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Omar M et al, 2015: Shared decision making: why do patients choose ureteroscopy?

Omar M, Tarplin S, Brown R, Sivalingam S, Monga M.
Stevan Streem Center for Endourology and Stone Disease, Glickman Urology and Kidney Institute, The Cleveland Clinic, 9500 Euclid Avenue, Q10-1, Cleveland, OH, 44195, USA.

Abstract

To evaluate patient's characteristics that affects their decision on the management of asymptomatic renal calculi, and to determine the impact of anesthetic on the selection of shockwave lithotripsy (SWL). A survey was distributed to 100 patients in our multi-disciplinary stone clinic. The patients were given a hypothetical scenario of an asymptomatic 8 mm lower pole stone and descriptions for managements options including active surveillance (annual radiography, 40 % chance of growth >10 mm within 4 years, 20 % chance of passage), SWL under conscious sedation (65 % success rate), and URS (90 % success rate, with stent placement for 1 week). Patients were asked what was the most important variable impacting the choice of treatment. Patients preferred SWL (45 %) over URS (32 %) and active surveillance (23 %). Patients with a previous experience with URS were more likely to choose it again (p = 0.0433). Decisions were driven primarily by success rate (52 %), followed by risk of complications (29 %), postoperative pain (7 %) and others (12 %). Patients choosing URS had the highest magnitude of history of pain (p = 0.03) and were more likely to prioritize success (78 %) and less likely to prioritize surgical risk (13 %) or anticipated pain after surgery (0 %) (p = 0.01). Most (85 %) of the patients would rely on the physician's recommendation for the treatment modality. Patients place differing value on risk versus success. As they rely heavily on the physician's recommendation, it is important that their urologist determine whether risk or success is of highest priority for them to facilitate a shared medical decision. 

Urolithiasis. 2015 Jul 25. [Epub ahead of print]

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Comments 1

Peter Alken on Friday, 15 January 2016 09:53

Double-J-Stent and URS is a story difficult to understand. In the present study participants were given a scenario that if URS plus stent was chosen “80 % of patients would experience some discomfort from the stent, discomfort would be severe in only 10 % of cases.” Somehow to the surprise of the authors one result of their study was that “Patients with a previous experience with URS were more likely to choose it again” and “those who chose URS were actually the least concerned about the prospect of a stent” despite the fact that “patients choosing URS had the highest magnitude of history of pain.”

Papers on URS or comparison of URS with other procedures frequently do not or not properly address the issue of stent related problems and stent removal. The majority of patients with stents do not like them: In a study by Joshi et al. (Joshi H B et al. Indwelling Ureteral Stents: Evaluation of Symptoms, Quality of Life and Utility. J Urol 169 (2003) 1065–1069) of patients who had had stent experience only 3% were pleased, 5% were mostly satisfied, 22% had mixed feelings, 22% were mostly dissatisfied, 34% were unhappy and 14 % thought it was terrible.
In a more recent study on stent design and patients complains by Davenpor et al. (Davenpor K et al. New Ureteral Stent Design Does Not Improve Patient Quality of Life: A Randomized, Controlled Trial;J Urol Vol. 185, 175-178, January 2011) appr. 60% of former stent patients voted against receiving a further stent due to symptoms they had experienced.
Finally one of the authors of the present paper, Monga M, co-authors and shares a non-commercial website for stone patients, http://www.KidneyStoners.org “A reliable source of information for kidney stone patients”.
On that website they offer patients to participate in a poll “How painful was your stent?” Up to the present date 9.592 patients have voted: The pane scale varies from 10 (the worst pain I’ve ever felt) to 1 (I didn’t feel a thing). The actual distribution of votes shows that the three highest stent related pain ranking from10 to 8 were given by 33%, 11% and 14 % respectively of the participants. So stents are in at least 58% a significant “pain in the bladder”.
Why then would a patient choose URS and stent again? The myth of shared decision making is dismantled a little bit: What is shared decision if most of the patients would likely defer the final decision to the physician despite the fact that they were experienced: 69 % were recurrent stone formers and 85 % had previous surgery. Major discomfort due to stents “in only 10 % of cases” as suggested to participants in the present study seems to be an optimistic doctor’s view.

Double-J-Stent and URS is a story difficult to understand. In the present study participants were given a scenario that if URS plus stent was chosen “80 % of patients would experience some discomfort from the stent, discomfort would be severe in only 10 % of cases.” Somehow to the surprise of the authors one result of their study was that “Patients with a previous experience with URS were more likely to choose it again” and “those who chose URS were actually the least concerned about the prospect of a stent” despite the fact that “patients choosing URS had the highest magnitude of history of pain.” Papers on URS or comparison of URS with other procedures frequently do not or not properly address the issue of stent related problems and stent removal. The majority of patients with stents do not like them: In a study by Joshi et al. (Joshi H B et al. Indwelling Ureteral Stents: Evaluation of Symptoms, Quality of Life and Utility. J Urol 169 (2003) 1065–1069) of patients who had had stent experience only 3% were pleased, 5% were mostly satisfied, 22% had mixed feelings, 22% were mostly dissatisfied, 34% were unhappy and 14 % thought it was terrible. In a more recent study on stent design and patients complains by Davenpor et al. (Davenpor K et al. New Ureteral Stent Design Does Not Improve Patient Quality of Life: A Randomized, Controlled Trial;J Urol Vol. 185, 175-178, January 2011) appr. 60% of former stent patients voted against receiving a further stent due to symptoms they had experienced. Finally one of the authors of the present paper, Monga M, co-authors and shares a non-commercial website for stone patients, http://www.KidneyStoners.org “A reliable source of information for kidney stone patients”. On that website they offer patients to participate in a poll “How painful was your stent?” Up to the present date 9.592 patients have voted: The pane scale varies from 10 (the worst pain I’ve ever felt) to 1 (I didn’t feel a thing). The actual distribution of votes shows that the three highest stent related pain ranking from10 to 8 were given by 33%, 11% and 14 % respectively of the participants. So stents are in at least 58% a significant “pain in the bladder”. Why then would a patient choose URS and stent again? The myth of shared decision making is dismantled a little bit: What is shared decision if most of the patients would likely defer the final decision to the physician despite the fact that they were experienced: 69 % were recurrent stone formers and 85 % had previous surgery. Major discomfort due to stents “in only 10 % of cases” as suggested to participants in the present study seems to be an optimistic doctor’s view.
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