Large reduction in opioid prescribing by a multipronged behavioral intervention after major urologic surgery

Abstract

Background: Surgeons play a pivotal role in combating the opioid crisis that currently grips the United States. Changing surgeon behavior is difficult, and the degree to which behavioral science can steer surgeons toward decreased opioid prescribing is unclear.

Methods: This was a single-institution, single-arm, pre- and postintervention study examining the prescribing of opioids by urologists for adult patients undergoing prostatectomy or nephrectomy. The primary outcome was the quantity of opioids prescribed in oral morphine equivalents (OMEs) after hospital discharge. The primary exposure was a multipronged behavioral intervention designed to decrease opioid prescribing. The intervention had 3 components: 1) formal education, 2) individual audit feedback, and 3) peer comparison performance feedback. There were 3 phases to the study: a pre-intervention phase, an intervention phase, and a washout phase.

Results: Three hundred eighty-two patients underwent prostatectomy, and 306 patients underwent nephrectomy. The median OMEs decreased from 195 to 19 in the prostatectomy patients and from 200 to 0 in the nephrectomy patients (P < .05 for both). The median OMEs prescribed did not increase during the washout phase. Prostatectomy patients discharged with opioids had higher levels of anxiety than patients discharged without opioids (P < .05). Otherwise, prostatectomy and nephrectomy patients discharged with and without opioids did not differ in their perception of postoperative pain management, activity levels, psychiatric symptoms, or somatic symptoms (P > .05 for all).

Conclusions: Implementing a multipronged behavioral intervention significantly reduced opioid prescribing for patients undergoing prostatectomy or nephrectomy without compromising patient-reported outcomes.

Keywords: behavioral intervention; behavioral science; nephrectomy; opioids; prostatectomy.

Appendix 1.. Examples of individual positive audit feedback (A), individual negative audit feedback (B), and peer comparison performance feedback (C).

A) Text message or e-mail: “I noticed most of your prostatectomies and nephrectomies did not get any opioids last month. Great job, we are really proud of the work you are doing!” B) Text message or e-mail: “I noticed many of your prostatectomies were discharged with a lot of opioids. Why? Were they complaining of a lot of pain? We would like you to cut back on your prescriptions. They are much higher than our group’s average.” C) Monthly peer comparison feedback figure regarding opioid prescribing after prostatectomy. Of note, in reality the letters across the x-axis were identifiable surgeons.

Appendix 2.. Median* oral morphine equivalents (OMEs) prescribed for patients after excluding the highest volume surgeon for prostatectomy (A) and nephrectomy (B) and after excluding the co-principal investigators for prostatectomy (C) and nephrectomy (D)

*Median represents the median of each surgeon’s median OMEs prescribed. After excluding the highest volume surgeon for prostatectomy (A) and nephrectomy (B) and after excluding the co-principal investigators for prostatectomy (C) and nephrectomy (D), the median OMEs prescribed among surgeons remained significantly decreased between the pre-intervention phase and intervention phase as well as between the pre-intervention phase and wash-out phase (all p<0.05; Wilcoxon sign-rank test with Bonferroni correction). There is no significant difference in the median OMEs prescribed during the intervention and wash-out phases. Error bars represent the 95% confidence intervals.

Appendix 2.. Median* oral morphine equivalents (OMEs) prescribed for patients after excluding the highest volume surgeon for prostatectomy (A) and nephrectomy (B) and after excluding the co-principal investigators for prostatectomy (C) and nephrectomy (D)

*Median represents the median of each surgeon’s median OMEs prescribed. After excluding the highest volume surgeon for prostatectomy (A) and nephrectomy (B) and after excluding the co-principal investigators for prostatectomy (C) and nephrectomy (D), the median OMEs prescribed among surgeons remained significantly decreased between the pre-intervention phase and intervention phase as well as between the pre-intervention phase and wash-out phase (all p<0.05; Wilcoxon sign-rank test with Bonferroni correction). There is no significant difference in the median OMEs prescribed during the intervention and wash-out phases. Error bars represent the 95% confidence intervals.

