Interventions to Reduce Opioid Prescriptions following Urological Surgery: A Systematic Review and Meta-Analysis.

PURPOSE: Opioid prescriptions after surgery are major contributors to the opioid abuse epidemic. Several measures designed to limit opioid prescriptions at discharge have been evaluated. We conducted a comprehensive review and meta-analysis of the effectiveness of various types of interventions in reducing opioid prescriptions after urological surgery. MATERIALS AND METHODS: A systematic review including MEDLINE®, Web of Science™ and Cochrane databases was conducted to identify studies on opioid prescriptions and urological surgery. Twenty-two studies met the inclusion criteria, of which 19 were used for quantitative analysis for reduction in opioid prescriptions. Additional outcomes included opioid consumption and satisfaction with analgesia. RESULTS: Of the 8,318 patients, 53% were in the pre- and 47% in the post-intervention cohort. Overall mean reduction/patient in prescribed opioids was -67.59 (95% CI 54.23 to 80.94) morphine milligram equivalents (MME). Direct interventions, implemented by providers within their local department or hospital, were more effective in reducing prescribed opioids compared to indirect, or systemic, interventions, at -76.68 MME (95% CI 60.04 to -93.31) vs -46.72 MME (95% CI 24.20 to -69.23; p=0.04). Opioid consumption significantly decreased post-intervention with a mean reduction of -18.31 MME (95% CI 7.89 to 28.72). Patient satisfaction with analgesia remained unchanged between the pre- and post-intervention groups. CONCLUSIONS: Successful reduction in opioid prescriptions, without compromising pain control, can be achieved through a variety of interventions. Direct interventions appear to have a greater impact than indirect interventions in reducing opioid prescriptions. Despite the reduction, unused, excess prescription opioids were still noted, which provides an opportunity for further control on opioid prescriptions.

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.

A Cost-Benefit Analysis of Medical Scribes and Electronic Medical Record System in an Academic Urology Clinic.

INTRODUCTION: Electronic medical records have introduced an additional level of complexity to the patient-provider encounter and medical scribes may offer a solution. We examined how a medical scribe system could support an academic urology clinic. To assess the financial feasibility of this model, we analyzed the additional costs associated with adding medical scribes and we discuss the potential benefits of this system. METHODS: We measured total patient wait and interaction times with staff, and estimated the additional staff required to maintain an increased patient load if medical scribes were introduced. We then calculated the average revenue per patient during the most recent 9 months of data to estimate the minimum increase in the number of patient visits needed to offset the additional staffing needs. RESULTS: Mean ± SD total wait time was 23 minutes 28 seconds ± 13 minutes 4 seconds. Average monthly expenses would increase by $17,452.50 for 6 additional staff members, including 1 nursing assistant, 1 patient service specialist, 1 nurse and 3 scribes. There was an average of 666 monthly office visits and average net revenue to the department was $107.78 per patient visit. The increase in the number of patient visits required to break even would be 162 additional patients per month, representing a 24.3% increase. Additional downstream revenue was considered. CONCLUSIONS: A medical scribe system in the example of an academic urology clinic setting could increase patient flow and decrease the burden on medical providers by reducing computer charting. This model is only financially prudent if the increased expenses are offset by additional revenue from increased patient visits.