BACKGROUND:The American Urological Association White Paper on Implementation of Shared Decision Making (SDM) into Urological Practice suggested SDM represents the state of the art in counseling for patients who are faced with difficult or uncertain medical decisions. The Michigan Urological Surgery Improvement Collaborative (MUSIC) implemented a decision aid, Personal Patient Profile-Prostate (P3P), in 2018 to help newly diagnosed prostate cancer patients make shared decisions with their clinicians. We conducted a qualitative study to assess statewide implementation of P3P throughout MUSIC.METHODS:We recruited urologists and staff from 17 MUSIC practices (8 implementation and 9 comparator practices) to understand how practices engaged patients on treatment discussions and to assess facilitators and barriers to implementing P3P. Interview guides were developed based on the Tailored Interventions for Chronic Disease (TICD) Framework. Interviews were transcribed for analysis and coded independently by two investigators in NVivo, PRO 12. Additionally, quantitative program data were integrated into thematic analyses.RESULTS:We interviewed 15 urologists and 11 staff from 16 practices. Thematic analysis of interview transcripts indicated three key themes including the following: (i) P3P is compatible as a SDM tool as over 80% of implementation urologists asked patients to complete the P3P questionnaire routinely and used P3P reports during treatment discussions; (ii) patient receptivity was demonstrated by 370 (50%) of newly diagnosed patients (n = 737) from 8 practices enrolled in P3P with 78% completion rate, which accounts for 39% of all newly diagnosed patients in these practices; and (iii) urologists' attitudes towards SDM varied. Over a third of urologists stated they did not rely on a decision aid. Comparator practices indicated habit, inertia, or concerns about clinic flow as reasons for not adopting P3P and some were unconvinced a decision aid is needed in their practice.CONCLUSION:Urologists and staff affiliated with MUSIC implementation sites indicated that P3P focuses the treatment discussion on items that are important to patients. Experiences of implementation practices indicate that once initiated, there were no negative effects on clinic flow and urologists indicated P3P saves time during patient counseling, as patients were better prepared for focused discussions. Lack of awareness, personal habits, and inertia are reasons for not implementing P3P among the comparator practices.

You have accessJournal of UrologyStone Disease: Surgical Therapy IV (PD54)1 Sep 2021PD54-04 THE MICHIGAN UROLOGICAL SURGERY IMPROVEMENT COLLABORATIVE APPROPRIATENESS CRITERIA FOR URETERAL STENT OMISSION FOLLOWING UNCOMPLICATED URETEROSCOPY FOR URINARY STONE DISEASE Spencer C. Hiller, Stephani Daignault-Newton, S. Mohammad Jafri, Ronald Rubenstein, Mazen Abdelhady, C. Peter Fischer, Elena Gimenez, Richard Sarle, William W. Roberts, Conrad Maitland, Rafid Yousif, Robert Elgin, Laris Galejs, Jeremy Konheim, David Leavitt, Eric Stockall, J. Rene Frontera, J. Stuart Wolf, John M. Hollingsworth, Casey A. Dauw, Khurshid R. Ghani, and for the Michigan Urological Surgery Improvement Collaborative Spencer C. HillerSpencer C. Hiller More articles by this author , Stephani Daignault-NewtonStephani Daignault-Newton More articles by this author , S. Mohammad JafriS. Mohammad Jafri More articles by this author , Ronald RubensteinRonald Rubenstein More articles by this author , Mazen AbdelhadyMazen Abdelhady More articles by this author , C. Peter FischerC. Peter Fischer More articles by this author , Elena GimenezElena Gimenez More articles by this author , Richard SarleRichard Sarle More articles by this author , William W. RobertsWilliam W. Roberts More articles by this author , Conrad MaitlandConrad Maitland More articles by this author , Rafid YousifRafid Yousif More articles by this author , Robert ElginRobert Elgin More articles by this author , Laris GalejsLaris Galejs More articles by this author , Jeremy KonheimJeremy Konheim More articles by this author , David LeavittDavid Leavitt More articles by this author , Eric StockallEric Stockall More articles by this author , J. Rene FronteraJ. Rene Frontera More articles by this author , J. Stuart WolfJ. Stuart Wolf More articles by this author , John M. HollingsworthJohn M. Hollingsworth More articles by this author , Casey A. DauwCasey A. Dauw More articles by this author , Khurshid R. GhaniKhurshid R. Ghani More articles by this author , and for the Michigan Urological Surgery Improvement Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002081.