ProState of the Nation Report A call to action: delivering more effective

ProState of the Nation
Report
A call to action: delivering more effective
care for BPH patients in the UK
GSK has sponsored the production of this supplement;
for details please see the back cover page of the report
ADT/MAM/09/43437/1
Date of preparation September 2009
ProState of the Nation Report
Forewords
Professor Roger Kirby
Consultant Urologist, The Prostate Centre
Amanda McLean
CEO, Prostate UK
When I trained as a Urologist during the
1980s, the only effective treatment
option for Benign Prostatic Hyperplasia
(BPH) was surgery; usually by
Transurethral Resection of the Prostate
(TURP). Gradually, during the 1990s,
medical therapy with alpha-blockers and
5 alpha-reductase inhibitors (5ARI) grew in popularity,
and now very few patients with uncomplicated BPH
are treated by surgery in the first instance – many men
now avoid surgery altogether. This ProState of the
Nation report is a call to action; not only for men who
need to be more proactive in maintaining their prostate
health, but also for GPs who, with a little education,
can care more effectively for the many individuals
whose quality of life is negatively affected by this most
prevalent and bothersome of conditions.
At Prostate UK, we receive calls every
day from, and on behalf of, men who are
suffering with BPH. It is a condition that
can, in the most severe and untreated
cases, have a devastating affect on a
man’s quality of life. This ProState of the
Nation report lays out clearly what the
issues are for men and the treatments that are available
to them. It demonstrates how, with appropriate training,
support and resources, GPs can do much to effectively
manage and alleviate the condition. It is also a wake-up
call to policy makers who have shied away from
confronting BPH and makes a compelling case for the
need for proactive diagnosis and intervention.
Dr John Nash
GPwSI Urology, Buckinghamshire
Denis Gizzi
Executive Director for System Reform and Service
Innovation, NHS Oldham
As a GP and hospital practitioner in
Urology, I am fortunate in seeing men
with BPH, both in primary and
secondary care. Due to the ageing
population, the prevalence of BPH is
increasing. The adverse effects of BPH
on quality of life, potential subsequent
acute urinary retention and hospitalisation for TURP
have long been underestimated.
The assessment and management of men with BPH is
straightforward in General Practice. Each GP will have
an average of 50 men on their list between the ages of
60–80 years suffering with moderate and severe
urinary symptoms of BPH – a condition for which there
is effective drug treatment. I hope that this ProState of
the Nation report will encourage my fellow GPs to
manage BPH in the community and I am enthusiastic
and eager to help facilitate this process.
2
We are living in an era characterised by
continuous improvement in condition
management, patient choice and
economic constriction. The opportunity
for conditions such as BPH (for which
office based medicine methods clearly
apply) to be managed closer to
patients’ homes via economically grounded models of
care should be explored.
The findings from research direct us to a model of care,
which is, in the most part, observation and diagnostic
based. The continuous drive to improve population
health, individual experience and economic viability has
led to new, bespoke shared-care models of urology
service delivery. These pathfinder services, located
within communities, allow for rapid access to expert
opinion, diagnostics and community-based treatments,
freeing up the hospital sector to concentrate resources
on those who need it most. Clinicians working together
in shared-care or integrated pathway management
teams offer a way forward for optimal BPH
management. The ongoing education of community
physicians on the best BPH management methods is
also critical for the long-term sustainability of the
optimal model of care.
Contents
Contents
BPH: the evidence
4
An explanation of the disease impact and treatment options
BPH: recommendations versus reality
8
A summary of current UK guidance versus the reality of management for GPs,
specialists and patients in the UK
BPH: counting the cost for the NHS
12
A summary of the cost burden for the NHS and opportunities to reduce cost and improve care
Improving the ProState of the Nation: a call to action
15
References
16
3
ProState of the Nation Report
BPH: the evidence
In the UK, about 3.2 million men – over one
third of those aged over 50 years – suffer from
the symptoms of benign prostatic hyperplasia
(BPH).*1–3 The troublesome and unpleasant
urinary symptoms associated with BPH do not
just impair the quality of life of men and their
families, but also increase the risk of serious
and expensive long-term complications such as
acute urinary retention (AUR), hospitalisation
and surgery.4
What does BPH mean for men?
