Revisiting Postoperative Pediatric Urology Opioid Prescriptions.

OBJECTIVE: To measure our opioid prescription rate, determine if our rate has decreased since 2019, and identify areas for future interventions to further decrease our opioid prescription rate. METHODS: We retrospectively reviewed all pediatric urology patients (age ..±18 years) who underwent a procedure between October 1, 2020 and October 22, 2021. We collected data on opioid prescribing, age, sex, surgeon, procedure, ethnicity, and race. We grouped procedures into 6 categories: circumcision, cystoscopy with the removal of foreign body/stone/stent, scrotal surgery, hypospadias repair/penile surgery, pyeloplasty/ureteral reimplant, and others. RESULTS: We analyzed 821 operative cases. Only 2.2% (18/821) of discharges included an opioid prescription. The prescription rate of 1 pediatric urologist was 4.6% (17/369), which was higher than the other 2 practitioners... (0.40%, 1/250%, and 0%, 0/202) (P.ß<.ß.001). The median age of patients who received an opioid prescription was older than patients without an opioid prescription (16.5 vs.ß5.0 years, P.ß<.ß.001). Surgery performed in an inpatient setting was more likely to result in an opioid prescription (9.7%, 3/31) than in the outpatient setting (1.9%, 15/790) (P.ß=.ß.03). No adverse effects of reduced opioid usage were noted. CONCLUSION: From October 2020 to October 2021, our institution had an opioid prescription rate of 2.2%. This represented a decrease from our previously reported rate of 8% in 2019. At the same time, we found no significant pain issues in our post-operative patients. Seventeen out of 18 prescriptions were written under 1 provider. Though heightened awareness has made a difference, targeted feedback is needed if we wish to reduce opioid usage further.

Implementation and Assessment of No Opioid Prescription Strategy at Discharge After Major Urologic Cancer Surgery.

Importance: Postoperative opioid prescriptions are associated with delayed recovery, perioperative complications, opioid use disorder, and diversion of overprescribed opioids, which places the community at risk of opioid misuse or addiction. Objective: To assess a protocol for eliminating postdischarge opioid prescriptions after major urologic cancer surgery. Design, Setting, and Participants: This cohort study of the no opioid prescriptions at discharge after surgery (NOPIOIDS) protocol was conducted between May 2017 and June 2021 at a tertiary referral center. Patients undergoing open or minimally invasive radical cystectomy, radical or partial nephrectomy, and radical prostatectomy were sorted into the control group (usual opioids), the lead-in group (reduced opioids), and the NOPIOIDS group (no opioid prescriptions). Interventions: The NOPIOIDS group received a preadmission educational handout, postdischarge instructions for using nonopioid analgesics, and no routine opioid prescriptions. The lead-in group received a postdischarge instruction sheet and reduced opioid prescriptions at prescribers' discretion. The control group received opioid prescriptions at prescribers' discretion. Main Outcomes and Measures: Primary outcome measures included rate and dose of opioid prescriptions at discharge and for 30 days postdischarge. Additional outcome measures included patient-reported pain and satisfaction level, unplanned health care utilization, and postoperative complications. Results: Of 647 opioid-naive patients (mean [SD] age, 63.6 [10.0] years; 478 [73.9%] male; 586 [90.6%] White), the rate of opioid prescriptions at discharge for the control, the lead-in, and the NOPIOIDS groups was 80.9% (157 of 194), 57.9% (55 of 95), and 2.2% (8 of 358) (Kruskal-Wallis test of medians: P < .001), and the overall median (IQR) tablets prescribed was 14 (10-20), 4 (0-5.3), and 0 (0-0) per patient in the control, lead-in, and NOPIOIDS groups, respectively (Kruskal-Wallis test of medians: P < .001). In the NOPIOIDS group, median and mean opioid dose was 0 tablets for all procedure types, with the exception of kidney procedures (mean [SD], 0.5 [1.7] tablets). Patient-reported pain surveys were received from 358 patients (72.6%) in the NOPIOIDS group, demonstrating low pain scores (mean [SD], 2.5 [0.86]) and high satisfaction scores (mean [SD], 86.6 [3.8]). There was no increase in postoperative complications in the group with no opioid prescriptions. Conclusions and Relevance: This perioperative protocol, with emphasis on nonopioid alternatives and patient instructions, may be safe and effective in nearly eliminating the need for opioid prescriptions after major abdominopelvic cancer surgery without adversely affecting pain control, complications, or recovery.

Does Neuromodulation Reduce Chronic Pain Patient Emergency Department Utilization?