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteral stents are associated with pain and urinary symptoms. Despite guidelines recommending stent omission following uncomplicated ureteroscopy (URS), they are frequently placed. We sought to define clinical scenarios suitable for stent omission by use of the RAND/UCLA Appropriateness Methodology. METHODS: We convened a panel of 15 urologists representing diverse practices from the Michigan Urological Surgery Improvement Collaborative (MUSIC). Panelists defined uncomplicated URS and agreed on 7 variables that influence stent decision-making: stone size, location, pre-stenting, urinalysis/culture result, ureteral dilation, ureteral access sheath, fragment status. Over 2 rounds, panelists scored 144 clinical scenarios for stent omission appropriateness based on all combinations of variables, from 1 (highly inappropriate) to 9 (highly appropriate). Median scores 1 to 3 were inappropriate; 4 to 6, uncertain; and 7 to 9, appropriate. Multivariable analysis was used to determine the odds of each variable being scored appropriate for omission. Panel findings were then applied to prior stenting practices for uncomplicated URS within MUSIC. RESULTS: Of the 144 scenarios, 88 (61%) were inappropriate for omission and 26 (18%) were appropriate for omission (Fig. 1). All variables impacted stent omission decision-making (Fig. 2). Stenting rates in MUSIC correlated with panel results (Fig. 3). Among cases highly appropriate for omission, stents had been placed in 55%. CONCLUSIONS: We identified 26 clinical scenarios appropriate for stent omission. Implementation of these results into real-world practice will help reduce stenting rates, with the goal to decrease patient morbidity and improve the quality of care. Source of Funding: Blue Cross Blue Shield of Michigan © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e923-e924 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Spencer C. Hiller More articles by this author Stephani Daignault-Newton More articles by this author S. Mohammad Jafri More articles by this author Ronald Rubenstein More articles by this author Mazen Abdelhady More articles by this author C. Peter Fischer More articles by this author Elena Gimenez More articles by this author Richard Sarle More articles by this author William W. Roberts More articles by this author Conrad Maitland More articles by this author Rafid Yousif More articles by this author Robert Elgin More articles by this author Laris Galejs More articles by this author Jeremy Konheim More articles by this author David Leavitt More articles by this author Eric Stockall More articles by this author J. Rene Frontera More articles by this author J. Stuart Wolf More articles by this author John M. Hollingsworth More articles by this author Casey A. Dauw More articles by this author Khurshid R. Ghani More articles by this author for the Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement Loading ...

OBJECTIVES To evaluate patient factors associated with post-ureteroscopy opioid prescriptions, provider-level variation in opioid prescribing, and the relationship between opioid-free discharges and ED visits. METHODS This is a retrospective analysis of a prospective cohort study of adults age 18 years and older who underwent primary ureteroscopy for urinary stones from June 2016 to September 2019 within the Michigan Urological Surgery Improvement Collaborative (MUSIC) Reducing Operative Complications from Kidney Stones (ROCKS) quality improvement initiative. Postoperative opioid prescription trends and variation among practices and surgeons were examined. Multivariable logistic regression models defined risk factors for receipt of opioid prescriptions. The association among opioid prescriptions and postoperative ED visits within 30 days of surgery was assessed among complete case and propensity matched cohorts, matched on all measured characteristics other than opioid receipt. RESULTS 13,143 patients underwent ureteroscopy with 157 urologists across 28 practices. Post-ureteroscopy opioid prescriptions and ED visits declined (86% to 39%, P<.001; 10% to 6%, P<.001, respectively). Practice and surgeon-level opioid prescribing varied from 8% to 98%, and 0% to 98%, respectively. Patient-related factors associated with opioid receipt included male, younger age, and history of chronic pain. Procedure-related factors associated with opioid receipt included pre- and post-ureteroscopy ureteral stenting and access sheath use. An opioid-free discharge was not associated with increased odds of an ED visit (OR 0.77, 95% CI 0.62-0.95, P=.014). CONCLUSIONS There was no increase in ED utilization among those not prescribed an opioid after ureteroscopy, suggesting their routine use may not be necessary in this setting. (C) 2021 Elsevier Inc.