Men suffer varying degrees of BPE and BOO, so BPH
presents as a wide spectrum of clinical symptoms.
These are categorised as either storage (irritative) or
voiding (obstructive).4
Storage symptoms
Frequency
Urinating more often despite no
increase in the volume of urine
What is BPH?
Nocturia
Needing to wake to pass urine
at night
BPH is the term used to describe the benign, i.e. noncancerous enlargement of the prostate gland, a
walnut-shaped gland located beneath the bladder.
In BPH, benign prostatic enlargement (BPE) causes
narrowing of the urethra where it passes through the
prostate, leading in turn to bladder outlet obstruction
(BOO) and lower urinary tract symptoms (LUTS).5
Urgency
Sudden urge to urinate
Incontinence
Involuntary leakage of urine
Bladder
Seminal
vescile
Vas
Deferens
Hesitancy
Difficulty in beginning to urinate
Poor stream
Weak, dribbling stream of urine
Intermittency
Urine stream stops and restarts
Abdominal
straining
Needing to push or strain to pass
urine, increasing the risk of
micturition syncope (temporary
loss of consciousness)
Prolonged
voiding
Taking a long time to urinate
Incomplete
bladder
emptying
Sensation of urine remaining in
the bladder, and possibly passing
more urine after apparently
completing urination
Terminal
dribbling
Urine continues to leak from the
penis after urination has
apparently completed
Prostate gland
Urethra
Penis
Voiding symptoms
Epididymus
Testicle
Figure 1: The male reproductive system
Enlargement of the prostate occurs in response to the
androgen (male hormone) dihydrotestosterone (DHT).
DHT is metabolised from testosterone by the action of
the enzyme 5 alpha-reductase and is the key androgen
responsible for healthy prostate growth.6 In adult men,
there is normally a balance between prostate cell
growth (proliferation) and cell death (apoptosis). BPH
develops when this balance tips in favour of increased
cell proliferation, resulting in prostatic enlargement.
Beyond the age of 40 years the prostate gland
enlarges in most men and by the age of 65 years half
of men have symptoms of BPH.7 BPH almost
exclusively affects men aged over 40 years because
prostate size increases slowly with age.
4
The more severe a man’s symptoms, the more likely it is
that his general health status and quality of life will be
adversely affected by BPH. BPH symptoms, such a
those listed below, can have a tremendous impact,
affecting daily activities and the quality of life of up to
75% of men aged 50–65 years with moderate to
severe symptoms.8
* In the UK, there are 9.4 million men aged over 50 years1 of which
it is estimated that 35% experience symptoms suggestive of
BPH.2 This corresponds to an estimated 3.2 million men in the UK
with clinical BPH.3
BPH: the evidence
•
As the prostate enlarges and BPH progresses, men
need to wake more often – in some cases up to five
times a night – to urinate. This degree of nocturia is
not a natural part of ageing and seriously disrupts
sleep, reducing daytime energy and negatively
affecting daily activities and general well-being.9
•
Nearly half of men with BPH have sexual problems,
such as difficulty in maintaining or achieving an
erection and painful ejaculation.10, 11
•
Up to 95% of men with moderate symptoms report
not being completely happy to spend the rest of
their lives with their current symptoms.12
•
51% of men report that BPH interferes with at least
one area of their daily lives, compared with 28%
without a formal diagnosis of BPH.13
But BPH does not just affect men. The disease also
has a serious impact on their partners, who suffer from
‘second hand prostatism’ that affects their quality of
life, daily routines and relationships.14
The possibility of AUR and surgery is a significant
concern for men with BPH. When it occurs, admission
for AUR has a serious impact on a patient’s quality of
life due to the costs of additional domestic support, the
burden of multiple visits to accident and emergency
departments and extra admissions to hospital.16 The
fear that AUR may recur and may need surgical
treatment can also have a serious effect on a man’s
quality of life.17
Older age, moderate-to-severe symptoms and decreased
flow rate are associated with an increased risk of BPH
progression. However, the most important risk factors
are prostate size and prostate-specific antigen (PSA).4
Prostate size
Patients who initially present with a larger prostate tend
to experience greater subsequent increases in prostate
volume and more severe symptoms.18 Men with a
prostate larger than 30ml are one-and-a-half times
more likely to have moderate-to-severe LUTS and three
times more likely to experience AUR.4 Men with a
prostate larger than 50ml are three-and-a-half times
more likely to have moderate-to-severe LUTS.4
Does BPH have any long-term risks?
