Understanding cultural and logistical contexts for urologists in low-income countries.

The provision of effective urological management in low- and middle-income countries requires the delivery of appropriate and effective care adapted to the needs, capability and resources of the host country. However, a deeper cognisance of the culture, the religious practices and the logistics of healthcare in that environment determines the ability to effectively to 'twin', that is, to provide a long-term healthcare partnership. Patient beliefs can have profound effects on the understanding of the aetiology of illness, its relevance to their long-term health and the stigmatization of their family's social status. Consequently, individuals may have a greater willingness to seek help from practitioners of traditional medicine due to its availability as well as the lower costs of such medicine by comparison to those of medicine from high-income countries (HICs). This can influence the treatment of many urological conditions and lead to late-presenting states such as malignant ureteric obstruction. Social mores, such as cultural paternalism, can also influence many practices that are assumed by HICs to be part of normal healthcare provision, including the delivery of patient information and provision of informed consent to treatment. Doctor's status and dress have greater importance in many countries in sub-Saharan Africa (sSA) than in the UK and the modes of greeting and addressing colleagues and patients can affect the fluency and effectiveness of clinical interactions. A local cultural and religious knowledge is essential, therefore, to optimize the assimilation of external help. Logistics are perhaps the most important factor that needs to be grasped to provide a sustainable healthcare environment. Limitations in resource allocation are a major factor in planning effective urological treatment in many countries in sSA, whether this is the provision of trained personnel, basic infrastructure, a tenable workspace, equipment or drugs. This paper explores all of these factors, and looks at how their recognition assists urologists in providing a twinning process.

Discussing life expectancy with surgical patients: do patients want to know and how should this information be delivered?

BACKGROUND: Predicted patient life expectancy (LE) and survival probability (SP), based on a patient's medical history, are important components of surgical decision-making and informed consent. The objective of this study was to assess patients' interpretation of and desire to know information relating to LE, in addition to establishing the most effective format for discussion. METHODS: A cross sectional survey of 120 patients (mean age = 68.7 years, range 50-90 years), recruited from general urological and surgical outpatient clinics in one District General and one Teaching hospital in Southwest England (UK) was conducted. Patients were included irrespective of their current diagnosis or associated comorbidity. Hypothetical patient case scenarios were used to assess patients' desire to know LE and SP, in addition to their preferred presentation format. RESULTS: 58% of patients expressed a desire to know their LE and SP, if it were possible to calculate, with 36% not wishing to know either. Patients preferred a combination of numerical and pictorial formats in discussing LE and SP, with numerical, verbal and pictorial formats alone least preferred. 71% patients ranked the survival curve as either their first or second most preferred graph, with 76% rating facial figures their least preferred. No statistically significant difference was noted between sexes or educational backgrounds. CONCLUSION: A proportion of patients seem unwilling to discuss their LE and SP. This may relate to their current diagnosis, level of associated comorbidity or degree of understanding. However it is feasible that by providing this information in a range of presentation formats, greater engagement in the shared decision-making process can be encouraged.

Clinical judgment analysis of the parameters used by consultant urologists in the management of prostate cancer.

PURPOSE: We assessed which clinical parameters consultant urologists use to recommend treatment for early prostate cancer. MATERIALS AND METHODS: A total of 30 consultant urologists reviewed 70 paper representations of patients with prostate cancer. Each contained 7 commonly available cues, including prostate specific antigen, Gleason grade, rectal examination, magnetic resonance imaging/laparoscopic stage, medical history, patient choice and age, in addition to 2 cues not yet routinely available, that is predicted life expectancy and 10-year survival probability, as calculated using actuarial formulas based on noncancer comorbidity. Consultants indicated how strongly they would recommend radical prostatectomy, radiotherapy with or without hormones, or active surveillance/hormones. Judgment analysis was performed using multiple regression analysis with significance considered at p

The measurement of response shift in patients with advanced prostate cancer and their partners.

BACKGROUND: There is increasing evidence to support the phenomenon of response shift (RS) in quality of life (QoL) studies, with many current QoL measures failing to allow for this. If significant response shift occurs amongst prostate cancer patients, it will be necessary to allow for this in the design of future clinical research and to reassess the conclusions of previous studies that have not allowed for this source of bias. This study therefore aimed to assess the presence of RS and psychosocial morbidity in patients with advanced prostate cancer and their partners. METHODS: 55 consecutive advanced prostate cancer patients and their partners completed the Prostate Cancer Patient & Partner questionnaire (PPP), shortly after diagnosis and again at 3 months and 6 months. At the follow-up visits, both patients and partners also completed a then-test in order to assess RS. RESULTS: Partners consistently showed greater psychological morbidity than patients in relation to the prostate cancer. This was most marked on the General Cancer Distress (GCD) subscale (p < 0.001, paired t-test), and regarding worries about treatment (p = 0.01). Significant RS was identified in partners and patients by the use of the then-test technique, particularly on the GCD subscale, the concerns about treatment and the concerns about urinary symptoms items. CONCLUSION: These results suggest the presence of RS in patients with advanced prostate cancer and their partners, with higher levels of psychosocial morbidity noted amongst partners. This is the first study to identify RS in partners and calls into question the interpretation of all studies assessing changes in QoL that fail to allow for this phenomenon.

