Significant Variability in Outpatient Opioid Prescriptions by Discharge Provider following Percutaneous Nephrolithotomy (PCNL)
Timothy K. O'Rourke, Jr., MD., David W. Sobel, MD., Nicole Thomasian, BS., Christopher Tucci, MS., RN., Gyan Pareek, MS., MD.
Brown University/Rhode Island Hospital, Providence, RI.
BACKGROUND: Various initiatives throughout the United States have been implemented to limit and standardize opioid prescriptions at time of discharge following urologic surgery. Efforts have been made to standardize discharge prescriptions according to procedure via non-opioid care pathways. State-level legislation introducing limitations to opioid prescribing was passed in Rhode Island in an effort to curb over-prescription in 2016. We sought to characterize the discharge prescribing patterns of residents and advanced practice providers (APPs) following percutaneous nephrolithotomy (PCNL) at a single academic institution in Rhode Island.
METHODS: All patients who underwent PCNL at a single institution from 2016-2018 were reviewed retrospectively. 163 patients were reviewed for a total of 182 discrete PCNL cases with associated hospital encounter and discharge. 16 urologic providers were responsible for each of these discharges (14 residents, 2 APPs). Prescriptions were stratified by provider to assess for differences as a function of discharging provider. All discharge opioid medications were converted to morphine equivalent daily dosing (MEDD) for standardization purposes. One-way analysis of variance (ANOVA) was performed to detect differences in potential MEDD prescribed at time of discharge between providers.
RESULTS: Over the time interval studied, 161/182 (88.4%) PCNL cases were discharged home with an opioid analgesic. A statistically significant difference in opioid prescribing practices between the sixteen discharge providers was identified [F(15,166) = 5.26, p<.0001] (Figure 1). Additionally, a statistically significant decrease in MEDD prescribing over time was identified [F(1,180) = 23.54, p<.0001] (Figure 2). No differences in MEDD prescribed were observed for age and gender.
CONCLUSIONS: Significant variability existed in the opioid-prescribing practices of urologic providers following PCNL from 2016 to 2018, however, the overall MEDD prescribed has declined over time. This suggests that a standardized approach to prescribing opioids may be beneficial in limiting the number of prescriptions generated. Provider education should focus on typical and expected postoperative pain requirements for individual cases. Educating patients preoperatively on expectations pertaining to discharge prescriptions may prevent requests for additional opioid pain medications at the time of discharge. Partnering with state Department of Health and legislative bodies may be helpful in the global effort curb the opioid epidemic. 
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