BPH is progressive and, without treatment, the
prostate continues to grow and symptoms become
more severe. In some cases this results in complete
blockage of the urethra and a sudden inability to pass
urine. This condition, known as Acute Urinary Retention
(AUR), is a medical emergency that is often
unexpected, always painful and involves treatment with
catheterisation or, in some men, prostate surgery.15
Prostate-specific antigen (PSA)
PSA is a protein produced by the prostate. Men with
baseline PSA greater than 1.4ng/ml are at approximately
double the risk of progressing to AUR over four years
compared with men with lower PSA levels.19
It is important to identify men with these risk factors
because appropriate treatment can delay or prevent BPH
progression and the risk of a patient developing AUR.20
Percentage of men affected
Impact of BPH on quality of life
Figure 2: BPH symptoms affect on quality of life13
5
ProState of the Nation Report
The troublesome and unpleasant symptoms of
BPH are the main reason why men first seek
help from their general practitioners. Many
men can be managed in primary care, but
BPH is commonly under-diagnosed and undertreated. Less than half of men with BPH are
diagnosed and, of those, only half receive
drug treatment.21
Diagnosing BPH
A comprehensive initial assessment is essential when a
man with LUTS first consults his GP or practice nurse.
A clinical history is essential to exclude other causes
of LUTS and to assess the severity of symptoms.22, 23
Large prostate volume and a high to normal PSA level
predict the increased risk of disease progression and
influence decisions about treatment and referral.
Assessment should therefore also include a validated
symptom assessment instrument, digital rectal
examination (DRE) and PSA testing.4
•
A validated assessment instrument, such as the
International Prostate Symptom Score (IPSS), helps
to quantify a man’s symptoms. The IPSS measures
the severity of storage and voiding symptoms; it is
also useful in assessing quality of life, disease
progression and in predicting/establishing treatment
response.23 The questionnaire is not diagnostic –
hence the need to first exclude other causes of LUTS.
•
A DRE is an integral part of good clinical examination.
Its main purpose is to assess the size, shape and
consistency of the prostate and to check for any
rectal pathology.4
•
PSA testing is used to assess the risk of prostate
cancer. It is also a useful surrogate for prostate
volume (the higher the PSA, the larger the
prostate). Men undergoing PSA testing should
receive information and counselling, as a high level
can also be a sign of prostate cancer.4, 24
6
Choosing the right treatment
In BPH, the aim of treatment is to relieve symptoms
and/or prevent complications (i.e. AUR and surgery)
and to slow/halt the disease progression. Currently
available options include watchful waiting, drug
treatment with alpha-blockers and 5 alpha-reductase
inhibitors (5ARIs) and surgery.
Watchful waiting
Watchful waiting involves regular monitoring of
symptoms and education and lifestyle advice. This is
appropriate for patients with a low risk of progression
and mild symptoms that are not particularly
bothersome.23
Alpha-blockers
These drugs rapidly relieve symptoms by relaxing the
smooth muscle of the prostate and bladder neck:
symptoms are improved by 20–50% and flow rates by
20–30% within 6–12 weeks. Alpha-blockers do not,
however, reduce prostate size, have little or no effect
on disease progression and do not lower the risk of
long-term complications such as AUR and surgery.25
All alpha-blockers are similarly effective, but sideeffects and ease of use vary between drugs.4 Although
alpha-blockers are generally well tolerated, commonly
reported side-effects include headache, dizziness,
postural hypotension, lack of energy, drowsiness, nasal
congestion and retrograde ejaculation.23
5 alpha-reductase inhibitors
5ARIs work differently from alpha-blockers, shrinking
the prostate by suppressing DHT and so addressing
the underlying cause of BPH. DHT is synthesised from
testosterone by two isoenzymes of 5 alpha-reductase:
type 1 and type 2.6 Two 5ARIs are currently available to
treat BPH.
