Strategies to Optimize Nephrolithiasis Emergency Care (STONE): Prospective Evaluation of an Emergency Department Clinical Pathway.

OBJECTIVE: To convene a multi-disciplinary panel to develop a pathway for Emergency Department (ED) patients with suspected nephrolithiasis and then prospectively evaluate its effect on patient care. MATERIALS AND METHODS: The STONE Pathway was developed and linked to order sets within our Electronic Health Record in April 2019. Records were prospectively reviewed for ED patients who underwent ultrasound or Computerized Tomography (CT) to evaluate suspected nephrolithiasis between January 2019 and August 2019 within our institution. The primary outcome measure was the proportion of patients whose ED CT was low dose (<4 mSv). Secondary outcome measures included receipt of pathway-concordant pain medications and urine strainers. Order set utilization was evaluated as a process measure. Balance measures assessed included repeat ED visits, imaging, hospitalizations, and a urologic clinic visit or surgery within 30 days of discharge. RESULTS: 441 patients underwent ED imaging, of whom 261 (59%) were evaluated for suspected nephrolithiasis. The STONE Pathway was used in 50 (30%) eligible patients. Patients treated with the Pathway were more likely to undergo low-dose CTs (49% vs 23%, P <.001), and receive guideline-concordant pain medications such as NSAIDs (90% vs 62%, P <.001), and were less likely to return to the ED within 30 days (13% vs 2%, P = .01). These measures demonstrated special cause variation following Pathway release. CONCLUSION: Clinical pathways increase compliance with evidence-based practices for pain control and imaging in nephrolithiasis emergency care and may improve the delivery of value-based care.

Inpatient Opioid Use Poorly Predicts Discharge Opioid Prescriptions Following Nephrectomy.

INTRODUCTION: The overprescribing of opioids after urological surgery places patients at risk for opioid overuse and dependency. However, few guidelines exist to help urologists consistently prescribe appropriate quantities of pain medications. We sought to characterize the variation in opioid prescribing habits at time of discharge following nephrectomy. METHODS: We performed a retrospective review of patients who underwent partial or radical nephrectomy between November 2016 and May 2018 at an academic medical center. We reviewed patient, procedure and provider level variables potentially associated with high opioid use. Daily inpatient opioid use and discharge opioid prescriptions were tabulated in oral morphine equivalents. RESULTS: We identified 173 eligible patients who used a daily average of 36 oral morphine equivalents during their hospitalization weaning to 27 oral morphine equivalents on the day of discharge. All but 2 patients were prescribed opioids at discharge with an average of 367 oral morphine equivalents per prescription (SD 284). On multiple linear regression preoperative opioid use, open vs minimally invasive approach, length of stay and last day opioid use were associated with discharge oral morphine equivalents (R2=0.51, p <0.05). CONCLUSIONS: Patients were discharged with excessive opioids with an average discharge prescription equivalent to 13.6 times the last inpatient day's use. When combined with other potential predictors of discharge opioid prescriptions inpatient use accounts for less than 50% of the variance between prescriptions. Systems are needed to help minimize variability in opioid prescribing practices and reduce the overall quantity prescribed.

High Burden of In-Person Kidney Cancer Surveillance in a Low Resource Population.

INTRODUCTION: Postoperative kidney cancer surveillance is predominantly based on imaging and laboratory evaluation rather than physical exam. We sought to characterize the burden of kidney cancer surveillance in a low resource population with an aim to identify opportunities for telehealth implementation. METHODS: We retrospectively reviewed patients who underwent partial or radical nephrectomy between November, 2016 and May, 2018 at an academic medical center. We reviewed patient demographic characteristics, travel distance to hospital, and Center for Medicare & Medicaid Services designation of home ZIP code as low income area or health professional shortage area. Followup visits were reviewed for imaging and laboratory studies as well as new physical exam findings. RESULTS: We identified 156 patients who attended 234 followup visits at mean 2.4 months (SD=2.9 months) postoperatively. Patient home ZIP codes were designated as low income area or health professional shortage area in 93 (59.6%) cases. One-way travel was mean 194 miles (SD=438 miles) per visit. When intended, laboratory or imaging studies were not obtained ahead of followup visits in 34 of 196 cases (17%). Based on the absence of new physical exam findings or procedures performed 201 (86%) visits could have potentially been performed remotely. CONCLUSIONS: Patients living in low income areas and health professional shortage areas are asked to travel long distances to perform kidney cancer surveillance often to review data that could be obtained remotely. Necessary imaging or laboratory studies are frequently not obtained ahead of appointments, further diminishing visit value. Kidney cancer surveillance may offer a promising opportunity for telehealth implementation within urology.