The Quality Improvement Summit is focused on improving patient safety, ensuring appropriate use of advanced imaging and reducing associated costs. The day included didactic presentations, panel discussions, and question and answer sessions.

2018 Quality Improvement Summit: Opioid Stewardship in Urology

The 2018 Summit was held on Dec. 8, 2018 at AUA Headquarters in Linthicum, MD.

2018 QI Summit Proceedings

Opioids Resources Tookit

Access slide presentations, videos and resource materials below.

Previous Summit Resources and Materials

2017 Quality Improvement Summit: Challenges and Opportunities for Stewardship of Urological Imaging 

2016 Quality Improvement Summit: Shared Decision Making and Prostate Cancer Testing

2014 Quality Improvement Summit Access: Infection Complications of Transrectal Prostate Needle Biopsy

Speakers will include a combination of healthcare providers such urologists, anesthesiologists, plastic surgeons, and pain management and addiction specialists, in addition to researchers, policy makers and others.

After attending the 2018 Quality Improvement Summit, participants will be able to:

• Explain the opioid epidemic in the context of surgical management of urologic diseases
• Describe steps that can be taken by urologists to influence the opioid epidemic
• Delineate roles urologists can play in combating the epidemic
• Identify opportunities to propose or implement new policies to combat the opioid epidemic   

During the summit, there will be ample opportunity for audience participation.  The cost to attend the QI Summit is $25 per attendee.  Following the summit, a proceedings paper will be published.

The AUA is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AUA designates this live activity for a maximum of 7.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Keynote

Session 1

Physician-led Multicomponent Interventions in Opioid Stewardship

Session 2

Understanding Postoperative Pain

Urology Perspectives: Challenging Urology Cases in Opioid Management

Session 3

High-Risk Patients and Exectations

Session 4

Policy and Outreach

*Dr. Murphy was scheduled to participate in the Quality Improvement Summit but was unable to do so due to unforeseen issues.

Videos

Part 1

Opening Remarks - Gregory Auffenberg, MD (00:00)

Keynote

The Role of Physicians and Prescription Pharmaceuticals in the Opioid Epidemic (12:00) - Chad Brummett, MD

Session 1: Physician-led Multicomponent Interventions in Opioid Stewardship

Procedure-specific Opioid Prescribing Guidelines (1:00:48) Richard J. Barth, MD

Opioid Reclamation Efforts (1:27:57) Jonah Stulberg, MD, PhD, MPH

MUSIC and Opioid Stewardship (1:49:34) Jim Dupree, MD

AUA Quality Improvement Summit: Keynote and Session 1 from AUA Digital Marketing on Vimeo.

Part 2

Session 2: Understanding Postoperative Pain

Pathophysiology of Post-Operative Pain (00:00) Brooke Chidgey, MD

Complementary Alternative Medicine Pain Management Strategies (15:58) Meghan Sperando-Fruge

Cognitive Behavioral Therapy and Other Non-Pharmacologic Approaches to Pain Management (41:34) Margaret Rukstalis, MD

Urology Perspectives: Challenging Urology Cases in Opioid Management

Introduction (1:17:05) Tudor Borza, MD

Kidney Stones Impact on Prescription Opioid Use (1:20:07) Vernon M. Pais, Jr., MD

The UNC Health Care System Opioid Stewardship Program (1:38:06) Matthew E. Nielsen, MD

Getting to Zero (1:49:18) Benjamin Davies, MD

AUA Quality Improvement Summit: Session 2 + Panel from AUA Digital Marketing on Vimeo.

Part 3

Session 3: High-risk Patients and Expectations

Expectation Setting for Opioid Prescribing (00:00) Behfar Ehdaie, MD

A Surgeon's Role in the Management of Opioid Misuse Disorders (31:50) Margaret Rukstalis, MD

The Role of Pain Specialists for Managing High-Risk Patients (55:55) Brooke Chidgey, MD

Session 4: Policy and Outreach

Opioid Education and Outreach (1:15:38) Jennifer Waljee, MD, MPH, MS

Opioid Prescribing and the FDA Safe Use Initiative (1:37:54) Scott Winiecki, MD

Closing Remarks (2:06:08) Timothy Averch, MD

AUA Quality Improvement Summit: Sessions 3 and 4 from AUA Digital Marketing on Vimeo.