5ARIs also significantly improve symptoms. Initial
improvement is seen in the first few months after
initiation, followed by sustained, progressive benefit in
the longer term. Importantly, long-term use of 5ARIs
reduces the risk of AUR and surgery.4 side-effects are
minimal but can include erectile dysfunction, ejaculatory
disorders and gynaecomastia.23
BPH: the evidence
Combination drug therapy
Summary
Benefits of combining an alpha-blocker
and a 5ARI
Benefit
Alpha-blocker 5ARI
Rapid improvement
in symptoms
√
Improved symptoms/flow
√
√
Maintenance of symptom/
flow improvements
√
√
Reduced prostate volume
√
Maintenance of reduced
prostate volume
√
Reduced long-term risk
of AUR and surgery
√
Treatment with a combination of an alpha-blocker and a
5ARI combines the complementary advantages of each
class of drug and has been shown to be more effective
than treatment with either of the individual drugs
alone.4, 26 This approach is recommended in men with
moderate-to-severe symptoms who have a high risk of
BPH progression.4
•
BPH is a common condition, affecting over a
third of men aged over 50 years in the UK
•
The unpleasant symptoms have a
considerable effect both on the patient and
their family
•
Appropriate treatment of BPH can delay
disease progression and reduce the risk of
patients developing AUR and eventually
requiring surgery
All of my day to day activities
are affected by BPH. The
constant need to be near a
toilet means that I am
restricted in the work I can
do. I can’t do outside work –
I must have a toilet nearby.
Holidays and excursions
are impossible.
Surgery
BPH surgery is used either as initial therapy for
patients with complications such as AUR, or for those
not responding to drug therapy. Although transurethral
resection of the prostate (TURP) remains the ‘gold
standard’, laser surgery is becoming more popular as it
is effective, has fewer side-effects and patients spend
less time in hospital.
7
ProState of the Nation Report
BPH: recommendations versus reality
Clinical guidelines, delivered by tools such as
the Map of Medicine, are increasingly
important in guiding the management of
common diseases and conditions, especially
in primary care. This is because, by basing
recommendations on the best available
evidence, clinical guidelines can change the
process of healthcare, reduce variations in the
standards of diagnosis and treatment and
improve patient outcomes.
What do the UK guidelines
recommend?4
Evidence-based guidelines for the management of
LUTS by the British Association of Urological
Surgeons (BAUS) have been available for some time.
First published in 2004, the BAUS guidelines reflect
advice contained in other international BPH guidelines.
Its recommendations on diagnosis and treatment are
specifically designed for use by GPs and practice
nurses in primary care. The BAUS recommendations
have also influenced the BPH pathway in the Map of
Medicine and the 18-week Commissioning pathway for
male LUTS.
The BAUS guidelines emphasise the importance of
accurate assessment of symptoms and prostate size.
The aim is to guide decisions about initial treatment
and to determine the risk of disease progression.
Diagnosis therefore includes a comprehensive,
evidence-based initial assessment, including symptom
assessment with the IPSS, physical examination
including DRE and, when appropriate, PSA testing.
Figure 3: Recommended primary care management of BPH.4 Adapted from Speakman et al. Guideline for the primary care
management of male lower urinary tract symptoms
8
BPH: recommendations versus reality
In order to help GPs identify men who are at high risk of
disease progression, the guidelines list predictive risk
factors that can be assessed in routine clinical practice:
•
Age over 70 years with LUTS
•
Moderate-to-severe LUTS (IPSS over 7)
•
PSA over 1.4ng/ml
•
Prostate volume over 30ml (about the size of a
golf ball)
•
Flow rate less than 12ml/sec
One of the hardest things
about living with BPH is
when my partner and I go
out together. She has to be
prepared for me to suddenly
want to dart off to a toilet or
to stop the car at the first
public convenience we find.
Many men newly presenting to their GP with LUTS can
be managed in primary care, but this assumes
appropriate referral by GPs to secondary care colleagues.
The BAUS guidelines provide clear recommendations
on indications and priorities for referral. See figure 4.
Choice of treatment is indicated by each patient’s risk of
disease progression, based on PSA level/prostate size.
See figure 5.
All other patients can be initially treated in primary care.
BAUS recommends that treatment is beneficial in most
men initially presenting with bothersome symptoms.