Appendix 2.. Median* oral morphine equivalents (OMEs) prescribed for patients after excluding the highest volume surgeon for prostatectomy (A) and nephrectomy (B) and after excluding the co-principal investigators for prostatectomy (C) and nephrectomy (D)

*Median represents the median of each surgeon’s median OMEs prescribed. After excluding the highest volume surgeon for prostatectomy (A) and nephrectomy (B) and after excluding the co-principal investigators for prostatectomy (C) and nephrectomy (D), the median OMEs prescribed among surgeons remained significantly decreased between the pre-intervention phase and intervention phase as well as between the pre-intervention phase and wash-out phase (all p<0.05; Wilcoxon sign-rank test with Bonferroni correction). There is no significant difference in the median OMEs prescribed during the intervention and wash-out phases. Error bars represent the 95% confidence intervals.

Appendix 2.. Median* oral morphine equivalents (OMEs) prescribed for patients after excluding the highest volume surgeon for prostatectomy (A) and nephrectomy (B) and after excluding the co-principal investigators for prostatectomy (C) and nephrectomy (D)

*Median represents the median of each surgeon’s median OMEs prescribed. After excluding the highest volume surgeon for prostatectomy (A) and nephrectomy (B) and after excluding the co-principal investigators for prostatectomy (C) and nephrectomy (D), the median OMEs prescribed among surgeons remained significantly decreased between the pre-intervention phase and intervention phase as well as between the pre-intervention phase and wash-out phase (all p<0.05; Wilcoxon sign-rank test with Bonferroni correction). There is no significant difference in the median OMEs prescribed during the intervention and wash-out phases. Error bars represent the 95% confidence intervals.

Figure 1.. Median* oral morphine equivalents (OMEs) prescribed for patients undergoing prostatectomy (A) and nephrectomy (B)

*Median represents the median of each surgeon’s median OMEs prescribed. The median OMEs prescribed among surgeons decreased significantly between the pre-intervention phase and intervention phase as well as between the intervention phase and wash-out phase for both prostatectomy (Figure 1A; both p=0.01; Wilcoxon sign-rank test with Bonferroni correction) and nephrectomy (Figure 1B; both p=0.01; Wilcoxon sign-rank test with Bonferroni correction). Specifically, the median OMEs decreased from 195 to 19 in the prostatectomy patients and from 200 to 0 in the nephrectomy patients. There is no significant difference in the median OMEs prescribed during the intervention and wash-out phases. Error bars represent the 95% confidence intervals.

Figure 1.. Median* oral morphine equivalents (OMEs) prescribed for patients undergoing prostatectomy (A) and nephrectomy (B)

*Median represents the median of each surgeon’s median OMEs prescribed. The median OMEs prescribed among surgeons decreased significantly between the pre-intervention phase and intervention phase as well as between the intervention phase and wash-out phase for both prostatectomy (Figure 1A; both p=0.01; Wilcoxon sign-rank test with Bonferroni correction) and nephrectomy (Figure 1B; both p=0.01; Wilcoxon sign-rank test with Bonferroni correction). Specifically, the median OMEs decreased from 195 to 19 in the prostatectomy patients and from 200 to 0 in the nephrectomy patients. There is no significant difference in the median OMEs prescribed during the intervention and wash-out phases. Error bars represent the 95% confidence intervals.

Figure 2.. Median oral morphine equivalents prescribed per surgeon for patients undergoing prostatectomy (A) and nephrectomy (B)

The median oral morphine equivalents prescribed per surgeon are decreasing for both prostatectomy (A) and nephrectomy (B) patients. By the end of the study, 40% and 60% of the attending surgeons prescribed a median of 0 oral morphine equivalents for prostatectomy and nephrectomy, respectively. Of note, if a given surgeon did not perform a procedure in a given month, then the data point for that month will be missing, making the line discontinuous.

Figure 2.. Median oral morphine equivalents prescribed per surgeon for patients undergoing prostatectomy (A) and nephrectomy (B)

The median oral morphine equivalents prescribed per surgeon are decreasing for both prostatectomy (A) and nephrectomy (B) patients. By the end of the study, 40% and 60% of the attending surgeons prescribed a median of 0 oral morphine equivalents for prostatectomy and nephrectomy, respectively. Of note, if a given surgeon did not perform a procedure in a given month, then the data point for that month will be missing, making the line discontinuous.

Figure 3.. Patient reported outcomes using the International Pain Outcomes questionnaire for prostatectomy (A-D) and nephrectomy (E-H)

Prostatectomy patients discharged with opioids had higher levels of anxiety than patients discharged without opioids (p<0.05; two-sample t-test). Otherwise, prostatectomy and nephrectomy patients discharged with and without opioids did not differ in their perception of postoperative pain management, activity level, other psychiatric symptoms, and somatic symptoms (all p >0.05; two-sample t-test). The questions are scored on a 0-10 scale, where 0 indicates no symptoms and 10 indicates severe symptoms.

