Sadik J, Lambrechts S, Kwan L et al: Management patterns for benign prostatic hyperplasia: impact of a patient decision aid. Urol Pract 2021; 8: 523.

Decision aids (DAs) are instruments designed to educate patients seeking treatment for a medical condition. They may take the form of a physical pamphlet, a watchable video, or an interactive Web-based program. They are often used to support the process of shared decision making with a physician. The American Urological Association recommends that patients seeking treatment for benign prostatic hyperplasia (BPH) be counseled with a shared decision making process, in which provider and patient decide on the treatment approach after discussing how the risks and benefits of each treatment option align with the patient’s goals.¹

The benefits DAs have for patients include improved knowledge about options, more clarity in treatment goals, and more accurate expectations of risks and benefits.² These benefits make their use a natural fit for men seeking care for BPH. In addition, DAs used in the context of BPH management increase patients’ perceived role in the decision making process,³ providing patients with greater capacity to apply their personal preferences to the choice of treatment.

There may be physician practice benefits to employing DAs as well. Educated patients who understand their options ahead of time may have shorter, higher quality counseling visits and higher decision satisfaction. Moreover, with an anticipated shortage of urologists to provide surgical care for a growing population of men with BPH,⁴ DAs offer the prospect of identifying a more appropriate subset of patients to receive a referral for surgical care for BPH. Identifying which patients are inclined toward surgical management of BPH may streamline the primary care referral process for BPH, as primary care providers on occasion refer rather than provide appropriate first line medical management for BPH.⁵

In our recent quality improvement study, we examined the effect of an online, interactive DA completed by patients before their urology consultation for BPH.⁶ Our study’s DA used a decision analysis model to represent outcomes based on the medical literature and quantified preferences for outcomes such as retrograde ejaculation using a method called “conjoint analysis.” It generated a report of patient-specific quantified preferences for review by doctor and patient. The report also ranked treatment options for the patient according to how they might provide value based on clinical and preference data used in an “on the fly” decision analysis. We analyzed treatment choice in men who had used the DA compared to men receiving a standard consultation visit. We also analyzed whether certain phenotypes or profiles of patient values or preferences were associated with treatment choice using latent class analysis (LCA). We hypothesized that, similar to “market segments” composed of consumers with particular tastes, we would find classes of men who had similar preferences for outcomes of care.

Men scheduled for a new patient urology visit for BPH at a single academic tertiary care center without a history of prostate surgery were invited to use the DA prior to their appointment. The group receiving standard consultation for BPH, which we term the “usual care” group, was identified with the same inclusion criteria for 5 months before introduction of the DA.

We collected treatment choice data and patients’ medication histories from the electronic health record. We extracted data on BPH procedures (including both hospital-based and office-based procedures) occurring up to 6 months after each patient’s urology consultation. LCA was used to categorize patients into classes based on their common measured values and preferences.

Figure. Latent class analysis of treatment and value preferences among men seeking treatment for BPH. UTI, urinary tract infection.

Interestingly, we found that 36% of the patients included in our study were referred for urology consultation without ever having trialed alpha-1 blocking therapy. The rate in the DA group (37%) was similar to the overall group.

LCA identified 2 distinct preference profiles. Patients in the first profile placed greater importance on avoiding sexual dysfunction, dizziness, and retrograde ejaculation relative to the men in the second profile (see figure). While all patients included in the analysis who underwent procedural BPH management (4) belonged to profile 2, the difference in rate of procedural care between the profiles was not statistically significant (p=0.99). The large skew in size between the 2 cohorts and small number of patients choosing procedural care in the analysis may have contributed to this null result. Patients in the DA group were significantly less likely to have an intervention by 6 months than those in the usual care group (10/155 vs 15/100, p=0.0250), which remained significant after controlling for BPH medication status (OR 2.4, 95% CI 1.1–5.9, p=0.0398).

Our study’s finding of an association between DA use and a lower surgical rate is consistent with studies of major elective surgery broadly² and BPH specifically.^7,8 Patients having greater ability to incorporate their values and preferences into treatment choice may contribute to this phenomenon. One study examining DA use in the context of BPH treatment found that DA use increases the correlation between patients’ values and their selected treatment choices,⁹ perhaps allowing patients with values more consistent with conservative treatment to identify and express those preferences to their counseling physician, who can then account for them in a treatment recommendation.

Over a third of the patients in our study never trialed medical therapy before their urology consultation for BPH, representing a subset of patients who may be appropriate for primary care initially. Solutions to this care inefficiency may include “shared care,” where guidelines are jointly formulated by specialists and referring primary care physicians, and introducing the DA into the referral workflow, which can provide information back to the referring provider on the appropriateness of medical management.

Given the anticipated shortage in the urologist workforce,¹⁰ integrating DAs into urology referral may increase the yield of patients who are most in need of urological specialty care, at least initially. Future work may further refine our ability to define preference clusters and incorporate them into care guidelines. Incorporation of preference data into care guidelines would support routine assessment of preferences in men with BPH during shared decision making visits.