Watchful waiting and lifestyle advice are appropriate
only for patients with very mild symptoms who are at
low risk of disease progression.4
The BAUS guidelines represent best practice in the
management of BPH in primary care, but adherence to
the guidelines varies widely in clinical practice. Adopting
the BAUS guidelines throughout the UK would ensure
that all men with BPH receive the most appropriate and
the most effective treatment.
Indications for direct urological referral
Treatment Recommendations
Elevated or rising agerelated PSA
Refer under two-week
wait scheme
Nodule in prostate
Refer under two-week
wait scheme
Haematuria
(blood in the urine)
Refer under two-week
wait scheme
Acute retention
Immediate treatment/
referral
Chronic retention
Priority if creatinine is
high
Recurrent urinary
tract infections
To be seen soon
Symptoms of possible
prostate cancer (e.g.
painful urination with
sterile pyuria*)
To be seen urgently
*Sterile pyuria: presence of increased numbers of white cells in a
urine sample that appears sterile using standard culture techniques
Men with smaller
prostates(<30ml or
PSA <1.4ng/ml)
Alpha-blocker + lifestyle
advice, reviewed
after 6–12 weeks
Men with larger
prostates (>30ml or
PSA >1.4ng/ml)
5ARI + lifestyle
advice, reviewed
after 3–6 months
Men with moderate-tosevere symptoms and
significant risk factors
for progression
Combination therapy
with alpha-blocker
+ 5ARI, reviewed
after 3–6 months
Men with large
prostates with no/mildly
bothersome symptoms
but significant risk
factors for progression
5ARI monotherapy
Men with bothersome
symptoms at follow-up
Consider urological
referral
Figure 5
Figure 4
Figures 4 and 5: Recommended primary care management of BPH.4 Adapted from Speakman et al.
Guideline for the primary care management of male lower urinary tract symptoms
9
Prostate of the Nation Report
The evidence-based BAUS guidelines are
designed to ensure that a man with LUTS
receives the most appropriate treatment and,
where necessary, secondary care referral.
But recent market research** among GPs,
urologists and men with BPH reveals important
barriers to the effective management of BPH,
especially in primary care. This has important
implications both for secondary care in terms
of inappropriate referrals and for patients’
quality of life and well-being.
I find it embarrassing when
at work as I have to regularly
excuse myself mid-meeting
to go for a break. It also
interrupts my wife’s sleep
when I have to go to the loo
in the middle of the night.
What do GPs say?27
GPs lack confidence in diagnosing LUTS and are
concerned about missing a case of prostate cancer.
As a result, under-treatment and under-diagnosis of
BPH is frequent in primary care. Furthermore, although
evidence-based BPH guidelines have been published,
GPs are either unaware of them or do not follow its
recommendations.
•
•
•
•
What do urologists say?28
Urologists report that they spend a large proportion of
their time seeing inappropriate BPH referrals – that is,
men who could be diagnosed and treated in primary
care. Reducing the number of these referrals would
reduce costs and waiting times, benefiting the NHS
and patients.
Only 24% of GPs routinely use the IPSS to assess
a man with LUTS, compared with 99% who routinely
use PSA and 89% who routinely perform a DRE.
•
Only 11% of GPs are very confident about
distinguishing between BPH and prostate cancer.
57% of GPs agree that PSA results are difficult to
interpret and 40% lack confidence in assessing
prostate size.
68% of urologists agree that PSA results are
difficult for GPs to interpret. 82% recognise that
GPs’ uncertainties about excluding prostate cancer
is a key barrier to BPH management in primary care.
•
41% of BPH referrals received by urologists could
be managed in primary care.
•
35% of urologists’ time with BPH patients is spent
seeing inappropriate GP referrals.
•
Up to 30% of urologists’ time with BPH patients
could be saved if GPs were confident in prescribing
alpha-blockers and 5ARIs alone, or in combination.
•
74% of urologists say that avoiding inappropriate
BPH referrals could reduce costs to the NHS and
86% say that it would reduce waiting times.
71% of GPs say that their uncertainty in diagnosing
prostate cancer is a barrier to treating BPH in
primary care. On average, GPs seek specialist
advice in 37% of cases of men with LUTS.
54% of GPs refer men with BPH before
maximising drug treatment in primary care (i.e.
before initiating combination treatment with an
alpha-blocker and 5ARI).
•
70% of GPs would welcome more information to
reassure them about using combination therapy in
men with BPH.
