SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERNS

SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERNS

Patients and methods Ten patients who had undergone Mitrofanoff reconstruction between 1989 and 1991 (minimum follow-up 10 years) were offered re-interview by one of the authors (J.F.), which involved a structured questionnaire assessing catheterization, continence and complications. Results One patient had died; nine patients were alive and eight agreed to the structured interview. All the patients had their original stoma and all were completely continent. Four of the patients had experienced stenosis, four had had stones and four had been ill with urinary tract infection(s). Conclusion. Despite the complications of infection, stones and some episodic stenosis, the Mitrofanoff channel remains functional for long periods without sustaining structural damage. Editorial Comment: After undergoing Mitrofanoff urinary diversion 9 of 10 patients were followed for 8 years or more, and all were dry. Episodes of stenosis of the stoma at the skin level occurred in 4 patients but surgical revision was not performed, and there was stone formation despite irrigation in 4. In general, the Mitrofanoff procedure has functioned well for a long period. It will be interesting to compare Mitrofanoff procedures to other procedures at long-term followup. Fray F. Marshall, M.D. Recommended Reading: Bukowski, R. M.: Cytokine combinations: therapeutic use in patients with advanced renal cell carcinoma. Semin Oncol, 27: 204, 2000 McLaughlin, J. K. and Lipworth, L.: Epidemiologic aspects of renal cell cancer. Semin Oncol, 27: 115, 2000 Urban, B. A. and Fishman, E. K.: Renal lymphoma: CT patterns with emphasis on helical CT. Radiographics, 20: 197, 2000

SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERNS The Effect of an Illustrated Pamphlet Decision-Aid on the Use of Prostate Cancer Screening Tests M. M. SCHAPIRA AND J. VANRUISWYK, Department of Internal Medicine, Medical College of Wisconsin and Division of Primary Care, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin J Fam Pract, 49: 418 – 424, 2000 BACKGROUND: Prostate cancer screening with serum prostate-specific antigen (PSA) and digital rectal examination (DRE) continues to increase. Our goal was to test the effect of a prostate cancer screening decision-aid on patients’ knowledge, beliefs, and use of prostate cancer screening tests. METHODS: Our study was a randomized controlled trial of a prostate cancer screening decision-aid consisting of an illustrated pamphlet as opposed to a comparison intervention. We included 257 men aged 50 to 80 years who were receiving primary care at a Department of Veterans Affairs Hospital in Milwaukee, Wisconsin. The decision-aid provided quantitative outcomes of prostate cancer screening with DRE and PSA. We subsequently evaluated prostate cancer screening knowledge, beliefs, and test use. RESULTS: The illustrated pamphlet decision-aid was effective in improving knowledge of prostate cancer screening tests: 95% of the experimental group were aware of the possibility of false-negative test results compared with 85% of the comparison group (P ⬍.01). Ninety-one percent of the experimental group were aware of the possibility of a false-positive screening test result compared with 65% of the comparison group (P ⬍.01). However, there was no difference in the use of prostate cancer screening between the experimental (82%) and comparison (84%) groups, (P ⬎.05). CONCLUSIONS: When used in a primary care setting, an illustrated pamphlet decision-aid was effective in increasing knowledge of prostate cancer screening tests but did not change the use of these tests. Editorial Comment: The authors investigated the use of a decision aid to determine the likelihood that patients will undergo prostate cancer screening using digital rectal examination and serum PSA testing. Specifically, the authors developed a pamphlet that illustrates the risks and benefits of screening for prostate cancer. The visual display provided by the pamphlet improved knowledge of screening outcomes but did not change prostate cancer screening test use. The authors conclude that prostate cancer screening is a clinical decision for which the risks are difficult to balance, or a type of decision referred to as a “toss-up” dilemma. Decision aids have improved patient knowledge of decision outcomes, reduced decision conflict and encouraged patients to become more active in the decision making process.

