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Socioeconomic Factors, Urological Epidemiology and Practice Patterns
1380
SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERNS
physician level factor, practice style, as a function of average per patient expenditures. We then determined which AUA BPH guideline elements explained variation in quantity and expenditures for BPH testing, and also examined the impact of patient and physician factors on practice style. Results: A nearly 15-fold variation in urologists’ average per-patient expenditures existed ($35 to $527 per month; Median $92). Practice styles were associated with physician (P ⬍.01 all examined variables) and patient (P ⬍.01 for comorbidity, race/ethnicity, and socioeconomic status) factors. Guideline recommended care was provided at lower rates by the lowest expenditure urologists compared with middle- to highest-intensity urologists (P ⬍.01). Practice style variations were attributable mainly to differences in tests characterized by the guidelines as optional and not-recommended (P ⬍.01). Conclusions: Expenditures for BPH evaluations vary substantially by geography, practice setting, and experience and are accounted for largely by differences in the use of optional and not-routinely recommended tests. Greater standardization could enhance patient care and reduce health care costs. Editorial Comment: Advancing age is associated with increased incidence and prevalence of benign prostatic hyperplasia in men. A number of different methods can be used to evaluate patients with BPH symptoms. This study used Medicare claims data to examine provider patterns of assessment, costs and concordance with published clinical guidelines. Significant variation was observed among practitioners, and much of this disparity could be explained by use of optional or nonrecommended tests. These findings may have important implications for future health care funding and public health policy particularly among older patients since this condition disproportionately affects elderly men. Tomas L. Griebling, M.D., M.P.H.
Socioeconomic Factors, Urological Epidemiology and Practice Patterns Re: Patient Satisfaction With Stress Incontinence Surgery K. L. Burgio, L. Brubaker, H. E. Richter, C. Y. Wai, H. J. Litman, D. B. France, S. A. Menefee, L. T. Sirls, S. R. Kraus, H. W. Johnson and S. L. Tennstedt University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama Neurourol Urodyn 2010; 29: 1403–1409.
Aims: To identify predictors and correlates of patient satisfaction 24 months after Burch colpopexy or autologous fascial sling for treatment of stress urinary incontinence (SUI). Methods: Participants were the 655 randomized subjects in the Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr). Variables potentially associated with satisfaction were tested in bivariate analysis, including demographics, baseline clinical characteristics of incontinence, and outcomes on validated subjective and objective measures. Satisfaction with treatment was defined as a response of “completely satisfied” or “mostly satisfied” on the Patient Satisfaction Questionnaire (PSQ) at 24 months. Variables significantly related to satisfaction were entered into multivariable regression models to test their independent association with satisfaction. Results: At 24 months post-surgery, 480 (73%) participants completed the PSQ. Mean (⫾SD) age of the sample was 52 (⫾10) years and 77% were white. Most (82%) were completely or mostly satisfied with their surgery related to urine leakage. In the final multivariable model, patient satisfaction was associated with greater reduction in SUI symptoms (from baseline to 24 months; OR ⫽ 1.17, 95% CI: 1.10, 1.24) and greater reductions in symptom distress (OR ⫽ 1.16; CI: 1.08, 1.24). Lower odds of satisfaction were associated with greater urge incontinence symptoms at baseline (OR ⫽ 0.09, CI: 0.04, 0.22), detrusor overactivity at 24 months (OR ⫽ 0.29, CI: 0.12, 0.69), and a positive stress test at 24 months (OR ⫽ 0.45, CI: 0.22, 0.91). Conclusions: Stress incontinent women who also have urge incontinence symptoms may benefit from
BENIGN PROSTATIC HYPERPLASIA
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additional preoperative counseling to set realistic expectations about potential surgical outcomes or proactive treatment of urge incontinence symptoms to minimize their post-operative impact. Editorial Comment: This randomized clinical trial compared satisfaction outcomes following fascial sling and Burch colpopexy for stress incontinence. The authors conclude that additional preoperative counseling to set realistic expectations may have a positive effect on outcomes. While likely true, I found it interesting that in the multivariate model preoperative expectations were not associated with postoperative satisfaction. Rather, the most important predictors of postoperative satisfaction were reduction in incontinence symptoms and in symptom distress from baseline. In other words, while expectations may influence satisfaction, good functional outcomes clearly have a greater impact. David F. Penson, M.D., M.P.H.
Benign Prostatic Hyperplasia Re: Phosphodiesterase-5 Inhibitors for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: A Systematic Review and MetaAnalysis L. Liu, S. Zheng, P. Han and Q. Wei Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China Urology 2011; 77: 123–129.
