Dr. Dowling is president of Dowling Medical Director Services, a private health care consulting firm specializing in quality improvement, clinical informatics, and health care policy affecting specialty care. He is the former medical director of a large, 

Robert A. Dowling, MD

According to the Centers for Disease Control and Prevention, antibiotic resistance is an urgent public health problem that is responsible for over 2.8 million infections and more than 35,000 deaths annually in the United States.

 Antibiotic prescriptions per capita vary widely across the US, and the misuse of antibiotics has undoubtedly contributed to the growing problem of resistance. We know that sepsis after prostate biopsy is more common in patients with a history of previous antibiotic use and is frequently due to resistant organisms. In this the second in a series of articles based on Medicare Part D prescription data, I will describe the Part D antibiotic prescribing habits/norms/benchmarks of urologists.

The Centers for Medicare & Medicaid Services recently updated its information on prescription claims for Medicare beneficiaries enrolled in Part D (Prescription Drug Coverage) aggregated by provider and drug to include 2019 data.

 (About two-thirds of Medicare beneficiaries are enrolled in Part D drug plans.) A related data set includes summary information on opioid and antibiotic prescribing rates. These data sets suppress information on providers or drugs with 10 or fewer claims because of the small chance of identifying a patient, but contain enough information to serve as good benchmarks in my opinion.

A total of 1.5 billion Part D claims involving 1.24 million Medicare providers were submitted in 2019, including 60 million antibiotic claims. The antibiotic prescribing rate can be defined as the number of antibiotic claims/all Part D claims (expressed as %), and averages 4.0% for all specialties. The specialties with the highest antibiotic prescribing rates are dental specialties (54%), plastic and reconstructive surgery (30%), infectious disease (23%), and colorectal surgery (22%). The overall antibiotic prescribing rate for urology in Part D was 18%. A total of 117 unique antibiotic drugs were prescribed in 2019; the top 20 drugs prescribed among all providers are listed in 

In 2019, 8815 urologists prescribed 2.5 million prescriptions (5.4%) of 46 types of antibiotics, the highest ranked non–primary care specialty (

). The most common drugs prescribed by urologists in 2019 to Part D beneficiaries were ciprofloxacin hcl, sulfamethoxazole/trimethoprim, cephalexin, and nitrofurantoin (

). Unlike for opioids—of which urologists tend to have 1 or 2 favorite drugs—most urologists prescribed 3 to 7 different antibiotics in 2019.

How do your habits compare to those of other urologists? To view your data, go to https://bit.ly/3tS5L86, search for your national provider identifier or name, and scroll to the column marked [Antbtc_Tot_Clms]. Compare your number of antibiotic claims to the benchmarks in 

. For example, if you are associated with 500 antibiotic claims, you prescribed more antibiotics than 85% of your urology peers in this data set. Keep in mind, although Medicare beneficiaries typically comprise a significant fraction of a urology practice, your prescribing habits reflected here may not be generalizable to all patients.

How do antibiotics contribute to the cost of prescription medicines in the Part D program? Antibiotics are relatively inexpensive drugs, which may contribute to the potential for overuse. The total cost for antibiotic claims in 2019 was $1.5 billion, a small fraction of total Part D spending. Urology antibiotic claims totaled only $32 million. There is some variation in cost among the class (nitrofurantoin and doxycycline are the most expensive), all of which are readily available as generic drugs (

Urologists prescribe antibiotics to Part D beneficiaries in higher quantities and rates than most other specialists, including surgical specialists; it is the nature of the specialty. It is well established that antibiotic overuse and misuse (for example, inappropriate duration) contribute to community resistance, and urologists are positioned to be important stewards of antibiotic prescribing. Key opportunities in urology include limiting antibiotic prophylaxis to 24 hours. Clinical guidelines and best practice statements for the appropriate indications, drugs, and durations are available from specialty societies including the American Urological Association

 and the Infectious Diseases Society of America (

). Medicare Part D data on each individual prescriber are readily available to urologists, patients, and the public and can be used to compare your prescribing habits against national and specialty benchmarks.

1. Antibiotic prescribing and use. Centers for Disease Control and Prevention. Updated October 7, 2021. Accessed April 21, 2022. 

2. Medicare Part D prescribers – by provider and drug. Centers for Medicare & Medicaid Services. Updated August 31, 2021. Accessed April 21, 2022. 

3. Urologic procedures and antimicrobial prophylaxis (2019). American Urological Association. June 2019. Accessed April 21, 2022. 

Articles

Urologists prescribe at rates higher than many other specialties.

