable to the DOSE database (i.e., the nine select ED sites located within the Edmonton area). Eligibility criteria for the subject-defined cohort included adults within the event-defined cohort who had AHCIP coverage for ≥ 2 years before and ≥ 1 year after their first trauma-related ED visit within the inclusion period (index ED visit). Cohorts were subgrouped according to mode of arrival to the ED (walk-in, ambulance) and the type of analgesic administered during the visit (both opioids and non-opioids, opioids only, non-opioids only, or none).

Measures

ED visit characteristics included the Canadian Triage and Acuity Scale (CTAS) level, trauma type and cause, as well as time from initial contact to analgesic administration, length of stay, and discharge destination. Characteristics of analgesics administered during the ED visit and dispensed ≤ 7 days after the index ED visit among those discharged home directly from the ED included route of administration, and drug class/name; opioids also included dose (morphine milligram equivalent [MME]), formulation, and days of supply [9]. Table S2 in the electronic supplementary material lists the analgesic drugs included.

Demographic characteristics on the index ED visit date included age, sex, and urban/rural residence. Clinical characteristics were determined during the 2-year pre-index period that included a Charlson Comorbidity Index (CCI) score, and health conditions associated with a high-risk of opioid use disorder (chronic pain, mental illness [depression, dementia, and schizophrenia], substance abuse, and physical illness [cerebrovascular disease, chronic heart failure, chronic pulmonary disease, diabetes, liver disease, migraine, renal disease, and rheumatoid arthritis/collagen vascular disease]) [10,11,12,13]; Table S3 in the electronic supplementary material details the case definitions [14,15,16,17,18]. Individuals who met chronic opioid use criteria (≥ 90 consecutive days of supply of opioids within a 1-year period, excluding buprenorphine and methadone used for treatment of opioid use disorder) was also reported [15].

Statistical Analyses

Continuous variables were reported using summary statistics (mean and standard deviation [SD], median and interquartile range [IQR], or minimum and maximum [min/max]), and categorical variables were reported using counts and percentages. Analyses were performed using SAS 9.4 software.

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