•
81% of GPs are unaware of the UK BPH guidelines
from BAUS.
** Online survey among 100 GPs and 50 urologists, and online survey
among 100 men aged over 40 years with formal BPH diagnosis.
Representative geographical spread in both surveys.
10
BPH: recommendations versus reality
What do men with BPH say?29
•
Patients bear the burden of late diagnosis and undertreatment of BPH. As a result, their condition continues
to have a serious impact on their daily lives. Men with
BPH say that they are happy to take additional
treatments to alleviate their symptoms and that
receiving a diagnosis of BPH was reassuring and
improved their quality of life.
Independent market research has highlighted the
negative effects on the quality of life of men with BPH,
but there are wider implications of under management
and under-treatment of the condition, in particular in
increased costs to the NHS.
•
•
•
•
75% of men with BPH report waking to urinate
more than once a night and that this symptom in
particular had an important impact on family life.
46% of men wait more than one year after the start
of their symptoms before seeking help from their GP.
64% of men with BPH are referred to secondary
care when they first present to their GP. Only
28% are prescribed treatment while waiting to see
the specialist.
61% of men are reassured when they are diagnosed
with BPH.
•
27% of men wait at least six months for treatment
after seeking help from their GP. Only 26% of men
are ever prescribed a 5ARI.
•
Over 90% of men still experience symptoms and
52% report little or no improvement despite their
initial BPH treatment.
•
52% of men are disappointed and 22% dissatisfied
that they still experience symptoms following their
initial treatment. Over 80% of men report that BPH
still affects their daily lives.
78% of men prescribed a BPH treatment would be
keen to take an additional tablet that reduced
prostate symptoms and the risk of needing surgery.
Summary
•
GPs lack confidence in diagnosing LUTS
due to concerns about missing a case of
prostate cancer
•
Clinical guidelines are available for the
management of BPH, however, awareness
of them at a primary care level is low
•
Urologists are currently spending a
considerable proportion of their time seeing
BPH cases which could be effectively
managed by GPs
•
The late diagnosis and under-treatment of
BPH has a serious effect on both the patient
and their families quality of life
Men don’t know a thing about
this disease. If I was speaking
to other men with BPH I
would tell them to get treated
immediately and not to ignore
any symptoms.
11
Prostate of the Nation Report
BPH: counting the cost for the NHS
BPH not only has a serious impact on the
quality of life of patients and their families;
the condition is also expensive for the NHS, in
terms of costs both for GP practices in primary
care and for urology services in secondary
care. This current economic burden can only
increase with the rising numbers of men with
BPH in the UK population and urgent action is
needed to improve the cost-effectiveness of
the diagnosis and treatment of BPH.
From Hospital Episode Statistics (HES) data
(2007/2008) urology currently represents the fifth
most expensive disease area for the NHS, accounting
for an expenditure of £1.16 billion each year.30
Surgery for BPH represents the tenth most commonly
performed operation across the NHS and acute urinary
retention (AUR) is amongst the top 5% of causes of
acute admissions to NHS hospitals.30
This section of the report provides updated estimates
looking at the consultation and treatment costs
associated with managing BPH in primary and in
secondary care. The review uses a range of data
sources. These estimates are indicative, not
authoritative.
The costs of BPH in primary and
secondary care
Although there are published estimates for the number
of men affected by BPH symptoms in the UK, accurate,
up-to-date data regarding the number of men that visit
their GP to discuss these symptoms are limited to
local, practice-based surveys. The latest published
national data are from the Third National Morbidity
Survey (1983), which reported that 0.51% of all GP
consultations were for BPH.31 If we adopt the
assumption that the proportion of consultations for
BPH has remained the same (0.51%), we can combine
these data with current all-cause consultation rates and
population data to estimate the average number and
cost of primary care consultations related to BPH each
year. Using an all-cause consultation rate of 5.332 per
person, applied to the UK population of 61 million33
there are an estimated 1,648,830 primary care
consultations for BPH in the UK each year. Using a
cost of £27.00 for each GP consultation34 results in a
total primary care consultation cost across the UK of
£44,518,410.