Objectives: To evaluate the efficacy and safety of phosphodiesterase-5 (PDE-5) inhibitors for treating lower urinary tract symptoms secondary to benign prostatic hyperplasia. Methods: Randomized controlled trials were identified and extracted from MEDLINE, Embase, Cochrane Central, and relevant reference lists. The database search, quality assessment, and data extraction were independently performed by 2 reviewers. Heterogeneity was analyzed using the chi-square test and I(2) test. If lacking of heterogeneity, fixed-effects models were used for the meta-analysis, otherwise randomeffects models were used. Results: A total of 5 studies (11 randomized controlled trials) were identified from the search strategy. Compared with placebo, short-term trials (ⱕ12 weeks) indicated that PDE-5 inhibitors significantly improved the International Prostate Symptom Score (mean difference ⫺2.60, 95% confidence interval [CI] ⫺3.12 to ⫺2.07; P ⬍ .00001), and statistical significance was observed in the International Prostate Symptom Score irritative and obstructive subscore, International Prostate Symptom Score quality of life and erectile function. However, no statistically significant difference was detected in maximal urinary flow rate (mean difference 0.21, 95% CI ⫺0.21– 0.64; P ⫽ .32) and postvoid residual urine volume (mean difference 0.09, 95% CI ⫺4.71– 4.89; P ⫽ .80). No statistically significant difference was found between the 2 groups in the incidence of serious adverse events (relative risk 0.52, 95% CI 0.25–1.07; P ⫽ .07), despite that adverse event with a greater incidence was detected in the PDE-5 group (relative risk 1.87, 95% CI 1.31–2.68; P ⫽ .0005). Conclusions: As the first-line treatment of erectile dysfunction, the PDE-5 inhibitor is also effective and safe for lower urinary tract symptoms secondary to benign prostatic hyperplasia. It could be considered as the first-line treatment in the future for the treatment of patients with comorbid benign prostatic hyperplasia and erectile dysfunction. Editorial Comment: During the last few years there has been increasing momentum in exploring the use of phosphodiesterase-5 inhibitors to treat lower urinary tract symptoms secondary to benign prostatic hyperplasia. Although there appears to be consistent subjective improvement compared to placebo as defined by changes in International Prostate Symptom Score, the lack of any objective improvements has been disappointing. These
SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERNS
physician level factor, practice style, as a function of average per patient expenditures. We then determined which AUA BPH guideline elements explained variation in quantity and expenditures for BPH testing, and also examined the impact of patient and physician factors on practice style. Results: A nearly 15-fold variation in urologists’ average per-patient expenditures existed ($35 to $527 per month; Median $92). Practice styles were associated with physician (P ⬍.01 all examined variables) and patient (P ⬍.01 for comorbidity, race/ethnicity, and socioeconomic status) factors. Guideline recommended care was provided at lower rates by the lowest expenditure urologists compared with middle- to highest-intensity urologists (P ⬍.01). Practice style variations were attributable mainly to differences in tests characterized by the guidelines as optional and not-recommended (P ⬍.01). Conclusions: Expenditures for BPH evaluations vary substantially by geography, practice setting, and experience and are accounted for largely by differences in the use of optional and not-routinely recommended tests. Greater standardization could enhance patient care and reduce health care costs. Editorial Comment: Advancing age is associated with increased incidence and prevalence of benign prostatic hyperplasia in men. A number of different methods can be used to evaluate patients with BPH symptoms. This study used Medicare claims data to examine provider patterns of assessment, costs and concordance with published clinical guidelines. Significant variation was observed among practitioners, and much of this disparity could be explained by use of optional or nonrecommended tests. These findings may have important implications for future health care funding and public health policy particularly among older patients since this condition disproportionately affects elderly men. Tomas L. Griebling, M.D., M.P.H.
Socioeconomic Factors, Urological Epidemiology and Practice Patterns Re: Patient Satisfaction With Stress Incontinence Surgery K. L. Burgio, L. Brubaker, H. E. Richter, C. Y. Wai, H. J. Litman, D. B. France, S. A. Menefee, L. T. Sirls, S. R. Kraus, H. W. Johnson and S. L. Tennstedt University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama Neurourol Urodyn 2010; 29: 1403–1409.