Part D data reveal how urologists are prescribing antibiotics

 focusing on the urologist’s role as a responsible prescriber of opioids in the context of an ongoing crisis of opioid overuse, abuse, and deaths in this country. I noted that urologists—relative to other specialties—collectively prescribed opioids in 2018 in numbers and rates lower than the national average. This information comes from publicly available Medicare Part D prescription claims data, which include detailed prescriber information. In this, the first in a series of articles based on this data set, I will provide an update on the Part D prescribing habits/norms/benchmarks of urologists, beginning with an update on opioids.

Several developments have led to the widespread availability of your prescribing activity. First, of course, is the widespread adoption of electronic prescribing. Large networks (ie, Surescripts) connecting electronic health record (EHR) systems, pharmacy benefit managers, retail and specialty pharmacies, and health plans generate big data based on your prescriptions. Second, legislative and regulatory activity at the state and federal levels now generally mandate electronic prescribing—increasing the completeness and value of these data sets. Third, all 50 states now have requirements to consult a statewide registry (prescription drug monitoring program) when prescribing controlled substances.

Finally, in recent years, the Centers for Medicare & Medicaid Services (CMS) has made Medicare and Medicaid spending data available at the provider level—including prescription claims. Large, multinational companies (eg, IQVIA) have aggregated your prescribing data and commercialized it to help pharmaceutical companies deploy their marketing and sales forces, guide research efforts, and develop strategic plans. These companies may know a lot more about your habits than you do.

Data on your Medicare Part D prescriptions are also available to you for free. Another good source of your prescribing data is your EHR—most have basic reporting on provider and drug. But your EHR cannot benchmark your habits to urologists outside your own practice. That is where you need a public data source.

CMS recently updated its information on prescription claims for Medicare beneficiaries enrolled in Part D (prescription drug coverage) aggregated by provider and drug to include 2019 data.

 (Approximately two-thirds of Medicare beneficiaries are enrolled in Part D drug plans.) A related data set includes summary information on opioid and antibiotic prescribing rates. These data sets suppress information on providers or drugs with 10 or fewer claims because of the small chance of identifying a patient but contain enough information to serve as good benchmarks.

A total of 1.5 billion Part D claims involving 1.24 million Medicare providers were submitted in 2019, including 65 million opioid claims (down almost 6% from 2018). The opioid prescribing rate is measured as the number of opioid claims/all Part D claims (expressed as a percentage), and averages 4.3% for all specialties. The specialties with the highest opioid prescribing rates are pain management (57%), anesthesia (53%), hand surgery (48%), physical medicine and rehabilitation (40%), and orthopedic surgery (36%). Urology ranks 82nd among specialties in overall opioid prescribing rate at 2.8% of claims. Collectively, urologists were identified with 390,982 opioid claims in 2019, down 6.4% from the previous year. The average number of Part D opioid claims/urology provider was 57, about the same as in 2018.

How do your habits compare with those of other urologists? In 2019, 6182 urologists prescribed 18 types of opioids (

). The most common drugs were hydrocodone/acetaminophen (48%), oxycodone HCl/acetaminophen (22%), and tramadol HCl (14%). Most urologists (93%) prescribed only 1 or 2 opioid drug types (

. To view your data, go to https://bit.ly/3tS5L86 and search for your National Provider Identifier or name, and scroll to the column marked [Opioid_Tot_Clms]. Compare your number of opioid claims with the benchmarks in 

. For example, if you are associated with 65 opioid claims, you prescribed more opioids than 70% of your peers in this data set. You can also compare your opioid prescribing rate with the urology benchmarks; a rate of 10% means your prescribing rate is more than 90% of urologists. Keep in mind that although Medicare beneficiaries typically account for a significant fraction of a urology practice, your prescribing habits reflected here may not be generalizable to all patients.

How do opioids contribute to the cost of prescription medicines in the Part D program? Opioids are relatively inexpensive drugs, which may contribute to the potential for abuse. The total cost for opioid claims in 2019 was
$2.8 billion, a fraction of total Part D spending. Urology opioid claims totaled only $3.2 million. There is considerable variation in cost among the class, all of which are readily available as generic drugs (Table 1).

Urologists prescribe opioids to Part D beneficiaries in smaller quantities and rates than most other specialists, including surgical specialists. It has been estimated that 6% to 9% of urologic surgery patients show evidence of persistent opioid use 3 months after their surgery,

 and it is encouraging from a public health perspective that fewer opioid claims were filed in 2019 than 2018. Urologists should be aware of the small but significant risk of opioid prescription leading to persistent use or even abuse and follow specialty guidelines for counseling and prescribing.

 Medicare Part D data on each individual prescriber are readily available to urologists, patients, and the public and can be used to compare your prescribing habits against national and specialty benchmarks. 

