BPH guideline adherence: ‘Room for improvement’

Orlando, FL-A retrospective evaluation to determine adherence to the AUA clinical practice guideline for the management of lower urinary tract symptoms/BPH among urologists practicing in an academic setting found generally positive results, but with room for improvement, researchers reported at the AUA annual meeting in Orlando, FL.

The study, conducted at Northwestern University, Chicago, used an automated electronic medical record extraction process to identify information from within clinical documentation and orders for first BPH/LUTS-related visits. The data were analyzed to determine rates at which individual diagnostic tests and portions of the history and physical exam addressed in the AUA guideline were performed. 

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The study included data from 3,494 new visits among men age ≥45 years seen by 12 urologists over a 5-year period (January 2008 to December 2012). Its results showed physician adherence rates ranged from 53.0% to 98.2% for the nine measures that are “recommended” by the AUA guideline for the initial evaluation of a patient with basic LUTS/BPH. The five “not routinely recommended” measures were performed no more than 10% of the time.

“This is a single-center analysis performed in an academic institution. Therefore, the findings may not be nationally generalizable, and so further study in more diverse practice settings would be useful,” said first author Gregory B. Auffenberg, MD, urology resident at Northwestern.

“We feel our analysis provides an important benchmark for comparative research of guideline adherence in different practice settings, and that as a benchmark, it will allow important future analyses to evaluate the effect of guideline adherence on patient outcomes,” added Dr. Auffenberg, who worked on the study with Christopher M. Gonzalez, MD, MBA, and co-authors.

In order to establish the accuracy of the automated data extraction, a manual review was performed to extract data from 360 randomly chosen patient charts. This validation process revealed an overall concordance rate of 96.7% between the automated and manual techniques, providing reasonable confidence in the accuracy of the reported results, Dr. Auffenberg said.

Next: Lowest adherence seen with IPSS measure

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Lowest adherence seen with IPSS measure

Of the nine measures that are recommended in the AUA guideline for the initial evaluation of a patient with BPH/LUTS, the study found adherence was lowest for International Prostate Symptom Score determination (53.0%). Adherence for evaluation of sexual function was 66.2%, while the adherence rate for all other recommended measures was >81%. The highest adherence was for physical exam (92.8%).

Dr. Auffenberg said the investigators were somewhat surprised by the low adherence with IPSS determination, but he noted there are impediments to collecting and recording the data. Dr. Auffenberg explained that the IPSS is completed as a paper survey and may either not be done by the patient or not entered into the record.

“The 53% adherence rate we identified for determining IPSS may not be truly reflective of the rate at which men are asked to provide this information. However, since the true value of getting this information is to follow the score over time, it only matters if the data are in the record,” Dr. Auffenberg said.

He added that potential solutions are being considered in which the questionnaire would be completed electronically and automatically entered into the record.

Discussing the study’s bias associated with its academic practice setting and need for assessing guideline adherence in the diversity of urology practices, Dr. Auffenberg agreed with a comment from the audience that such studies might be challenging and there may be pushback from community practitioners against collecting the data unless the goals of data acquisition are very clear.

“However, I am optimistic in our new EMR era that practitioners will become more amenable to this type of research and that they will perceive it in a positive light rather than as having potentially punitive consequences,” he said. “The reason why we are doing these studies is to improve patient care and outcomes and reduce costs, and it is not simply to be monitoring physicians and telling them whether they are doing a good or bad job.”

To improve LUTS/BPH guideline adherence at Northwestern, a guideline-driven clinical decision support module has been developed. It will be integrated into the EMR at Northwestern and some collaborating institutions, allowing collection of a more robust set of data, Dr. Auffenberg said.

The study had partial funding from the AUA.UT

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