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Quality Improvement & Patient Safety I (PD05)1 Apr 2020PD05-03 OPIATE OMISSION AFTER URETEROSCOPY DOES NOT LEAD TO INCREASED EMERGENCY DEPARTMENT VISITS: RESULTS FROM A STATEWIDE QUALITY IMPROVEMENT COLLABORATIVE Scott Hawken*, Spencer Hiller, Kavya Swarna, Jill Slayton, Conrad Maitland, David Wenzler, John Hollingsworth, Khurshid Ghani, Casey Dauw, and for the Michigan Urological Surgery Improvement Collaborative Scott Hawken*Scott Hawken* More articles by this author , Spencer HillerSpencer Hiller More articles by this author , Kavya SwarnaKavya Swarna More articles by this author , Jill SlaytonJill Slayton More articles by this author , Conrad MaitlandConrad Maitland More articles by this author , David WenzlerDavid Wenzler More articles by this author , John HollingsworthJohn Hollingsworth More articles by this author , Khurshid GhaniKhurshid Ghani More articles by this author , Casey DauwCasey Dauw More articles by this author , and for the Michigan Urological Surgery Improvement Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000825.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Emergency department (ED) visits after ureteroscopy (URS) are common and are often due to postoperative pain. As a part of a statewide quality initiative to reduce ED visits, we sought to determine if opiate omission following URS is associated with unintended consequences, such as increased ED visits. METHODS: The Michigan Urological Surgery Improvement Collaborative’s Reducing Operative Complications from Kidney Stones (MUSIC ROCKS) initiative was established in 2016. It is comprised of urologists across the state whose goal is to improve the care of patients with stone disease. We identified patients that underwent primary URS and examined quarterly trends in postoperative opiate prescription. Variation in opiate prescribing was assessed at the practice level. Using demographic, clinical, and operative data, we constructed a multivariable model to define risk factors for opiate prescription. After adjusting for patient and practice-level factors, we determined whether opiate omission was associated with postoperative ED visits within 30 days of surgery. RESULTS: We identified 9,268 patients who underwent URS (2016-2019). Post-URS opiate prescriptions have shown an absolute decline of 43.4% since the inception of MUSIC ROCKS (Figure). There was wide variation in practice-level opiate use (8.8% to 98.7%, p<0.01). The odds of receiving an opiate were higher in males (OR 1.32, 95%CI 1.17-1.49, p<0.01), those with a stent (OR 1.72, 95%CI 1.49-1.99, p<0.01), or a diagnosis of chronic pain (OR 1.68, 95%CI 1.01-2.66, p=0.04). Those less likely to receive opioids were older (OR 0.99, 95%CI 0.98-0.99, p<0.01), had greater comorbidity (OR 0.82, 95%CI 0.69-0.98, p=0.03), and were prescribed an NSAID (OR 0.23, 95%CI 0.19-0.28, p<0.01). Omission of opiates following URS was not associated with increased ED visits (OR 0.83, 95%CI 0.67-1.04). CONCLUSIONS: Since establishment of a statewide quality improvement program in Michigan, opiate prescriptions following URS have declined substantially without an increase in ED visits. Patient factors and practice variation contribute to the risk of receiving an opiate underscoring the need for continued efforts in this area. Source of Funding: funding from Blue Cross Blue Shield of Michigan © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e84-e85 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Scott Hawken* More articles by this author Spencer Hiller More articles by this author Kavya Swarna More articles by this author Jill Slayton More articles by this author Conrad Maitland More articles by this author David Wenzler More articles by this author John Hollingsworth More articles by this author Khurshid Ghani More articles by this author Casey Dauw More articles by this author for the Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Quality Improvement & Patient Safety I (PD05)1 Apr 2020General & Epidemiological Trends & Socioeconomics: Quality Improvement & Patient Safety I (PD05) View All Author Informationhttps://doi.org/10.1097/JU.0000000000000825AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Expand All Advertisement PDF downloadLoading ...

A 65-year-old male adult foster care patient presented to the emergency room with altered mental status and respiratory depression which required intubation. The patient was also found to be hypoglycemic and hypertensive. He was admitted to the medical intensive care unit where a chronic type B aortic dissection and an exophytic superior pole right renal mass measuring 4.5 × 5.5 cm were discovered on computed tomography scan (Fig. 1). He continued experiencing recurrent episodes of hypoglycemia during his admission and was placed on double portion meals and intravenous glucose with dextrose 10% (D10) in water. Following a hyponatremic episode, the patient was switched to dextrose 5% in normal saline (D5NS) with dextrose 50% (D50) and glucagon provided as needed for persistent hypoglycemia, all of which hindered his discharge. The work-up completed by his primary team concluded that the patient's hypoglycemia was likely due to a paraneoplastic syndrome due to the right renal mass. Biopsy of the renal mass showed low-grade clear cell papillary type renal cell carcinoma (RCC). Urology was subsequently consulted for possible right radical nephrectomy.