BACKGROUND: Chronic pain (CP) affects roughly 100 million adults in the United States. These subjects present disproportionately to the emergency department (ED). Neuromodulation (NM) has been shown to reduce ED visits longitudinally in subjects. OBJECTIVE: To compare ED utilization rates between subjects with CP with and without NM. METHODS: Subjects with failed back surgery syndrome, complex regional pain syndrome, or neuropathic pain diagnosis who visited the hospital between January 1, 2019, and December 31, 2019, were included. Subjects were divided into a NM-treated cohort and a non-NM cohort. Demographic information, medications, and pain provider visits were obtained. Pain-related ED visits between 2017 and 2019 were compared. RESULTS: A total of 2516 subjects were identified; 291 (11.6%) previously underwent NM. The non-NM cohort had significantly higher rate of pain-related ED visits compared with the NM cohort (15.1% vs 10.0%, P = .018). Younger age (odds ratio [OR] = 0.888 [0.843-0.935]), shorter distance to the hospital (OR = 0.807 [0.767-0.849]), lower household income (OR = 0.865 [0.831-0.901]), opioid use (OR = 1.375 [1.291-1.465]), nonopioid use (OR = 1.079 [1.033-1.128]), and non-NM therapy (OR = 1.751 [1.283-2.390]) were significant predictors of ED visits. Opioid use was the only significant predictor (OR = 6.124 [1.417-26.473]) associated with ED visits in the NM cohort. CONCLUSION: Subjects who underwent NM had fewer visits to the ED when compared with similar subjects who received conventional treatment. Opioid use prompted increased ED utilization in both cohorts. We posit that NM leads to improvement in pain outcomes, integration with multidisciplinary pain specialists, and reduction in severity and frequency of acute pain exacerbations, thereby limiting health care resource utilization.

Preoperative evaluation of coagulation status in neuromodulation patients.

OBJECTIVE: The incidence of hemorrhage in patients who undergo deep brain stimulation (DBS) and spinal cord stimulation (SCS) is between 0.5% and 2.5%. Coagulation status is one of the factors that can predispose patients to the development of these complications. As a routine part of preoperative assessment, the authors obtain prothrombin time (PT), partial thromboplastin time (PTT), and platelet count. However, insurers often cover only PT/PTT laboratory tests if the patient is receiving warfarin/heparin. The authors aimed to examine their experience with abnormal coagulation parameters in patients who underwent neuromodulation. METHODS: Patients who underwent neuromodulation (SCS, DBS, or intrathecal pump implantation) over a 9-year period and had preoperative laboratory values available were included. The authors determined abnormal values on the basis of a clinical protocol utilized at their practice, which combined the normal ranges of the laboratory tests and clinical relevance. This protocol had cutoff values of 12 seconds and 39 seconds for PT and PTT, respectively, and < 120,000 platelets/µl. The authors identified risk factors for these abnormalities and described interventions. RESULTS: Of the 1767 patients who met the inclusion criteria, 136 had abnormal preoperative laboratory values. Five of these 136 patients had values that were misclassified as abnormal because they were within the normal ranges at the outside facility where they were tested. Fifty-one patients had laboratory values outside the ranges of our protocol, but the surgeons reviewed and approved these patients without further intervention. Of the remaining 80 patients, 8 had known coagulopathies and 24 were receiving warfarin/heparin. The remaining 48 patients were receiving other anticoagulant/antiplatelet medications. These included apixaban/rivaroxaban/dabigatran anticoagulants (n = 22; mean ± SD PT 13.7 ± 2.5 seconds) and aspirin/clopidogrel/other antiplatelet medications (n = 26; mean ± SD PT 14.4 ± 5.8 seconds). Eight new coagulopathies were identified and further investigated with hematological analysis. CONCLUSIONS: New anticoagulants and antiplatelet medications are not monitored with PT/PTT, but they affect coagulation status and laboratory values. Although platelet function tests aid in a subset of medications, it is more difficult to assess the coagulation status of patients receiving novel anticoagulants. PT/PTT may provide value preoperatively.

Postoperative pediatric urology opioid prescriptions at a tertiary academic medical center.

