Comparison of prescribing patterns before and after implementation of evidence-based opioid prescribing guidelines for the postoperative urologic surgery patient

https://doi.org/10.1016/j.amjsurg.2019.11.037Get rights and content

Highlights

  • We created a tiered-guideline for opioid prescribing after urologic surgery.

  • Fewer opioids were prescribed as a result of guideline implementation.

  • Despite this, refill rates remained stable.

  • Further work is necessary to increase guideline adherence.

Abstract

Background

We developed evidence-based guidelines for postoperative opioid prescribing after urologic surgery and assessed changes in prescribing after implementation.

Methods

Prescribing data for adults who underwent 21 urologic procedures were used to derive a four-tiered guideline for postoperative opioid prescribing. This was implemented on January 1, 2018, and prescribing patterns including quantity of opioids prescribed (oral morphine equivalents; OME) and refill rates were compared between patients undergoing surgery prior to (January–April, 2017; n equals 1732) and after (January–April, 2018; n equals1376) implementation.

Results

The median OME (IQR) prescribed was significantly lower for 2018 compared with 2017 [100 (0; 175) versus 150 (60; 225); p < .0001]. The median prescribed OME decreased in 14/21 procedures (67%). The refill rates did not significantly change. Guideline adherence rates after implementation, based on individual procedures, ranged from 33 to 95%.

Conclusions

Fewer opioids were prescribed after implementing a prescribing guideline. Additional study is required to assess patient opioid utilization.

Introduction

Policy updates wherein pain was reinforced as the “5th vital sign” prompted substantial changes in our approach to pain control, and we have seen a dramatic increase in opioid prescribing, resulting in unforeseen consequences.1 The drug-overdose death rate tripled over the past two decades, and 40% of these deaths involved a prescription opioid.2,3 As a result, we currently face an opioid epidemic. Surgeons play an important role, as we prescribe an estimated 10% of opioids, and more than 5% of opioid-naïve patients who are prescribed opioids may realize new persistent use after the index procedure.4,5 In fact, a recent study from Howard and colleagues suggested that the quantity of opioids prescribed by surgeons was independently associated with the amount of opioids consumed by patients postoperatively.6

Authorities are taking notice, and targeted approaches are underway to curb excessive opioid prescribing.7 Enhanced recovery protocols, which call for the use of non-opioid medications including local anesthetics, non-steroidal anti-inflammatories (NSAIDS), acetaminophen, anti-spasmodics, and anti-convulsants, are one such approach to limiting opioid prescribing that have shown promise.8,9 Guidelines for postoperative opioid prescribing are another approach that has shown some progress with supportive early results.10, 11, 12 However, the majority of such guidelines pertain to one or only a few surgical procedures, and the availability of readily-accessible evidence-based guidance for postoperative pain management specific to urology is severely lacking.9,11,13

In our own practice, we previously identified significant variation in opioid prescribing practices amongst a large group of urologic surgeons, and saw this as an impetus to introduce standardized prescribing practices.14 We hypothesized that a more standardized approach to opioid prescribing would significantly change prescribing patterns at our institutions. Herein, we describe the development and implementation of an evidence-based opioid prescribing guideline for common urologic procedures, and compare prescribing patterns in the time period before and after the guideline dissemination.

Section snippets

Materials and methods

We convened a multi-disciplinary opioid task force with representatives from urology, anesthesiology, nursing, pharmacy, and health-services research in June 2017 to evaluate departmental opioid prescribing. Administrative billing data was used to identify patients ≥18 years of age who underwent one of 21 common urologic procedures at our three affiliated medical centers in Minnesota, Arizona, and Florida between January 1, 2015 and December 21, 2016. Patients who underwent more than one

Results

Prescribing data [Supplementary Table 2] for opioid naïve patients undergoing 21 urologic procedures for the years 2015–2016 (n = 9253) was used to develop our four-tiered guideline.21[Table 1] Opioid prescribing was compared amongst patients who underwent surgery between January 1, 2017 and April 30, 2017 (before guideline implementation, n = 1732) and those who underwent surgery between January 1, 2018 and April 30, 2018 (after guideline implementation, n = 1376).

The median OME (IQR)

Discussion

Here, we demonstrated that providing a large, diverse group of urologists with a simple, easy to follow guideline resulted in real changes in opioid prescribing. In essence, our data support that physician “buy-in” with standardized prescribing is possible, even amongst a heterogeneous group of urologic surgeons at multiple institutions with varying practice patterns. We hypothesized that a loftier goal such as recommending drastic cuts to opioid prescribing, while desirable in the long term,

Conclusions

We report our urologic-surgery specific, evidence-based guideline for postoperative opioid prescribing in the adult opioid-naïve patient. Upon implementation of the guideline, we found that fewer opioids were prescribed and there was greater consistency amongst providers. Further work, including the incorporation of patient utilization data, is necessary to ensure congruity between provider and patient expectations for postoperative pain management.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

The authors have no relevant conflicts of interest to disclose.

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