Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Obstruction

How Can Clinical Expertise Contribute to Rational Management?

Published in: European Urology, v. 39, suppl. 3, 2001, p. 13-19

Posted on RAND.org on December 31, 2000

by Herman Stoevelaar, Joseph McDonnell, J. L. B. Ruud Bosch, James P. Kahan

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OBJECTIVE: To perform a systematic analysis of clinical expertise on treatment for benign prostatic hyperplasia (lower urinary tract symptoms (LUTS) suggestive of benign prostatic obstruction (BPO)) and to investigate the usefulness of these data in further guideline development. METHODS: A modified Delphi method was used to analyze the opinions of a panel of 15 European urologists on the appropriateness of 4 common treatments for 1,152 indications (hypothetical cases) for LUTS suggestive of BPO. Each indication consisted of a unique combination of 9 diagnostic variables, found to be relevant in treatment choice in previous research. The study population was restricted to patients for whom current guidelines do not provide clear indications on the most appropriate treatment. The panelists individually rated the appropriateness of three active treatments (surgery, 1-adrenoceptor antagonists, finasteride) using a 9-point scale, all in comparison with watchful waiting. Aggregate panel judgments were calculated from individual ratings for each indication (appropriate, inappropriate, and uncertain). The relationship between diagnostic characteristics and panel opinions was analyzed using logistic regression methods. The results were compared to those of an identical panel study including 12 Dutch urologists. RESULTS: Strong agreement existed for 42.5% of the indications, while strong disagreement was found in only 0.1%. For patients who had not previously been treated for LUTS, surgery was considered appropriate in 44% of the indications. For 1-adrenoceptor antagonists and finasteride these percentages were 56 and 6 respectively. Strong contra-indications were found only for finasteride (34%). Logistic regression analysis demonstrated consistent panel opinions, indicating a strong cumulative impact of almost all diagnostic variables on the panel judgment appropriate. The figures on appropriateness were highly comparable to the results of the Dutch study (overall agreement 84%, kappa 0,76). A computer program was constructed to facilitate the implementation and evaluation of the panel recommendations in daily clinical practice. CONCLUSIONS: Given the consistency of the panel opinions, the results may be useful in complementing evidence-based guidelines for LUTS suggestive of BPO in the gray area of treatment choice.

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