A frequently used patient and physician-directed educational intervention does nothing to improve primary care of prostate conditions

Effects of a prostate awareness pilot on GP consultations and PSA requests

BACKGROUND

A Department of Health prostate awareness initiative, piloted in Coventry in 2006, promoted reporting of symptoms of benign prostatic hyperplasia, prostatitis and prostate cancer to GPs without causing sudden increases in workload. Qualitative evaluation showed a wide distribution of materials.

OBJECTIVES

Evaluation of effects of the pilot on rates of GP urological consultations, prescriptions and prostate-specific antigen (PSA) requests in general practice in Coventry and three control areas.

METHODS

Data on GP consultations provided by the General Practice Research Database for three to five practices per area covered the periods 1 October 2005 to 31 March 2006 and 1 October 2006 to 31 March 2007. Pathology laboratory data on PSA requests covered 18 months from 1 December 2005 in consenting practices: 44/55 (80%) in Coventry and 102/159 (64%) in control areas. The rates of GP consultations for urological symptoms and of prescriptions issued for urological conditions per 100 person-years in men with no prior diagnosis of benign or malignant prostate disease and rates of PSA tests per 100 men were analysed.

RESULTS

There was no significant change in consultation rates for urological symptoms over time in Coventry. The rate of prescriptions and of PSA testing increased in Coventry before the pilot began (P < 0.001) but there was no sudden increase after the pilot launch with similar trends in the control areas.

CONCLUSIONS

There was no increase in GP workload following the start of the pilot. Routine data can be used in evaluation but should be linked to surveys of awareness, health-seeking behaviour and delivery of campaign materials.

Developing instruments to measure the quality of decisions: early results for a set of symptom-driven decisions

OBJECTIVE

To identify a set of critical facts and key goals and concerns for five common medical conditions, benign prostate disease, hip and knee osteoarthritis, herniated disc and spinal stenosis and examine the validity of the method for identifying these items.

METHODS

Investigators identified facts and goals through literature reviews and qualitative work with patients and providers. A cross-sectional survey of patients and providers was conducted to examine the accuracy, importance and completeness of the identified items.

RESULTS

42 facts (6-16 per condition) and 31 goals and concerns (4-13 per condition) were identified. 182 responses were obtained from patients (76.5% response rate) and 113 responses from providers (78% response rate). Overall, the facts were accurate, important and complete across all conditions. For one condition (hip osteoarthritis), the goals did not meet the criteria for completeness. There was more disagreement between patients and providers around the ranking of goals than of facts.

CONCLUSIONS

Overall, respondents found the identified facts and goals accurate, important and complete. Significant differences between patients' and providers' rankings highlight the importance of including both perspectives.

PRACTICE IMPLICATIONS

Instruments to measure whether or not patients are informed and the extent to which treatments reflect patients' goals must balance patients' and providers' perspectives when selecting items to include.

Diagnosis and treatment of lower urinary tract symptoms in the elderly by general practitioners

AIM

We investigated the diagnosis and treatment of lower urinary tract symptoms (LUTS) by general practitioners (GPs) according to the Practical Manual for LUTS Evaluation and Treatment in the Elderly For GPs.

METHODS

Using the manual, 14 GPs determined LUTS severity using the International Prostate Symptom Score, Quality of Life Index, post-void residual urine volume and the International Consultation on Incontinence Questionnaire-Short Form, then evaluated utilization of the frequency volume charts and other examinations to treat LUTS and assessed treatment effectiveness.

RESULTS

This study included 52 men (aged 71 +/- 9 years) and 37 women (73 +/- 9). Voiding symptoms were more frequent in men but storage symptoms occurred similarly in both sexes. The overall severities of LUTS were similar between sexes. Of 36 men and 27 women who were treated, water restriction for polyuria and nocturnal polyuria was recommended for 17 men and 14 women, bladder training for six women, and pelvic floor exercise for three men and 16 women as behavioral therapy. Of 27 men and 25 women whose treatment effectiveness was assessed by GPs, effectiveness was judged as "fairly good" or greater in 20 men (74%) and 23 women (92%). Eleven men (40%) and 20 women (80%) were satisfied with their treatment.

CONCLUSION

It is suggested that GPs can provide high-quality LUTS practice when they follow the manual and use the recommended tools for evaluation and monitoring.

What works with men? A systematic review of health promoting interventions targeting men

Background

Encouraging men to make more effective use of (preventive) health services is considered one way of improving their health. The aim of this study was to appraise the available evidence of effective interventions aimed at improving men's health.

Methods

Systematic review of relevant studies identified through 14 electronic databases and other information resources. Results were pooled within health topic and described qualitatively.

Results

Of 11,749 citations screened, 338 articles were assessed and 27 met our inclusion criteria. Most studies were male sex-specific, i.e. prostate cancer screening and testicular self-examination. Other topics included alcohol, cardiovascular disease, diet and physical activity, skin cancer and smoking cessation. Twenty-three interventions were effective or partially effective and 18 studies satisfied all quality criteria.

Conclusion

Most of the existing evidence relates to male sex-specific health problems as opposed to general health concerns relevant to both men and women. There is little published evidence on how to improve men's uptake of services. We cannot conclude from this review that targeting men works better than providing services for all people. Large-scale studies are required to help produce evidence that is sufficiently robust to add to the small evidence base that currently exists in this field.