Aims: To identify predictors and correlates of patient satisfaction 24 months after Burch colpopexy or autologous fascial sling for treatment of stress urinary incontinence (SUI). Methods: Participants were the 655 randomized subjects in the Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr). Variables potentially associated with satisfaction were tested in bivariate analysis, including demographics, baseline clinical characteristics of incontinence, and outcomes on validated subjective and objective measures. Satisfaction with treatment was defined as a response of “completely satisfied” or “mostly satisfied” on the Patient Satisfaction Questionnaire (PSQ) at 24 months. Variables significantly related to satisfaction were entered into multivariable regression models to test their independent association with satisfaction. Results: At 24 months post-surgery, 480 (73%) participants completed the PSQ. Mean (⫾SD) age of the sample was 52 (⫾10) years and 77% were white. Most (82%) were completely or mostly satisfied with their surgery related to urine leakage. In the final multivariable model, patient satisfaction was associated with greater reduction in SUI symptoms (from baseline to 24 months; OR ⫽ 1.17, 95% CI: 1.10, 1.24) and greater reductions in symptom distress (OR ⫽ 1.16; CI: 1.08, 1.24). Lower odds of satisfaction were associated with greater urge incontinence symptoms at baseline (OR ⫽ 0.09, CI: 0.04, 0.22), detrusor overactivity at 24 months (OR ⫽ 0.29, CI: 0.12, 0.69), and a positive stress test at 24 months (OR ⫽ 0.45, CI: 0.22, 0.91). Conclusions: Stress incontinent women who also have urge incontinence symptoms may benefit from
BENIGN PROSTATIC HYPERPLASIA
1381
additional preoperative counseling to set realistic expectations about potential surgical outcomes or proactive treatment of urge incontinence symptoms to minimize their post-operative impact. Editorial Comment: This randomized clinical trial compared satisfaction outcomes following fascial sling and Burch colpopexy for stress incontinence. The authors conclude that additional preoperative counseling to set realistic expectations may have a positive effect on outcomes. While likely true, I found it interesting that in the multivariate model preoperative expectations were not associated with postoperative satisfaction. Rather, the most important predictors of postoperative satisfaction were reduction in incontinence symptoms and in symptom distress from baseline. In other words, while expectations may influence satisfaction, good functional outcomes clearly have a greater impact. David F. Penson, M.D., M.P.H.
Benign Prostatic Hyperplasia Re: Phosphodiesterase-5 Inhibitors for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: A Systematic Review and MetaAnalysis L. Liu, S. Zheng, P. Han and Q. Wei Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China Urology 2011; 77: 123–129.
Objectives: To evaluate the efficacy and safety of phosphodiesterase-5 (PDE-5) inhibitors for treating lower urinary tract symptoms secondary to benign prostatic hyperplasia. Methods: Randomized controlled trials were identified and extracted from MEDLINE, Embase, Cochrane Central, and relevant reference lists. The database search, quality assessment, and data extraction were independently performed by 2 reviewers. Heterogeneity was analyzed using the chi-square test and I(2) test. If lacking of heterogeneity, fixed-effects models were used for the meta-analysis, otherwise randomeffects models were used. Results: A total of 5 studies (11 randomized controlled trials) were identified from the search strategy. Compared with placebo, short-term trials (ⱕ12 weeks) indicated that PDE-5 inhibitors significantly improved the International Prostate Symptom Score (mean difference ⫺2.60, 95% confidence interval [CI] ⫺3.12 to ⫺2.07; P ⬍ .00001), and statistical significance was observed in the International Prostate Symptom Score irritative and obstructive subscore, International Prostate Symptom Score quality of life and erectile function. However, no statistically significant difference was detected in maximal urinary flow rate (mean difference 0.21, 95% CI ⫺0.21– 0.64; P ⫽ .32) and postvoid residual urine volume (mean difference 0.09, 95% CI ⫺4.71– 4.89; P ⫽ .80). No statistically significant difference was found between the 2 groups in the incidence of serious adverse events (relative risk 0.52, 95% CI 0.25–1.07; P ⫽ .07), despite that adverse event with a greater incidence was detected in the PDE-5 group (relative risk 1.87, 95% CI 1.31–2.68; P ⫽ .0005). Conclusions: As the first-line treatment of erectile dysfunction, the PDE-5 inhibitor is also effective and safe for lower urinary tract symptoms secondary to benign prostatic hyperplasia. It could be considered as the first-line treatment in the future for the treatment of patients with comorbid benign prostatic hyperplasia and erectile dysfunction. Editorial Comment: During the last few years there has been increasing momentum in exploring the use of phosphodiesterase-5 inhibitors to treat lower urinary tract symptoms secondary to benign prostatic hyperplasia. Although there appears to be consistent subjective improvement compared to placebo as defined by changes in International Prostate Symptom Score, the lack of any objective improvements has been disappointing. These