Surgeon preference drives prescription of post-operative opioids, not patient needs, after minimally invasive pediatric urology procedures.
Ravindra Sahadev, MBBS DNB, Dana A. Weiss, MD, Christopher Long, MD, Gregory E. Tasian, MD, Thomas F. Kolon, MD, Aseem R. Shukla, MD, Arun K. Srinivasan, MD.
Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Title:
Surgeon preference drives prescription of post-operative opioids, not patient needs, after minimally invasive pediatric urology procedures.
Background: Children undergoing minimally invasive urologic procedures are discharged with prescriptions for analgesics including opioids, but sparse guidance exists as to the actual need for opioids. Given the increasing concerns related to prescription narcotics abuse, our prescription practices needs to be validated. We sought to examine our institutional opioid prescription patterns, preferences, patient outcomes and identify factors associated with opioid prescriptions. We hypothesized that discharge opioid prescriptions are associated with surgeon preference and to identify potential paths towards an opioid free pediatric minimally invasive surgeries.
Methodology:
We performed a retrospective cohort study of children who underwent laparoscopic and robot-assisted surgery for various pediatric urological conditions between May 2017 and February 2018. Patients who underwent concomitant procedures by other surgical teams, and those with complex medical history that prolonged hospital stay were excluded. The primary outcome was opioid prescription at discharge. Secondary outcomes were post discharge pain-related patient queries. Data collected include patient-characteristics including age, sex, race, co-morbidities, and surgical details, surgeon, discharge prescription details and post-operative pain related calls and emergency room visits. Patient cohorts were analyzed by Mann Whitney U test with statistical significance set at p=0.05. Variables with more than two groups were analyzed by ANOVA. Logistic regression test was used to study multiple associations using SPSS® v.20.
Results: We included 155 children who underwent laparoscopic (87) or robot-assisted (68) procedures during the study interval. The cohort age ranged from 3 months to 20 years (median
age 4.85 years), and consisted of 65% boys and 35% girls. Key baseline data is shown in Table1. Only 20% of included patients were prescribed opioids at discharge. Older children, children with higher BMI, those requiring opioid prescriptions during the hospital stay, longer operative time and surgeon preference were all positively associated with discharge opioid prescription by univariate analysis. On multivariable logistic regression, surgeon preference was the only factor associated with opioid prescriptions given to patients at discharge. Further, when we compared the patient outcomes (Phone calls and emergency room visits) there was no statistical difference between the opioid prescribed and non-prescribed group.
Conclusions: Opioid prescription rate at discharge in our practice is relatively low. Opioid prescription practice is strongly driven by surgeon preference rather than patient factors. Prescription of opioids at discharge did not change post-operative phone calls or ER visits for pain related concerns. This study is informing a prospective effort to eliminate opioid prescription practices after minimally invasive surgery at our institution.
| Parameters | Total cases n=155 | ||
| Opioids prescribed (n=30, 19.35%) | NO opioids prescribed (n=125, 80.65%) | Significance p | |
| Median Age in Years (Range) Average ± SD | 13.66 (1.23-20) 12 ± 6.42 | 3.42 (0.25-17) 5.2 ± 4.94 | < .00001 |
| Boys: Girls (%) | 23: 7 (77:23) | 78: 47 (62:38) | 0.2 |
| Median BMI in kg/m2 | 21 | 17.9 | .00096 |
| History of Previous surgery (%) | 12 (40) | 30 (24) | 0.1078 |
| Average Duration of surgery in Minutes | 204.48 | 161.08 | .03752 |
| Average Length of Hospital Stay in Hours | 32 | 28.6 | .0969 |
| Inpatient opioid administration (PACU + wards) (%) | 25 (83) | 68 (54) | 0.0110 |
| Types of Surgery RA-Pyeloplasty (%) RA-Reimplantation (%) RA-Appendico-vesicostomy (%) RA-Uretero-ureterostomy (%) Diagnostic Lap/Orchidopexy (%) Lap Hernia repair (%) Lap Nephrectomy (%) Lap excision of urachal remnant (%) Lap Renal cyst ablation (%) Laparoscopic Gonadectomy for DSD (%) | 8 (26.66) 3 (10) 1 (3.3) 0 7 (23.3) 6 (20) 3 (10) 1 (3.3) 1 (3.3) 0 | 30 (24) 17 (13.6) 5 (4) 3 (2.4 ) 25 (20) 22 (17.6) 10 (8) 4 (3.2) 3 (2.4) 3 (2.4) | 0.986 one way ANOVA |
| Prescription by individual Surgeons (no of operations) A (1) B (5) C (28) D (43) E (57) F (12) G (8) H (1) | 0 0 12 (42.85%) 9 (20.9%) 6 (10.52%) 2 (16.66%) 0 1 (100%) | 1 (100%)* 5 (100%) 16 (57.15%) 34 (79.01%) 51 (89.47%) 10 (83.33%) 8 (100%) 0 | 0.04 one way ANOVA |
| Post op Outcomes Post op pain related calls (%) ER visits related to pain (%) Secondary opioid prescription (%) | 4 (13.3%) 2 (6.7%) NA | 16 (12.8%) 2 (1.6%) 1 (0.8) | 1.0000 0.117 - |
* Percentage of Number of cases operated by that particular surgeon.
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