The AUA recognizes the importance of including residents and fellows in events, especially those related to quality improvement and patient safety. Therefore, a program has been established to promote resident and fellow involvement in the Quality Improvement Summit. Now in its second year, the program awarded travel scholarships to seven individuals who attended the 2018 Quality Improvement Summit. As part of the event's concluding activities, these individuals shared their reflections on the program and what lessons they learned.

Christi Butler, MD

Dr. Butler is currently in residency at University of California, San Francisco and is also working on a certificate in patient advocacy from the University of California, Los Angeles. She attended the Warren Alpert Medical School at Brown University and earned an undergraduate degree from Harvard University.

Julia Finkelstein, MD

Dr. Finkelstein earned her undergraduate degree from Cornell University and her medical degree from New York University School of Medicine. She took her residency training at the New York-Presbyterian Hospital/Columbia University College of Physicians & Surgeons. She is currently a pediatric urology fellow at Boston Children’s. She will earn a Masters in Public Health this spring from the Harvard T.H. Chan School of Public Health.

Elizabeth A. Green, MD

After earning an undergraduate degree in bioengineering from the University of Pennsylvania, Dr. Green attended medical school at Vanderbilt University. She continued her internship and residency training at Vanderbilt.

Tim Large, MD, MS

Dr. Large is an endourology fellow in the Department of Urology of the Indiana University Methodist Hospital. He also completed his residency and internship at the Indiana University Hospital. He attended medical school at Georgetown University where he also received a Masters degree in physiology and biophysics. He earned his undergraduate degree from the University of Wisconsin-Madison.

Vikram Madhavan Narayan, MD

Dr. Narayan is completing a urologic oncology fellowship at the University of Texas MD Anderson Cancer Center. He underwent his residency training at the University of Minnesota and obtained his medical and undergraduate degrees from the University of Florida.

Ruchika Talwar, MD

Dr. Talwar is taking her residency training at University of Pennsylvania, Penn Medicine Health System. She attended Rutgers New Jersey Medical School, which was part of a seven-year accelerated bachelor of arts/medical degree program with the New Jersey Institute of Technology, Albert Dorman Honors College, where she earned her undergraduate degree.

Anna M. Zampini, MD, MS, MBA

Dr. Zampini is finishing her residency at the Glickman Urological and Kidney Institute, Cleveland Clinic Foundation in Cleveland, OH. While attending Tufts University School of Medicine, she simultaneously earned a Master of Business Administration in Health Management from Brandeis University Heller School of Social Policy and Management. Additionally, Dr. Zampini has a Master of Science in Nutritional Biochemistry and Metabolism from the Tufts University Friedman School of Nutrition Science and Policy. She earned her undergraduate degree from the University of Guelph.

As part of the follow up of their experience, the recipients shared feedback on the Summit and quality improvement in general.

