PD28-05: Harnessing Choice Architecture in Urologic Practice: Implementation of an Opioid-Sparing Protocol Grounded in Behavioral Theory

Saturday, September 11, 2021 8:00 PM to 10:00 PM


Authors: Alex Nourian, Adrien Bernstein, Marshall Strother, Andres Correa, Rosalia Viterbo, Richard Greenberg, David Chen, Marc Smaldone, Robert Uzzo, Alexander Kutikov

Introduction: Narcotics are prescribed excessively following surgery and may lead to persistent opioid use. As many urologic oncology procedures are performed minimally invasively, an opportunity exists to push forward initiatives to minimize postoperative narcotic use. Here we report an effort to change entrenched clinical practice based on modern behavioral economics principles.

Methods: A quality improvement initiative to reduce inpatient opioid prescribing was launched in December 2019 at a tertiary cancer referral center. In phase I (December 2019-July 2020), urology providers were instructed to avoid postoperative opioids. Phase II (beginning August 2020) was grounded in social cognitive and nudge therapy and provided education to the entire care team (nurses, housestaff, and attendings) and order set modification to reflect an opioid sparing protocol (OSP). To assess efficacy, we analyzed the proportion of robotic prostatectomy (RALP) patients monthly that adhered to an OSP during each phase. Patient characteristics were compared by phase using Fisher’s exact and Pearson’s chi-square to compare categorical variables and Wilcoxon rank sum to evaluate continuous covariates. Logistic regression adjusting for phase, age, history of anxiety, depression or opioid use, assessed odds of adherence to OSP.

Results: During phase I and II, 187 and 83 patients underwent RALP, respectively. 517 RALP patients from the preceding 2 years were selected for comparison. In the three cohorts, there were similar overall frequencies of patients with histories of anxiety (5.8%), depression (4.7%), and prior opioid use (9.4%).  Adherence to the OSP substantially increased during each subsequent phase (85.5% vs 43.3% vs 20.9% respectively, p<0.001). The multivariable logistic regression also demonstrated significantly greater adherence to the OSP for patients in phase II (OR 21.6, 95% CI 10.3-45.5) and phase I (OR 2.7, 95% CI 1.6-4.5) compared with the baseline cohort.

Conclusions: Adherence to an OSP is most effective when initiatives incorporate the entire care team and are supported by nudge therapy-based structural changes.  Using these strategies, most patients following robotic prostatectomy can avoid  narcotics postoperatively.

Source of Funding: None.

Therapeutic Area
Health PolicyPractice Management