1. Dowling RA. The urologist’s role as a responsible opioid prescriber. 

. May 31, 2021. Accessed March 30, 2022. https://bit.ly/3ITBn1x

2. Medicare Part D prescribers - by provider and drug. Centers for Medicare & Medicaid Services. Updated August 31, 2021. Accessed March 30, 2022. https://bit.ly/3qO8wFE

3. Ziegelmann MJ, Findlay BL, Britton CJ, Habermann EB. Opioid prescribing after urologic surgery: we are part of the problem and part of the solution-an invited commentary on “an opioid prescription for men undergoing minor urologic surgery is associated with an increased risk of new persistent opioid use”. 

. 2020;9(3):997-1000. doi:10.21037/tau-2020-05

4. AUA position statement: opioid use. American Urological Association. Updated January 2019. Accessed March 30, 2022. https://bit.ly/3uC3FHl

5. Prescription opioids: what you need to know. Centers for Disease Control and Prevention. May 9, 2016. Accessed March 30, 2022. https://bit.ly/3o1XxFU

Medicare Part D data reveal how urology compares with other specialties.

How often are urologists prescribing opioids?

Physicians in many specialties continue to derive substantial revenue from administering drugs reimbursed by Medicare Part B, commonly referred to as “’buy and bill.” Under current rules, physicians are reimbursed based upon the average sales price of a drug plus 6%, adjusted for sequestration. In November 2021, the Centers for Medicare & Medicaid Services (CMS) formally rescinded a proposed rule—the Most Favored Nation Model—for Medicare Part B drugs and biologicals that would have indexed payments for Part B drugs to the reduced amounts paid by peer countries and tested a flat add-on fee to replace the current model of average sales price plus a percentage.

The policy concerns that led to this (now canceled) proposed measure still exist: growth in drug costs, growth in drug utilization, and a perception that the current reimbursement model encourages the use of more expensive drugs and overutilization. The top specialties paid under part B in 2019 were ophthalmology, hematology-oncology, rheumatology, internal medicine, family practice, neurology, and urology. In this article, I update the spending and costs for Medicare Part B Drugs commonly used by urologists in the office setting and explain why the information should matter to you.

CMS recently released detailed Part B drug spending data for 2016 to 2020, and total Medicare spending by provider and specialty for 2019.

 “Spending” in this context includes the estimated total costs, including deductible, coinsurance, and Medicare spending. Total spending in 2020 for
603 Part B drugs was $38.5 billion, up 3.4% from 2019; this is a much slower growth rate than from 2018 to 2019 which may be explained in part by reduced demand for services during the pandemic. One drug—pembrolizumab (Keytruda)—accounted for $3.5 billion (9.1%) of all spending in the program in 2020. Spending on any drug may increase because of increased utilization, increased price, or both.

According to the 2019 data, drug administration accounted for 13.9% of total Part B Medicare revenue in urology, and the specialty ranks 10th in percentage of Medicare revenue from Part B drugs. The top specialties earning revenue from buy-and-bill drugs in 2019 (Medicare revenue %) were hematology-oncology (61%), hematopoietic cell transplantation and cellular therapy (50%), hematology (49%), ophthalmology (43%), gynecological oncology (34%), and allergy/immunology (28%; 

Twenty-one drugs commonly used by urologists account for less than 7% of total Medicare Part B drug spending, and spending in 2020 was down almost 3% for this subset of drugs compared with 2019. Of these 21 drugs commonly used in the urology office for Medicare beneficiaries, the drug with the largest 2020 total spend—as in 2019—was denosumab (Xgeva) ($1.63 billion); in 2020, utilization for denosumab actually decreased by 3% but spending per unit (price) increased 4.6%, resulting in higher overall spending. Denosumab spending has increased 4.1% per year over the last 5 years. The dominant specialty for denosumab is hematology-oncology, and urologists accounted for an estimated 4.5% of denosumab spending (eighth-ranked specialty).

Using estimates based on 2019 specialty data, the largest spend for urology in 2020 was leuprolide ($232 million) followed by sipuleucel-T (Provenge; $113 million), denosumab ($73 million), degarelix acetate ($15 million), and onabotulinumtoxinA (Botox; $14 million). Urologists were the principal specialty reimbursed by Medicare Part B in 2019 for all the androgen deprivation therapies as well as sipuleucel-T, BCG, dimethyl sulfoxide, and most of the testosterone replacement therapies. These are the drugs to watch.