1. How did you become involved in quality improvement?
   • Butler–I've always had an interest in vulnerable populations who feel the effects of poor quality healthcare the most. Quality improvement are simple ways of addressing just that by critically looking at how we do things and figure a way to make it better. Our institution values quality improvement and we take on a project annually as a department; so it's been ingrained in me for some time.
   • Finkelstein–While I sincerely appreciated many of the opportunities of residency training, I found myself seeking rewarding experiences outside of the urology department. In that pursuit, I discovered and joined the Housestaff Quality Council during my residency. As a member, I became heavily involved in an institution-wide initiative to decrease the incidence of catheter-associated urinary tract infections. Participation in this initiative was a crucial experience for me, providing an introduction to quality improvement processes.
   • Green–I became involved in quality improvement somewhat by accident. In my practice setting, we have a high rate of chronic opioid use. I always felt as though those patients undergoing major urologic procedures who were on preoperative narcotics stayed in the hospital longer and had higher complication rates than those who were not. When I reviewed the literature, I found examples of this sort of research in other fields but minimal data in urology. I spent my research block studying pre- and post-operative opioid use around cystectomy. I was shocked not just by the amount of preoperative opioid that patients were using but also by the amount of opioid we were prescribing postoperatively—multiple times recent guideline recommendation. Based on this finding I wanted to see if we could do better.
   • Large–I saw the QI program advertised through the AUA website. I thought the topic of opioid stewardship was extremely interesting. I had written about our experience with opioid free surgery and wanted to learn more about the topic of opioid reduction methods.
   • Narayan–In medical school, I helped co-direct a free clinic for uninsured patients that was sponsored by the family medicine department at the University of Florida. We had an overwhelming response from patients and others who came to the clinic to fill gaps in their healthcare, and we quickly needed to find ways to become more efficient so that we could help more people. I helped spearhead a process improvement project that tracked patients during each stage of their clinic visit to help find areas of waste and inefficiency, and we were able to shorten our wait times and ultimately expand the free clinic to more people in the city.
   • Talwar–As an intern on a surgical service, I became intimately aware of the many systems-level frustrations that often lead to delays in care, discharges, or near-misses in the post operative setting. When I tended to notice patterns, I looked for a way to formulate solutions with support from the administration. I joined the Quality and Safety Collaborative that consists of APPs and housestaff, which focused on event reporting using “safety huddles”, rapid debriefs of a recent safety event, as a key way to reduce error and miscommunication within our Division. We have also conducted re-enactments of events reported in our “Penn Safety Net” system, to analyze, discuss and prevent future errors and near misses.
   • Zampini–I developed an interest in quality improvement while in medical and while pursuing a dual MD/MBA. When I was a 4th year resident I was able to pursue several quality initiatives within my Department and worked directly with the Quality Director of the Urology Department. For the following 2-3 years, I have continued to be involved with quality initiatives and now serve as the chief urology resident responsible for quality improvement projects.
2. How did you become interested in opioid stewardship?
   • Butler–I became involved with quality improvement as a part of my 5th year research interests. I saw the impact the opioid epidemic was having on our country and the roll as surgeons that we play and wanted to take on a project that addressed this.
   • Finkelstein–Towards the end of my Urology residency and now as a Fellow in Pediatric Urology and Patient Safety and Quality at Harvard Medical School, I have become particularly interested in opioid use (and misuse). Appropriate use of opioids is often required to effectively manage moderate-to-severe pain in children. Yet, published guidance regarding opioid treatment for pediatric patients is limited, which has led to tremendous variation in opioid prescribing in this population.
   • Large–I went to a course where one of the international speakers put up his list of postoperative PRN medications to manage stent pain after ureteroscopy (URS). There was no narcotic listed. My mentor suggested we stop using narcotics after URS. From that point forward, we have been narcotic free. We published out experience on the new clinical practice. It is not without its challenges. Managing patient expectations is the hardest task when adopting a narcotic free approach to surgery.
   • Narayan–My co-residents and I noticed during residency at the University of Minnesota that we often prescribed post-operative pain medications based on guidelines given to us by our prior seniors, or simply out of habit based on “what we had seen done before.” Like much of the country, we were dismayed by the growing opioid epidemic nationally and wanted to do our part to minimize the surgeon-driven surplus medication in the community. We ran a QI initiative during our chief year that tracked the amount of opioids prescribed to patients undergoing outpatient endoscopic surgery, surveyed patients to find out how much they actually used, and issued new guidelines to our junior residents to drastically reduce and in some cases eliminate opioid prescription altogether for certain procedures. We tracked the impact of these efforts on patient outcomes and found no significant increase post-operatively in patients seeking new opioid prescriptions, ER visits, or in readmissions, and in the process I think we were able to successfully make a lasting impact on the way our residents thought about responsible opioid prescribing.
