Preoperative NarxCare Overdose Risk Scores Greater than 200 Are Associated With Worse 1-Year Patient-Reported Outcomes and Dissatisfaction after Primary Total Knee Arthroplasty

Ahmed K Emara; Shujaa T Khan; Ignacio Pasqualini; Khaled A Elmenawi; Chao Zhang; Cleveland Clinic Adult Reconstruction & Research Group; Nicolas S Piuzzi

doi:10.1016/j.arth.2025.08.028

Preoperative NarxCare Overdose Risk Scores Greater than 200 Are Associated With Worse 1-Year Patient-Reported Outcomes and Dissatisfaction after Primary Total Knee Arthroplasty

J Arthroplasty. 2025 Sep 1:S0883-5403(25)01036-8. doi: 10.1016/j.arth.2025.08.028. Online ahead of print.

Authors

Ahmed K Emara¹, Shujaa T Khan¹, Ignacio Pasqualini¹, Khaled A Elmenawi¹, Chao Zhang¹; Cleveland Clinic Adult Reconstruction & Research Group¹; Nicolas S Piuzzi¹

Collaborators

Cleveland Clinic Adult Reconstruction & Research Group:
Lakshmi S Gudapati, Michael R Bloomfield, Trevor G Murray, Robert M Molloy, Viktor E Krebs, John P McLaughlin, Peter A Surace, Matthew E Deren

Affiliation

¹ Cleveland Clinic Foundation, Department of Orthopaedic Surgery, Cleveland, Ohio.

PMID: 40902686
DOI: 10.1016/j.arth.2025.08.028

Abstract

Background: The NarxCare Overdose Risk Score (ORS) is a measure of prescription drug use with scores ranging from 0 to 999, and higher scores suggest worse prescription drug use patterns, including opioids, sedatives, and stimulants. We aimed to evaluate the association of preoperative NarxCare ORS with clinically meaningful improvements in patient-reported outcome measures (PROMs) and satisfaction at one year.

Methods: Patients undergoing primary total knee arthroplasty at an academic health care system (2018 to 2022) were included. Of 6,710 patients, 44.8% had ORS 0, 28.0% had 100 to 199, and 15.1% had 200 to 299. The PROMs evaluated included the Knee Disability and Osteoarthritis Outcome Score (KOOS) Pain, Physical Function Short Form (PS), and Joint Replacement (JR). Clinically relevant improvements were determined by the minimal clinically important difference (MCID), Patient Acceptable Symptoms State (PASS), and substantial clinical benefit (SCB) thresholds. Multivariable regression models were used to assess the relationship between baseline ORS and 1-year PROMs.

Results: Compared to ORS 0, higher ORS was linked to worse outcomes. TheMCID failure for KOOS-JR increased with ORS 100 to 199 (odds ratio (OR) = 1.28, P = 0.033), 200 to 299 (OR = 1.51, P = 0.003), 300 to 399 (OR = 1.84, P = 0.001), and 400 to 499 (OR = 2.27, P = 0.003). The PASS failure rose across KOOS Pain (OR = 1.23 to 2.59, P = 0.003), KOOS -PS (OR = 1.26 to 3.87, P ≤ 0.001), and KOOS-JR (OR = 1.45 to 2.69, P = 0.03) from ORs 100 to 199 to ≥ 500. Dissatisfaction at one year was associated with ORS 100 to 199 to ≥ 500 (OR = 1.21 to 2.85, P ≤ 0.026). The SCB failure for KOOS-JR was linked to ORS 100 to 499 (OR = 1.18 to 1.80, P ≤ 0.032).

Conclusions: Higher preoperative NarxCare ORS is independently associated with reduced odds of achieving meaningful improvements in pain, function, and satisfaction at one year after total knee arthroplasty. This readily available metric may help guide preoperative counseling and has important implications for evolving Centers for Medicare & Medicaid Services policies that tie reimbursement to PROM performance.

Keywords: Narx; TKA; arthroplasty; knee; patient-reported outcomes measures; prescription drug.