Figure 3.. Patient reported outcomes using the International Pain Outcomes questionnaire for prostatectomy (A-D) and nephrectomy (E-H)

Prostatectomy patients discharged with opioids had higher levels of anxiety than patients discharged without opioids (p<0.05; two-sample t-test). Otherwise, prostatectomy and nephrectomy patients discharged with and without opioids did not differ in their perception of postoperative pain management, activity level, other psychiatric symptoms, and somatic symptoms (all p >0.05; two-sample t-test). The questions are scored on a 0-10 scale, where 0 indicates no symptoms and 10 indicates severe symptoms.

Figure 3.. Patient reported outcomes using the International Pain Outcomes questionnaire for prostatectomy (A-D) and nephrectomy (E-H)

Prostatectomy patients discharged with opioids had higher levels of anxiety than patients discharged without opioids (p<0.05; two-sample t-test). Otherwise, prostatectomy and nephrectomy patients discharged with and without opioids did not differ in their perception of postoperative pain management, activity level, other psychiatric symptoms, and somatic symptoms (all p >0.05; two-sample t-test). The questions are scored on a 0-10 scale, where 0 indicates no symptoms and 10 indicates severe symptoms.

Figure 3.. Patient reported outcomes using the International Pain Outcomes questionnaire for prostatectomy (A-D) and nephrectomy (E-H)

Prostatectomy patients discharged with opioids had higher levels of anxiety than patients discharged without opioids (p<0.05; two-sample t-test). Otherwise, prostatectomy and nephrectomy patients discharged with and without opioids did not differ in their perception of postoperative pain management, activity level, other psychiatric symptoms, and somatic symptoms (all p >0.05; two-sample t-test). The questions are scored on a 0-10 scale, where 0 indicates no symptoms and 10 indicates severe symptoms.

Figure 3.. Patient reported outcomes using the International Pain Outcomes questionnaire for prostatectomy (A-D) and nephrectomy (E-H)

Prostatectomy patients discharged with opioids had higher levels of anxiety than patients discharged without opioids (p<0.05; two-sample t-test). Otherwise, prostatectomy and nephrectomy patients discharged with and without opioids did not differ in their perception of postoperative pain management, activity level, other psychiatric symptoms, and somatic symptoms (all p >0.05; two-sample t-test). The questions are scored on a 0-10 scale, where 0 indicates no symptoms and 10 indicates severe symptoms.

Figure 3.. Patient reported outcomes using the International Pain Outcomes questionnaire for prostatectomy (A-D) and nephrectomy (E-H)

Prostatectomy patients discharged with opioids had higher levels of anxiety than patients discharged without opioids (p<0.05; two-sample t-test). Otherwise, prostatectomy and nephrectomy patients discharged with and without opioids did not differ in their perception of postoperative pain management, activity level, other psychiatric symptoms, and somatic symptoms (all p >0.05; two-sample t-test). The questions are scored on a 0-10 scale, where 0 indicates no symptoms and 10 indicates severe symptoms.

Figure 3.. Patient reported outcomes using the International Pain Outcomes questionnaire for prostatectomy (A-D) and nephrectomy (E-H)

Prostatectomy patients discharged with opioids had higher levels of anxiety than patients discharged without opioids (p<0.05; two-sample t-test). Otherwise, prostatectomy and nephrectomy patients discharged with and without opioids did not differ in their perception of postoperative pain management, activity level, other psychiatric symptoms, and somatic symptoms (all p >0.05; two-sample t-test). The questions are scored on a 0-10 scale, where 0 indicates no symptoms and 10 indicates severe symptoms.

Figure 3.. Patient reported outcomes using the International Pain Outcomes questionnaire for prostatectomy (A-D) and nephrectomy (E-H)

Prostatectomy patients discharged with opioids had higher levels of anxiety than patients discharged without opioids (p<0.05; two-sample t-test). Otherwise, prostatectomy and nephrectomy patients discharged with and without opioids did not differ in their perception of postoperative pain management, activity level, other psychiatric symptoms, and somatic symptoms (all p >0.05; two-sample t-test). The questions are scored on a 0-10 scale, where 0 indicates no symptoms and 10 indicates severe symptoms.