Trials of decision aids for prostate cancer screening: a systematic review

BACKGROUND

Patient decision aids are used to promote informed decision making. This review examines the methods and findings of studies that have evaluated the impact of prostate cancer screening decision aids on patient outcomes.

METHODS

MEDLINE, the Cochrane Registry, reference lists, and abstracts from professional meetings were searched through December 2006. Search terms included prostate cancer screening and decision making. Studies were included if a patient education intervention for prostate cancer screening had been evaluated against a control condition.

RESULTS

Eighteen eligible trials, involving 6221 participants, were identified. Sixteen studies enrolled primary care patients, while the remaining two studies were community-based. All the prostate cancer screening decision aids were in English, with varied reading levels. Consistent with previous reviews, the patient decision aids improved patient knowledge and made patients more confident about their decisions. The aids appeared to decrease interest in prostate-specific antigen testing and screening behavior among patients seeking routine care (relative risk [RR]=0.88, 95% confidence interval [CI]=0.81-0.97, p=0.008); the aids had no impact on the screening behavior of patients seeking screening services. Additionally, patients who received patient decision aids were more likely to prefer watchful waiting as a treatment option if they were found to have prostate cancer than were controls (RR=1.53, 95% CI=1.31-1.77, p<0.001).

CONCLUSIONS

Prostate cancer screening decision aids enhance patient knowledge, decrease decisional conflict, and promote greater involvement in decision making. The absence of outcome measures that reflect all elements of informed decision making continues to limit the field.

Reduction in uptake of PSA tests following decision aids: systematic review of current aids and their evaluations

A man's decision to have a prostate-specific antigen (PSA) test should be an informed one. We undertook a systematic review to identify and appraise PSA decision aids and evaluations. We searched 15 electronic databases and hand-searched key journals. We also contacted key authors and organisations. All decision aids and evaluations that discussed PSA were included, with meta-analyses performed on two outcomes from the evaluations: PSA testing and patient knowledge of PSA and related issues. Seven decision aids and 11 evaluations were included. The meta-analysis showed a significantly reduced probability in PSA testing after a decision aid: -3.5% (95% confidence interval: 0.0 to 7.2%; P = 0.050). There were significant improvements in knowledge within 2 weeks after a decision aid: 19.5% (95% confidence interval: 14.2 to 24.8%; P < 0.001). The effect on knowledge was less pronounced within 12-18 months after a decision aid: 3.4% (95% confidence interval: -0.7 to 7.4%; P = 0.10). PSA decision aids improve knowledge about PSA testing, at least in the short term. Men given these decision aids seem to be less likely to have the PSA test.

Psychological effects of a suspicious prostate cancer screening test followed by a benign biopsy result

PURPOSE

To evaluate the psychological implications of an apparently false-positive screening result for prostate cancer.

METHODS

The sample comprised 167 men with a benign biopsy result in response to a suspicious screening test result (biopsy group) and 233 men with a normal prostate-specific antigen (PSA) test result (control group). The men responded to a questionnaire within about 6 weeks of their biopsy or PSA results. They were asked about demographic characteristics, medical history, psychological effects, biopsy experience, and prostate cancer knowledge.

RESULTS

The survey response rate was 85% (400/471). The mean (+/- SD) age of respondents was 60 +/- 9 years (range, 40 to 88 years); 88% (n = 350) were white. Forty-nine percent (81/167) of men in the biopsy group reported having thought about prostate cancer either "a lot" or "some of the time", compared with 18% (42/230) in the control group (P < 0.001). In addition, 40% (67/167) in the biopsy group reported having worried "a lot" or "some of the time" that they may develop prostate cancer, compared with 8% (18/231) in the control group (P < 0.001).

CONCLUSION

Men who underwent prostate biopsy more often reported having thought and worried about prostate cancer, despite having received a benign result. This underrecognized human cost of screening should be considered in the debate about the benefits and harms of prostate cancer screening.

The effect of a distance-learning programme on patient self-management of Lower Urinary Tract Symptoms (LUTS) in general practice: a randomised controlled trial

OBJECTIVE

To determine whether a distance-learning programme on LUTS provided to the general practitioner affected patient self-management.

METHODS

A randomised trial was performed to examine the effects of the distance-learning programme (an educational package for the GP and a patient information leaflet) compared with written guidelines on LUTS mailed to the GP. In 63 general practices (32 intervention and 31 control) across the Netherlands all patients older than 50 years presenting LUTS for the first time were invited to participate. Main outcome measures were patient evaluation of quality of care received and perceptions of enablement.

RESULTS

A total of 151 patients was included. The intervention increased patient enablement regarding maintenance of independence (OR = 3.14) and coping with illness (OR = 2.21). Overall enablement scores were not changed. Patients in the intervention group had more positive evaluations of general practice care received (OR = 2.28 to 3.95). An explorative analysis suggested that the effects of the intervention were mediated in particular by handing out of patient information leaflets.

CONCLUSIONS

A distance-learning programme on LUTS for general practitioners had positive effects on patient self-management. Handing out leaflets appeared to be a crucial mediating factor.