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However, a recent meta-analysis indicated that although decision aids have a consistent effect on improving knowledge, they are less likely to alter decisions about health care intervention. This study supports this observation. Should clinicians decide to use decision aids to assist patients in understanding the risks and benefits of prostate cancer screening, they should not be surprised if the number of patients who choose to undergo prostate cancer screening is not altered. Peter C. Albertsen, M.D. A Simple Comorbidity Scale Predicts Clinical Outcomes and Costs in Dialysis Patients S. BEDDHU, F. J. BRUNS, M. SAUL, P. SEDDON AND M. L. ZEIDEL, Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania Am J Med, 108: 609 – 613, 2000 PURPOSE: In a university-based dialysis program, we found that 25% of the patients accounted for 50% of the costs and 42% of the deaths. We determined whether the Charlson Comorbidity Index, a simple measure of comorbid conditions, could predict clinical outcomes and costs in these patients. METHODS: Patients on hemodialysis or peritoneal dialysis from July 1996 to June 1998 at the University of Pittsburgh outpatient dialysis unit were studied. Comorbidity scores and outcomes were determined by reviewing the Medical Archival Retrieval System database and outpatient records. RESULTS: Two hundred sixty-eight patients were observed for 293 patient-years. The Comorbidity Index strongly predicted admission rate (relative risk per each unit increase ⫽ 1.20; 95% confidence interval [CI]: 1.16 to 1.23, P ⫽ 0.0001), hospital days and inpatient costs (both P ⬍0.0001), and mortality (relative risk per unit increase ⫽ 1.24, 95% CI: 1.11 to 1.39, P ⫽ 0.0002.). Age and diabetes, used in the Health Care Financing Administration dialysis capitation model, correlated poorly with outcomes. CONCLUSIONS: The modified Charlson Comorbidity Index predicts outcomes and costs in dialysis patients. This index may be useful in determining appropriate payment for care of dialysis patients under capitated payment schemes and as a research tool to stratify dialysis patients in order to compare the outcomes of various interventions. Editorial Comment: The authors used the Charleson Co-Morbidity Index to assess whether differences in co-morbidity predict cost outcomes in patients undergoing renal dialysis. The results of this study indicate that the index is capable of discriminating among these patients. This index is widely used in many studies involving health care assessment, including those on patients with breast or prostate cancer and chart based abstractions. The interested clinician will find this short article helpful in understanding how the Charleson Co-Morbidity Index can be used in clinical research. Peter C. Albertsen, M.D. Essence of Evidence-Based Medicine: A Case Report G. P. BROWMAN, Program in Evidence-Based Care, Cancer Care Ontario and Health Information Research Unit, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada J Clin Oncol, 17: 1969 –1973, 1999 Purpose: To illustrate the complexities of the evidence-based approach in clinical oncology practice and the implications for guidelines and evaluation of processes of care. Patient and Methods: A case report is presented in which a limited systematic review of the literature was used to address a specific clinical problem in an individual patient. Experts’ opinions were also sought. Results: A reasonable clinical decision was made by a participating patient based on indirect evidence of benefit that would be insufficient to support the same decision as a health policy in some jurisdictions. Conclusion: The practice of evidence-based oncology requires clinical judgment about the validity and applicability of research evidence. The factors that influence an evidence-based decision in the clinical context differ from those in the broader policy context, which could lead to legitimate differences in recommendations based on the same information. Used properly, the individual case report can be a powerful tool to illustrate complex clinical decision phenomena. Editorial Comment: The author reports on the use of evidence based medicine in clinical practice. He used his experience with the treatment of 1 patient, a male psychologist, who faced the choice of using bisphosphonates to treat early stage prostate cancer. The article is valuable as it reviews some of the principles of evidence based medicine and highlights some potential pitfalls encountered when implementing this approach in general practice. Peter C. Albertsen, M.D.

SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERNS

Cost Utility Analysis of Sildenafil Compared With Papaverine-Phentolamine Injections E. A. STOLK, J. J. V. BUSSCHBACK, M. CAFFA, E. J. H. MEULEMAN AND F. F. H. RUTTEN, Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, Department of Urology, Hospital St. Antoniushove, Leidschendam and Department of Urology, University Medical Centre St. Radboud, Nijmegen, The Netherlands BMJ, 320: 1165–1168, 2000 Objective: To compare the cost effectiveness of sildenafil and papaverine-phentolamine injections for treating erectile dysfunction. Design: Cost utility analysis comparing treatment with sildenafil (allowing a switch to injection therapy) and treatment with papaverine-phentolamine (no switch allowed). Costs and effects were estimated from the societal perspective. Using time trade-off, a sample of the general public (n ⫽ 169) valued health states relating to erectile dysfunction. These values were used to estimated health related quality of life by converting the clinical outcomes of a trial into quality adjusted life years (QALYs). Participants: 169 residents of Rotterdam. Main outcome measures: Cost per quality adjusted life year. Results: Participants thought that erectile dysfunction limits quality of life considerably: the mean utility gain attributable to sildenafil is 0.11. Overall, treatment with sildenafil gained more QALYs, but the total costs were higher. The incremental cost effectiveness ratio for the introduction of sildenafil was £3639 in the first year and fell in following years. Doubling the frequency of use of sildenafil almost doubled the cost per additional QALY. Conclusions: Treatment with sildenafil is cost effective. When considering funding sildenafil, healthcare systems should take into account that the frequency of use affects cost effectiveness. Editorial Comment: The authors conducted a rigorous cost analysis of sildenafil to treat erectile dysfunction. They compared outcomes among patients using sildenafil and those using injection therapy. To quantify the improvement in quality adjusted life years, they performed time trade-off analyses using a group of men and women who were presented with various scenarios concerning erectile dysfunction. The conclusion was that sildenafil provided sufficient improvement in quality adjusted life years and is comparable in cost to other funded health care programs, such as breast cancer screening and renal transplantation. The latter is frequently considered the benchmark of what society considers appropriate to pay to improve quality of life. Caveats surrounding this analysis include the fact that the general public was interviewed rather than men who have erectile dysfunction. Therefore, it is unclear whether cost estimates would have been dramatically different if men who have this condition were assessed. Furthermore, the study was funded by researchers who received grant monies or speaking fees from Pfizer. Overall, the study provides reasonably convincing data that sildenafil, if used once a week, provides a sufficiently high improvement in quality adjusted life years that it should be included in any formulary of health benefits provided by insurance. Peter C. Albertsen, M.D. Comparison of Recommendations by Urologists and Radiation Oncologists for Treatment of Clinically Localized Prostate Cancer F. J. FOWLER, JR., C. M. MCNAUGHTON, P. C. ALBERTSEN, A. ZIETMAN, D. B. ELLIOTT AND M. J. BARRY, Medical Practices Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts JAMA, 283: 3217–3222, 2000 CONTEXT: Multiple treatment options are available for men with prostate cancer, but therapeutic recommendations may differ depending on the type of specialist they consult. OBJECTIVE: To define and contrast the distribution of management recommendations by urologists and radiation oncologists for a spectrum of men with prostate cancer. DESIGN, SETTING, AND PARTICIPANTS: Mail survey sent in 1998 to a random sample of physicians in the United States, who were listed as urologists (response rate 64%, n ⫽ 504) and radiation oncologists (response rate 76%, n ⫽ 559) in the American Medical Association Registry of Physicians and practicing at least 20 hours per week. MAIN OUTCOME MEASURE: Questionnaire addressing beliefs and practices regarding prostate cancer management. RESULTS: Forty-three percent of radiation oncologists vs 16% of urologists would recommend routine prostate-specific antigen testing for men aged 80 years and older. For men with moderately differentiated, clinically localized cancers, and a more than 10-year life expectancy, 93% of urologists chose radical prostatectomy as the preferred treatment option, while 72% of radiation oncologists believed surgery and external beam radiotherapy were equivalent treatments. For most tumor grades and prostate-specific antigen levels, both specialty groups were significantly more likely to recommend the treatment in their specialty than the other treatment. Both groups reported giving patients similar estimates of the risks of complications due to surgery and radiation. Neither group favored watchful waiting in their treatment management except for a subset of men with life expectancies of less than

