Assessing health care need for prostatectomy.

This thesis describes a study that estimated the health care need for prostatectomy in a typical district of 250,000, among men who have both the appropriate indications for treatment and who would choose treatment if offered. It established the appropriate indications for prostatectomy using a literature review and a nominal group type consensus panel consisting of 6 urologists and 3 general practitioners. These were expressed in terms of different combinations of type of retention, type and severity of symptoms, and level of comorbidity. A 2-stage community survey of 2000 men aged 55 and over randomly selected from 8 general practices, using postal questionnaires, was conducted in North West Thames health region. The surveys collected information about: (1) self-reported frequency and severity of lower urinary tract symptoms; (2) the impact of these symptoms on daily activities and on health status; (3) the advice-seeking behaviour of men with symptoms and consequent action of GPs and urologists; and (4) patient preference for treatment. These results were combined to estimate the number of prostatectomies required in a typical district. The overall response rate was 66% (initial survey=78%, follow-up survey=84%). 20% of men reported moderate or severe lower urinary tract symptoms. Of these, 28% found their symptoms to be a medium or big problem and that, depending on the activity, between 9% and 39% experienced interference with their daily activities. Health status, as measured by either the Nottingham Health Profile or the SF-36, worsened as symptom severity increased. Forty five per cent of men with symptoms had seen their general practitioner for their symptoms. Of these, 62% were referred on to a urologist, of which the majority (71 %) were offered, and accepted surgery. When presented with details and information on the risks and benefits of prostatectomy, a substantial proportion (22%) of men with lower urinary tract symptoms, reported that they would probably, or definitely, refuse treatment, while a 47% of men were unsure. The estimate of required number of prostatectomies in a district with a population of 250,000 ranged from 225 to 4329 depending on the level of appropriateness, symptom severity and preference adopted. The decision about which estimate to use in purchasing prostatectomy for lower urinary tract symptoms must be made by local authorities.