Among the drugs used to treat non–muscle-invasive bladder cancer in 2020, mitomycin utilization dropped 21% from 2019 and the price dropped 38%, resulting in total spending of $8.5 million, down 51% from the prior year. Gemcitabine utilization was down 3.4%, the price was down 22%, and total spending down 24.5% compared with the previous year. Valrubicin spending was down 29%, driven entirely by decreased utilization. The price of BCG was relatively unchanged from 2019, and other year-on-year comparisons are not possible because the new Healthcare Common Procedure Coding System code was assigned midyear (2019).

In the androgen deprivation therapy market (

), leuprolide acetate was still the most commonly administered drug, with spending in 2020 of $285 million (down 5.5% from 2019). Urologists account for an estimated 81% of leuprolide spending. Over the past 5 years, growth in spending per dose of leuprolide acetate has decreased 1.75% annually as 2 manufacturers compete for position in this market. Utilization was down for all the drugs in this class except goserelin acetate (up 2.2%). Collective spending on these 5 drugs was $326 million, down 4.6% from the previous year.

In general, among these 21 drugs, those with 1 or 2 manufacturers have seen higher annual growth in spending per dose (a surrogate for price) and those with 3 or more manufacturers have seen lower or negative annual growth. Goserelin acetate and gentamicin have been notable exceptions to this rule over the past 5 years, with 10% annual growth over 5 years despite apparent competition among 3 or more manufacturers. BCG has a single manufacturer unable to meet current demand, yet the price has barely changed in the last 2 years.

Urology practices continue to derive substantial revenue from administering “buy-and-bill” drugs, including from the Medicare Part B program (14% of revenue). Of 21 Part B drugs commonly used by urologists, total spending in 2020 increased for 5 drugs and decreased for 16 drugs over the previous year. Urologists were the principal prescribers for 14 of 21 common drugs they administer. Urologists should understand that spending in the Part B program continues to attract the attention of CMS and other payers; although reimbursement to the specialty is still only a fraction (1.5%) of the total Part B drug spend by CMS, urologists are the principal drivers of utilization for 14 drugs, including some expensive agents.

1. Medicare physician & other practitioners – by provider and service. Centers for Medicare & Medicaid Services. Updated August 31, 2021. Accessed March 19, 2022. https://bit.ly/3N8i5sw

2. Medicare Part B spending by drug. Centers for Medicare & Medicaid Services. Updated January 27, 2022. Accessed March 19, 2022. https://bit.ly/3JxWmIg

Urologists are the principal drivers of utilization for 14 drugs.

Leuprolide tops urology spending for Medicare Part B drugs

Hippocrates wrote, “The physician must be able to tell the antecedents, know the present, and foretell the future—must mediate these things and have 2 special objects in view with regard to disease: namely, to do good or to do no harm.”

He wrote these words in the fifth century BC, and the modern interpretation of the phrase—“First, do no harm”—is that physicians should recommend tests or treatments for which the potential benefits outweigh the risks of harm.

Creating a culture of patient safety takes this concept further: Physicians arguably should recognize serious safety risks—even if they are uncommon—and stringently practice the behaviors that

 harm to patients. For example, a surgical time-out prevents wrong-site surgery, 2 patient identifiers on a specimen label prevent most labeling errors, and high-level disinfection or sterilization of instruments prevents patient-to-patient transmission of bacteria, fungi, and viruses.

To prevent these harms, these behaviors must become ingrained, habitual, part of our culture, and practiced 100% of the time. In a urology practice, harms may occur because the simple behaviors known to reduce or prevent some harms are not practiced each and every time. The culture of safety is still evolving, and events may seem so rare that it feels like “overkill” to expend energy on prevention.

In this article, I will examine prevention strategies for one of those harms that should resonate with most urologists—the forgotten ureteral stent.

It is indisputable that a retained ureteral stent can and does cause harm. That harm can result from encrustation, infection, obstruction, or complications from the treatment of these preventable problems. That harm can include loss of a kidney or death.

 How often does this harm occur? Estimates show that 1.5% to 12.5% of stenting procedures result in a forgotten stent in the modern era.

Urologists perform stent insertions hundreds of times in their careers, so even if the incidence is “only” 1%, every urologist has patients at serious risk for this preventable harm. Most urologists have seen patients with retained stents, even if they did not perform the original surgery. This is not a rare event, it can be life threatening, and it is largely preventable.

Many patients with a forgotten ureteral stent are labeled “noncompliant”; this label implies they knew they had a stent, fully understood the consequences of not having it removed, and chose to harm themselves.

What are the actual factors that lead to a retained stent and its complications? Lack of insurance or access to care is a common reason but not the only reason cited by patients with forgotten stents.