The assessment of patient life-expectancy: how accurate are urologists and oncologists?

OBJECTIVE: To assess the degree of accuracy, precision and consistency with which consultant urologists, oncologists and junior doctors predict a patient's 10-year life-expectancy. SUBJECTS AND METHODS: Eighteen doctors of varying seniority independently examined 70 patient case scenarios containing detailed medical histories; 13 of these cases were duplicate scenarios. Bland-Altman analyses were used to compare doctors' estimates of the probability of each hypothetical patient surviving 10 years with that calculated using actuarial methods. Intra- and interdoctor reliability were also assessed. RESULTS: Compared with actuarial estimates, doctors underestimated the 10-year survival probability by an overall mean of 10.8% (95% confidence interval, 10.1-11.5%). The 18 individual doctors ranged from a mean underestimation of 33.2% to a mean overestimation of 3.9%. Variation around these means was considerable for each doctor, the standard deviations being 14.5-20.9%. Inter-doctor reliability was 0.58, while overall intra-doctor reliability was 0.74, but for individual doctors was 0.31-0.94. Junior doctors were less accurate in their predictions than the senior doctors. Five doctors tended to overestimate where life-expectancy was poor and underestimate where it was good. CONCLUSIONS: Doctors were poor at predicting 10-year survival, tending to underestimate when compared with actuarial estimates. There was also substantial variability both within and between doctors. The inaccuracy, imprecision and inconsistency amongst the doctors in assessing patient life-expectancy is an important finding and has significant implications for managing patients. Many patients may be denied treatment after a pessimistic assessment of life-expectancy and (less commonly) some may inappropriately be offered treatment after an optimistic assessment. The particular inaccuracy in junior doctors compared with their senior colleagues also highlights the need for training. The development of a tool to assist in both training and clinical practice has the potential to improve doctors' decision-making and patient care.

Development and validation of a quality-of-life measure for men with nocturia.

OBJECTIVES: To develop and assess the psychometric properties of a short self-report nocturia-specific Quality-of-Life (QOL) questionnaire. METHODS: The Nocturia Quality-of-Life questionnaire (N-QOL) was developed using focus group interviews with men experiencing nocturia. To refine it further and psychometrically validate the questionnaire, 107 men with nocturia (from four urology clinics in the United Kingdom) completed the pilot N-QOL, along with measures of health status and sleep quality. To assess reproducibility, men from one clinic completed the pilot N-QOL again at 1 week. RESULTS: After standard item reduction analyses, 18 items were dropped from the pilot questionnaire. The psychometric properties of the remaining 13-item instrument were tested in accordance with standard criteria. Factor analysis identified two subscales, sleep/energy and bother/concern, loading at 0.5 and greater. The N-QOL overall score and subscales proved to be internally consistent (alpha = 0.84 to 0.90) and reproducible (intraclass correlation coefficient = 0.74 to 0.82). N-QOL scores correlated with sleep quality (P <0.01) as measured by the Pittsburgh Sleep Quality Index and energy/vitality and social functioning (P <0.01) as measured by the SF-36 Health Survey, demonstrating good convergent validity. The N-QOL also demonstrated statistically significant differences between the scores of those experiencing one, two, and three or more episodes of nocturia on an average night, indicating excellent discriminant validity. CONCLUSIONS: These analyses provide support for the psychometric validity of the N-QOL for use in a male population with nocturia.

The effect of erectile dysfunction on quality of life: psychometric testing of a new quality of life measure for patients with erectile dysfunction.

PURPOSE: We assessed the psychometric properties of the newly developed Erectile Dysfunction Effect on Quality of Life (ED-EQoL) instrument for quantifying the effect of erectile dysfunction on quality of life. MATERIALS AND METHODS: The questionnaire was assessed in a cohort of 283 men recruited from 11 centers in the United Kingdom. Internal consistency was examined by Cronbach's alpha, test-retest reliability was determined by administering the instrument on 2 occasions 2 weeks apart without treatment in the interim, construct validity was assessed by comparison with other quality of life measures and responsiveness was evaluated by comparing the change in the ED-EQoL after treatment with change in other measures. RESULTS: The ED-EQoL was simple to complete and captured wide variation in quality of life. It demonstrated good internal consistency and reliability, and generally correlated in an expected manner with other quality of life measures. Correlation with initial erectile function was relatively low but the change in function after treatment was reflected by the change in quality of life. CONCLUSIONS: When assessing erectile dysfunction in clinical practice or research, it is important to consider the effect on quality of life in addition to function. To our knowledge the ED-EQoL is the first erectile dysfunction specific quality of life instrument developed and extensively validated according to accepted principles of questionnaire design. Combined with a measure of erectile function its use is recommended in routine clinical practice and in research to provide a holistic approach to the assessment of erectile dysfunction and its treatment.