   • Talwar–During my time as the primary intern for the urology service, I quickly noticed our inconsistent practice patterns with regards to pain management after robotic surgery. During the week, our patients were discharged with 30 pills, regardless of whether or not they were used as an inpatient. On the weekends, the discharge narcotic regimen varied greatly depending on who was on call. Our outpatient providers commented that patients would return unused pill bottles to their outpatient appointments, hoping to dispose of them. This led to a quality improvement project to study the Penn Urology practice patterns with respect to post-operative pain. After analyzing our preliminary data, it was clear that we grossly overprescribed narcotics. In response, we developed a multimodal, opioid-free, peri/post-operative pain management strategy, recently implemented for all robotic urologic procedures at the Hospital of University of Pennsylvania. For patients whose pain is not controlled on our baseline multimodal regimen, we created a step-wise escalation algorithm including stronger pain medication options. Our ureteroscopic procedures for nephrolithiasis are also opioid free, and we are administering validated surveys at various time points to prospectively collect patient-reported outcomes data regarding pain intensity and interference. Armed with this data, we hope to better understand the patient experience after urologic procedures to adequately and treat pain while curbing our contribution to the opioid epidemic.
   • Zampini–I was inspired to pursue opioid stewardship in two ways. One, by hearing the Attorney General speak on the Turn the Tide campaign and two, by becoming involved in an opioid research study. The Turn the Tide campaign, then appeared to be, and still is, very relevant to the patient population in Ohio. I was concerned that we were did not have enough information around appropriate opioid prescribing in Urology and started working on a new quality project to exam opioid prescribing and patient use within our department.
3. What takeaways from the Quality Improvement Summit will/have you tried to introduce to your practice?
   • Butler - Certainly the most impactful message that was re-iterated was the number of unused opioids per prescription written. I enjoyed hearing the different approaches people are taking to address this: no narcotics, limiting to prescriptions pills to less than 10, providing disposal bags.
   • Finkelstein - At the QI summit, it was very helpful to find out about other providers’ efforts in this domain. While the focus was on adult populations, the general information and many of the practices could be applied to our pediatric patients. We are working to record postoperative narcotic use and pain information stratified by procedure. As demonstrated at the summit, we hope to create pocket cards with a standardized amount of postoperative opioids that should be prescribed for specific procedures. We are also trying to improve our education about opioid disposal, as a result of the knowledge that I gained at the summit.
   • Green - My main takeaway was that there is limited data in our field on exactly what we are prescribing, what patients are using, and what we should be prescribing. I was also impressed by the recurrent theme that patients will take more opioid if they are given more and that there is no connection between the amount of narcotic given and patient complaints.
   • Large - The first takeaway is that there is now data to alleviate the anxiety for providers about avoiding/minimizing the use of narcotics. I hope to present to our group on the benefits of adopting a narcotic free surgery and the resources available to help providers manage expectations about postoperative pain. I also was surprised that the problem with opioids is two-fold for physicians. The first issue is that we are often the source for the initial exposure - and that working to minimize exposure to opioid naive patients should be a major priority. However, the second factor that had a more lasting impact is that 60% of narcotics are obtained from unused opioids at friends/family homes and that destruction of unused opioids should be of equal importance in the battle against the opioid crisis.
   • Narayan - The first takeaway was the fact that prescribing more opioids after surgery was not associated with improved patient satisfaction. One of the concerns that had been raised by many of our peers during our QI initiative in residency was that, while yes, patients may not necessarily be returning to the ER or asking for more medications—what if they were suffering at home silently? It was nice to see reassuring data in this regard be presented at the summit. The second takeaway was the importance of setting expectations with patients pre-operatively. One of the talks went into great lengths to explain how a key part of pre-op counseling should be to tell patients that they may have some pain, and explain how this pain would be addressed. I think this is particularly important for patients who have chronic pain and may already be opioid dependent. I plan to regularly talk to patients now about pain management as part of my pre-op counseling routine. Finally, the opioidprescribing.info website has been an immensely useful point of reference.
   • Talwar - The collaborative spirit of the summit brought a lot of different perspectives into the spotlight. There was an extensive network of engaged urologists, anesthesiologists, and psychiatrists, all with a fresh and unique take on opioid stewardship. Personally, I will attempt to draw upon many of the communication based suggestions on appropriate pre-operative expectation setting. Patients should have realistic goals regarding pain control after surgery. I don’t believe that we, as clinicians, stress that pain needs to be at a level that allows an individual to function, not fully eliminated in the immediate recovery period. Additionally, leveraging payers to incentivize a standardized number of narcotic pills allows us to reduce variations in similar practices, as MUSIC has done through their Modifier-22 program. Many practices across the nation have similar regional collaboratives. Partnering with individuals within the policy sphere and insurance companies ensures all stakeholders work towards the same, patient-centered goal.