 Other patients report forgetting about the stent or never knowing they had a stent or needed follow-up. Patients at higher risk of a forgotten stent include those who are male sex, ethnic minorities, unemployed, and non–English speaking.

There are also physician and practice risk factors. Many patients at risk for retained stents are seen emergently outside the office and undergo unscheduled surgery. These patients may escape preoperative registration with the practice and some of the safeguards that come with office policies. The only opportunity to confirm contact information and arrange follow-up might depend upon the physician. 

Poor communication, delayed charge posting, incomplete record keeping, and inconsistent patient engagement are potential risk factors in the treating physician or practice. Some patients with chronic ureteral stents undergo periodic stent exchanges—this is a risk factor, as is the common practice of relying on the patient to initiate contact in a few months for their exchange.

Although some of these factors cannot be controlled, recognizing them is an important part of a strategy to prevent harm from the forgotten stent.

What behaviors can prevent a retained stent and its attendant harms? What follows are my 6 suggestions for behaviors to practice each time, every time a stent is inserted:

1. Affix a hospital-style wristband (available from your facility or on Amazon for less than 15 cents apiece) with the date of anticipated stent removal to the patient’s wrist; the band is not to be removed until the stent is removed. If the patient speaks limited English, inform and apply the wristband in their preferred language. Patients with chronic stent exchanges may use a medical alert silicone version of the wristband.

2. Verify the telephone number of the patient or their emergency contact by calling the number from the facility phone before the patient is discharged.

3. For patients with a tether who are instructed in self-removal, give the patient a return form stating, “I removed my ureteral stent on (date),” along with a preaddressed (to your practice) stamped envelope. The form can include a picture of a stent so patients know it was removed in its entirety.

 patients are discharged from the facility. A patient without insurance may refuse to schedule, may transfer their care, or may not keep their appointment; or they may keep their appointment, register with your practice, and pay their bill eventually. In any case, a retained stent is best prevented by having that follow-up conversation 

you potentially lose contact with the patient. As long as they have an internal foreign body, it is a safety issue, not a financial issue. Do not rely on the patient to initiate the appointment. At the earlier of either surgery documentation in the electronic health record or charge posting in the practice management system, set a chart alert in the system that reads, “PATIENT HAS INDWELLING STENT.” Remove the alert only when removal is documented.

5. Track every stent insertion and removal. This can be a manual process (ie, a registry), a software-assisted reminder or patient engagement tool,2 or a data-driven analysis. The process should include the stent insertion date, the documented stent removal date, and a method for contacting patients with removals that are overdue or not recorded. If your process occurs outside the medical record, be sure to document removal in the record. Think of this like a sponge count—the case isn’t complete until you have verified there isn’t a foreign body left in the patient. You don’t do a sponge count in 98% of open or vaginal cases; you do it in all cases to prevent the rare complication (gossypiboma) from a retained foreign body.

6. Make reasonable efforts to contact those patients who have stent removal that is undocumented or overdue. This includes phone calls, portal messages, emergency contacts, and certified letters. When it comes to a stent, no news is never good news.

The bottom line and why it matters: Retained ureteral stents are commonly thought of as a patient compliance issue, out of the physician’s control, or a malpractice risk for the urologist. Although they can be all of these, I would encourage you to think of the forgotten stent primarily as a patient safety issue—an avoidable bad outcome.

Become a safety enthusiast. Using a safety paradigm may help you reduce or even eliminate this problem in your practice. As Benjamin Franklin once said, “An ounce of prevention is worth a pound of cure.”

1.Adanur S, Ozkaya F. Challenges in treatment and diagnosis of forgotten/encrusted double-J ureteral stents: the largest single-center experience. 

2016;38(6):920-926. doi:10.3109/0886022X.2016.1172928

2. Krishna S, Abello A, Steinberg P. Forget forgotten stents: review of ureteral stent tracking systems. 

 2021;8(6):645-648. doi:10.1097/UPJ.0000000000000265

3. Weedin JW, Coburn M, Link RE. The impact of proximal stone burden on the management of encrusted and retained ureteral stents. 

2011;185(2):542-547. doi:10.1016/j.juro.2010.09.085

4. Divakaruni N, Palmer CJ, Tek P, et al. Forgotten ureteral stents: who’s at risk? 

2013;27(8):1051-1054. doi:10.1089/end.2012.0754

Think of the forgotten stent primarily as a patient safety issue, writes Robert A. Dowling, MD.

Robert A. Dowling, MD

Articles

Part D data reveal how urologists are prescribing antibiotics

How often are urologists prescribing opioids?

Leuprolide tops urology spending for Medicare Part B drugs

6 steps to help you track ureteral stents