Patient Attitudes Toward Treatments for Overactive Bladder

Abstract & Commentary

By Frank W. Ling, MD

Clinical Professor, Departments of Obstetrics and Gynecology, Vanderbilt University School of Medicine, and Meharry Medical College, Nashville

Dr. Ling reports no financial relationships relevant to this field of study. This article originally appeared in the August issue of OB/GYN Clinical Alert.

Synopsis: Women with overactive bladder hold differing views of their treatment options in light of the severity of their symptoms as well as the risks/benefits of the modality.

Source: Wu JM, et al. Patient preferences for different severities of and treatments for overactive bladder. Female Pelvic Med Reconstr Surg 2011;17:184-189.

RESEARCHERS FROM DUKE UNIVERSITY AND THE UNIVERSITY of California, San Francisco enrolled 40 patients with symptoms of overactive bladder (OAB), i.e., urgency, frequency, and/or urge incontinence, and 40 patients with no history of OAB symptoms. The women’s view of symptoms and treatments were measured with a utility score.

A utility is defined as “...a quantitative measure of the value that an individual assigns to a specific health outcome.” Scores range from 0 to 1.0 where 0 represents death and 1.0 is perfect health. Utilities were measured for four levels of OAB severity as well as three urge incontinence treatments. Significant side effects and/or complications were measured as well. Three treatments/complications were assessed and were defined as the following: 1) anticholinergic agents without side effects or with constipation/dry mouth; 2) botulinum toxin injection with urinary retention; and 3) sacral neuromodulation with no complications or with subsequent irritation in the lower extremeties or vagina.

Each subject was asked to rate on a scale from 0 to 100 how she would feel about living with each set of health outcomes. The rating was converted to a score between 0 and 1.0, i.e., a rating of 93 became a utility score of .93. Each proposed clinical scenario was described in great detail. By having richer descriptions, there is less room for ambiguity in the subject’s response. Subjects also were allowed to adjust their rankings in relation to their answers to all other responses that they had given. This allowed the subject to change earlier responses in light of additional situations described later in the instrument, thereby allowing her to respond to each item within the context of all the scenarios described. The highest scores (both median and mean) were for mild urge incontinence (0.92 and 0.82, respectively). As the severity of urgency increased, scores decreased. A condition of frequency/urgency without incontinence scored between mild and moderate incontinence.

As for treatments for OAB, the least invasive (oral anticholinergics) with no side effects scored the highest (0.93 and 0.84). The lowest scores assigned to treatment were botulinum toxin complicated by urinary retention (0.75 and 0.64).

Commentary

Although the concept of “utility” may be new to the reader, it is one that makes both clinical and common sense. Future studies may emphasize the importance of utility scores as newer treatments are studied. The utility score considers quality of life, a concept that many can appreciate but is difficult to measure. Understanding how a patient compares the effects of a chronic health condition vs possible complications of treatment for that condition provides insight into how significant symptoms and treatment are on a patient’s lifestyle.

In this article, for example, the authors point out that low utility score of moderate urge incontinence (0.85) and severe urge incontinence (0.73) show that this condition has a “profound” effect on quality of life. For comparison, the following utilities are offered: blindness in one eye (0.93), asthma with dyspnea (0.89), moderate chest pain (0.83), and mild dementia (0.65). Findings that more severe OAB symptoms are assigned a lower utility score and that any treatment is given a higher utility than the same treatment with a complication show that this measure of utility makes clinical sense.

More importantly, in any given patient that we see in the office each day, we commonly provide choices that simulate this very process. “Mrs. Jones, is the pain bad enough that you would be willing to undergo a surgical procedure such as laparoscopy with its potential complications?” The same implied question applies to any medical or surgical therapy that is offered to a patient. Certainly the likelihood of a specific complication also will color the patient’s response, since the utility is a description that presumes that the complication did occur.

Beyond the general concept of utility, the specific findings of the study should lead the clinician back to the important theme of OAB and its effect on quality of life. OAB should not be viewed as merely a nuisance, as utility of both moderate and severe urge incontinence would indicate. Since utility of anticholinergics without side effects scored higher than botulinum toxin without complications, which, in turn, scored higher than sacromodulation without side effects, it would appear that those treatments might logically be offered to patients in that order.

The reader should not be surprised to see the use of “utility” a lot more in our literature in the years to come. Remember, you heard it first here.