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10 years and cancers with very favorable prognoses (Gleason score of 3 or 4 and prostate-specific antigen level ⬍/⫽5 ng/mL). CONCLUSIONS: Based on this study, while urologists and radiation oncologists do agree on a variety of issues regarding detection and treatment of prostate cancer, specialists overwhelmingly recommend the therapy that they themselves deliver. Reprinted with permission from American Medical Association. Editorial Comment: The authors conducted a survey of radiation oncologists and urologists practicing in the United States. Approximately 900 physicians from each specialty returned a questionnaire that presented clinical scenarios of patients with varying Gleason scores and prostate specific antigen (PSA). The results of the survey demonstrated that 93% of urologists would recommend radical prostatectomy as a preferred treatment option for localized prostate cancer, while 72% of radiation oncologists believe surgery and external beam radiotherapy are equivalent treatments. The survey indicated that urologists and radiation oncologists agreed more than they disagreed. Despite the controversy over the value of PSA screening physicians in both specialties recommended almost unanimously that PSA screening be done routinely at least until age 75 years. After this age, urologists were less enthusiastic about screening, while radiation oncologists would pursue screening even among men with less than a 10-year life expectancy. Radiation oncologists and urologists consider surgery and radiation therapy to offer significant survival benefits to men with a 10-year life expectancy. For men with life expectancies of less than 10 years only a minority of specialists think that surgery or radiation therapy offers a significant survival advantage. This survey demonstrates that urologists and radiation oncologists are in relatively close agreement on the probabilities of complications among the 3 treatments, surgery, radiation therapy and brachytherapy. Urologists and radiation oncologists are reluctant to recommend watchful waiting and generally recommend androgen deprivation as primary therapy only for men with significantly elevated serum PSA or high Gleason scores. Interestingly, urologists and radiation therapists believed that brachytherapy was at least as effective as external beam radiotherapy, and urologists were slightly more positive about the former. The most dramatic difference between these 2 groups is in regard to primary therapy for localized prostate cancer. Radiation oncologists tend to believe that radiation therapy is superior to radical prostatectomy in men with moderately differentiated disease, whereas urologists are convinced overwhelmingly that radical prostatectomy is better in this group. Only randomized trials will determine which of these specialists is correct but the recommendation to patients is to obtain a second opinion from both since the ultimate decision regarding therapy may be influenced by the respective biases of these competing specialists. Peter C. Albertsen, M.D.

BOOK REVIEW Classic Papers in Urology E. W. GERHARZ, M. EMBERTON

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T. O’BRIEN, Oxford: Isis Medical Media Ltd., 360 pages, 1999

I had trouble putting this book down, which is a compliment for a urology textbook. The editors assigned 15 topics to experts who selected the 10 most important publications in their subject area, and no restraints were imposed on the date, size or source of the citations. Most experts selected relatively contemporary literature but a few went back to the first half of the twentieth century. Almost all citations were pertinent and a few were surprising but the experts made good cases for all choices. A standard brief format is provided that summarizes, lists parallel articles for comparison and highlights the strengths and weaknesses of each article. Also, a ranking of manuscripts based on the number of times each has been cited in the world urology literature is provided. Overall, this enjoyable text is useful for anyone with an interest in the history of urology and is a must for the novice urologist who wishes to become acquainted with our urological forefathers. Donald E. Novicki, M.D. Mayo Clinic Scottsdale Scottsdale, Arizona