INTRODUCTION: Opioid abuse is a public health crisis, and often this starts postoperatively. Limited data are available on pediatric urology practitioners. We examined the likelihood of postoperative opioid prescriptions in our practice. OBJECTIVE: To determine rates of post-operative opioid prescriptions following urologic surgery in a tertiary academic center, and to identify what factors are related to opioid prescriptions. STUDY DESIGN: We retrospectively reviewed opioid prescriptions for children who underwent a procedure in the operating room between 1/1/17 and 12/31/19. We collected data on gender, age, surgeon, procedure, length of stay, ethnicity, race, and whether opioids had been used pre-operatively. We grouped procedures into five categories: minor penile surgery, cystoscopic procedures, scrotal surgery, hypospadias repair/penoplasty, and pyeloplasty/ureteral reimplant. Multivariable logistic regression was used to determine odds ratios (OR) of opioid prescriptions. RESULTS: 1102 procedures had data available. 14.2% (n = 156) received opioid prescriptions. Using minor penile surgery as a baseline, scrotal surgery increased the odds of an opioid by 1.42; hypospadias, pyeloplasty, and other procedures reduced the odds by 0.53, 0.55, and 0.54, respectively (no patient received opioids for endoscopic procedures). Ambulatory procedures had a lower rate of opioids (0.40), and age was a major factor, with the odds of a prescription increasing by a factor of 1.45 per year of age. Since January of 2017, the opioid prescription rate has decreased from 18% in 2017 to 7.7% in 2019. DISCUSSION: We found a relatively low rate of opioid prescribing in our pediatric patients, mostly in older children undergoing penile and scrotal procedures. Our rate was comparable to several other institutions that have examined their prescription rates in surgical patients. Heightened awareness has resulted in decreased opioid usage over time (to 6.9%). Limitations included the retrospective nature of our study, which did not allow us to assess whether pain control was adequate or if the opioids prescribed were used by patients. Opioids are rarely needed in pediatric patients. CONCLUSIONS: 85.8% of post-operative pediatric urology patients at our institution were not provided with prescription opioids. Factors associated with a higher likelihood of receiving a prescription were increasing age and scrotal surgery.

Failure to Attend Urology Appointments: A Retrospective Analysis of a Single Urban Academic Practice.

INTRODUCTION: We sought to examine why patients miss appointments in a large academic urology practice. METHODS: We conducted a retrospective analysis of 83,983 patient appointments in our faculty urology group between May 1, 2017 and December 1, 2020. Appointment data from 17 providers were included. Data were collected on diagnosis, age, gender, insurance type, nonattendance history, lead time between scheduling and appointment, clinic location and outpatient procedures vs general office visit or telehealth visit. RESULTS: A total of 7,592 (9.0%) appointments were missed. Patients seen for oncologic diagnosis had the lowest missed appointment rate (4.5%), as compared with benign urology (9.6%) and pediatrics (13.0%). Previous nonattendance history within the last year was associated with nonattendance again (OR 2.47, 95% CI 2.29-2.66). Patients with Medicaid had the highest rate of missed appointments (17.2%; OR 2.16, 95% CI 2.02-2.32). Increased lead time between appointments increased the odds of nonattendance (OR 1.018/week, CI 1.016-1.020). Patients undergoing procedures had the lowest nonattendance rate (3.4%), compared with both new (11.4%) and followup (10.5%) visits, while both telephone (2.9%; OR 0.41, 95% CI 0.32-0.53) and video (2.8%; OR 0.37, 95% CI 0.20-0.71) visits had lower rates of nonattendance when compared to in-person visits. CONCLUSIONS: We found a nonattendance rate of 9% in our practice. Those patients with oncologic diagnoses and those having procedures or telemedicine visits had the lowest rates. Those who have missed an appointment in the past are at the highest risk nonattendance and should be targeted to improve patient health as well as practice efficiency.

Impact of Enhanced Recovery after Surgery Protocols on Opioid Prescriptions at Discharge after Major Urological Cancer Surgery.

INTRODUCTION: Enhanced recovery after surgery protocols are designed to limit the use of opioids during inpatient stay to facilitate recovery and early discharge. It is not clear whether the enhanced recovery after surgery related limitations on opioids are associated with opioid prescribing at discharge. We wished to evaluate whether the enhanced recovery after surgery efforts had an impact on opioid prescriptions given after discharge following major urological cancer surgery. METHODS: We reviewed the opioid prescription data following hospital discharge after major urological cancer surgery from 2016 to 2018, including cystectomy, renal surgery (total, partial) and prostatectomy. Patient calls and refill requests were recorded for 30 days after discharge. Multivariable analysis was performed to evaluate the effect of various factors on normalized opioid tablets given at discharge. RESULTS: A total of 409 patients met the inclusion criteria, with 207 before and 202 after ERAS protocols. Following enhanced recovery after surgery, potent opioid (oxycodone, hydrocodone) prescriptions decreased by 53% while tramadol use increased by more than four-fold (p <0.001). Reduction in opioid prescriptions was noted for prostatectomy (30%, p <0.001), cystectomy (27%, p=0.02) and all renal procedures (32%, p <0.001) after enhanced recovery after surgery protocol. On multivariable analysis, enhanced recovery after surgery protocol was an independent predictor of reduced opioids given at discharge. CONCLUSIONS: Enhanced recovery after surgery protocol implementation was associated with a significant decrease in the opioid prescriptions at discharge after all major urological cancer procedures. Prescribing patterns shifted away from more potent opioids. These findings provide a benchmark for further interventions and reduction in the outpatient opioid prescriptions after open and minimally invasive surgery. KEY WORDS: enhanced recovery after surgery; opioid epidemic; pain management; medication therapy management; analgesics, opioid.