   • Zampini - I have been inspired by several aspects of the Quality Improvement Summit! 1. There is need for further information regarding appropriate opioid prescribing and patient education on appropriate opioid use and multimodal analgesia. 2. There is a need for greater information on and access to opioid disposal. We are working on reassessing our opioid prescribing and creating better prescribing guidelines. I have also spoken with several staff regarding a Drug Take Back event and obtaining MedSafe disposal units in our clinics.
4. The AUA is eager to involve young urologists like you in quality improvement. What advice do you have for the AUA? What projects would be of interest?
   • Finkelstein - I think it is important to offer opportunities such as this travel scholarship for trainees to attend QI events. It is important to provide these opportunities and others to connect trainees with established urologists who can provide mentorship as well as with other trainees carrying out similar work. I am sure there would be interest in work on minimally invasive surgery. As a pediatric urologist, there is interest in developing transitional care programs and collaborating on this.
   • Green - I think opportunities such as this are the perfect way to involve young urologists. I was impressed to find that many of the trainees who were present at the Quality Improvement Summit felt as though the trainees and junior faculty were the ones driving practice change around opioid stewardship. Many of the trainees, however, were leading these efforts without direct access to thought leaders in the field and with only the sparse published data on the topic. The travel scholarships gave people like me who had the desire to affect change the data and resources to help sell these changes in clinical practice.
   • Large - Whenever there is a major event such as the QI summit, having a scholarship program to get motivated young urologists out to the AUA headquarters is important. Seeing the history of our specialty reinforces the fact that urologists are an organized and motivated group of physicians that bring about change they want to see in healthcare. It also serves to show that collaboration is key and that we succeed most when we work as a group rather than as individuals.
   • Narayan - One of the things we need to be better at is anticipating the next “crisis” before it actually becomes a crisis. The AUA already does a great job of publishing white papers and guidelines to help minimize the inefficiencies associated with non-standardized care, and to provide synthesized guidance to urologists where the data might be confusing. I have two project ideas:
     1. First, one area we as urologists should be leaders in is improving access to care for the diseases we treat. For example, most patients with testicular cancer have a curable disease, but concerns over insurance access and costs of seeing a urologist (in this young and often poorly insured population) cause many patients to skip expensive follow-up visits or treatments, leading them to return only when they have symptoms of advanced disease. Tracking this and promoting changes at the national level is likely necessary to improve this problem. Additionally, bladder cancer is among the most expensive malignancies we treat as urologists because of the follow-up, chemotherapy, intravesical therapy, and morbidity from therapy, yet there has been little to no improvement in outcome disparities by race over the past decade, almost all of which can likely be attributed to access of care issues. The AUA should expand the AQUA registry (or similar) to bladder cancer patients to help us keep track of variations in practice patterns, its influence on cost, and access to care. My suspicion is that access to effective intravesical therapies such as BCG widely varies around the country and this in turn increases the overall bladder cancer disease burden.
     2. Second, drug shortages have become a big problem in many parts of the country, particularly as health care systems have merged and have been able to store surplus medications for themselves. In residency, among the items that we often faced “shortages” of included normal saline (affecting CBI, TURPs, and other endoscopic procedures), BCG (a known issue since there is only one manufacturer currently in the country), and tamsulosin (!), which happened at the VA. These shortages usually lead to delays in care, higher expenses for the patient, or use of second-line treatment paradigms with often less than optimal outcomes. How often do these shortages affect the care urologists provide around the country? Which parts of the country are affected the most and why? What are the alternatives most urologists use if the “first-line” therapy is unavailable and what guidelines can we develop for clinicians in this regard? We need to undertake studies to address these questions to help us formulate possible solutions.
   • Talwar - Opportunities like the summit scholarship are extremely educational and a great source of exposure for training urologists. It serves as a platform to share and exchange ideas. If the AUA would be willing to facilitate and fund QI projects led by residents on a multi-institutional level, it would allow us to build upon the connections made at such events and benefit from pooling resources that are unique, but otherwise limited, to each individual institution.
   • Zampini - I plan to continue to work in the area of quality improvement throughout my career. For me, it is a way to incorporate best practices into daily urology practice. I would say to the AUA to continue to invite urology trainees to the Quality Improvement Summits in years to come, perhaps facilitate trainees becoming involved in AUA meetings and discussion on QI, either in person, or remotely (call in meeting). Quality Podcasts describing best practices could be nice as well.