12
In this estimated cost analysis
the cost of GP consultations
for BPH for 2007/2008 in the
UK was more than £44 million
UK primary care GP consultation cost
All-cause GP consultation rate of 5.3
Multiplied by UK population of 61 million =
323,300,000 consultations
Of which 0.51% or 1,648,830 are for BPH
Multiplied by the cost of a GP consultation at £27
Gives a total primary care GP consultation
cost of £44,518,410
Cost of drug treatment for BPH in
the UK
According to cost data provided by IMS (an
independent company providing pharmaceutical and
healthcare market intelligence to pharmaceutical and
biotech companies along with government agencies,
policymakers, researchers and financial analysts
around the world) the annual drug cost for BPH in
the UK in 2008/2009 is £69,228,637.*35 This consists
of £40,058,187 for alpha-blockers and £29,170,450
for 5ARIs.35
In this estimated cost analysis
the cost of drug treatment for
BPH for 2008/2009 in the UK
was more than £69 million
* IMS RSA data for G4C products 07/2008–06/2009.35 This
excludes the alpha-blocker doxazosin as it is assumed that this drug
is primarily prescribed to treat hypertension.
BPH: counting the cost for the NHS
Cost of treating BPH-related
complications in the UK
Using HES data for 2007/2008, which are based on
all hospital treatments in England, an estimate of the
volume of hospital treatment for BPH can be made for
the UK as a whole.
HES data for England reports that 28,499 men were
admitted to hospital with AUR at a total tariff cost of
£29,702,780 and 26,618 patients were admitted to
hospital for BPH-related surgery (for example, TURP)
at a cost of £55,357,650.36 Adding these costs
together and applying an uplift factor of 19% to reflect
the whole UK population gives a total cost for treating
these major complications of BPH in secondary care
of £101,221,912.36
It seems reasonable to assume that additional costs
are incurred as a result of patients requiring review in a
urology clinic, either before their admission for surgery
or following their discharge after surgery or AUR.
It is standard practice (and therefore assumed) that all
patients admitted for BPH-related surgery will have a
pre-operative consultation at a tariff of £161 followed
by a single post-operative follow-up at a tariff of £80**.
Similarly, it is assumed that all men admitted with
AUR have a follow-up review at a tariff of £80. This
equates to an additional cost of £10,346,881 directly
attributable to the costs of treating key BPH
complications in the UK.
Using these costs, based on HES tariff data for
England and factored up to reflect the whole UK
population, it is estimated that the total UK secondary
care cost associated with these BPH-related
complications is £111,568,793.
Cost of treating BPH complications in the UK
An AUR treatment tariff cost for England
of £29,702,780 x 19% (factor up to UK
population) = £35,346,308
A BPH-related surgery tariff cost of
£55,357,650 x 19% (factor up to UK
population) = £65,875,604
An AUR follow-up urology consultation cost of
£80 x 28,499 admissions = £2,279,920 x19%
(factor up to UK population) = £2,713,105
BPH-related surgery pre-operative and followup urology consultation costs of [£80 + £161]
x 26,618 admissions x 19% (factor up to UK
population) = £7,633,776
The total cost of treating BPH in secondary
care is therefore estimated to be £111,568,793
In this estimated cost analysis
the secondary care cost related
to AUR and BPH-related
surgery is £111,568,793
** According to HES data 96% of BPH-related surgery admissions
are elective.
13
ProState of the Nation Report
Conclusions
According to this illustrative cost analysis the secondary
care costs associated with managing AUR and BPHrelated surgery, which are common complications of
BPH, stands at £111,568,793. This is almost 60%
more than the amount spent on drugs to treat BPH
(£69,228,637)35 and more than 3.5 times the
expenditure on the 5ARI class of drugs (£29,170,450),35
which are proven to reduce the risks of both AUR and
BPH-related surgery.26
The time and cost burden associated with primary care
consultations should also be considered when
evaluating the impact of treating BPH on the NHS. In
this cost analysis it is estimated that 1,648,830 GP
consultations are for BPH at a total cost to the NHS of
£44,518,410 per annum.
The calculations detailed in this report are indicative
and not authoritative; therefore, the final total costs are
undoubtedly an approximation of the costs associated
with treating BPH.
In 1990, the direct cost of treating BPH in the UK in
primary and secondary care was estimated to be
between £59 and £77 million.31 While a comparison
with these updated figures should be viewed with
caution due to differences and limitations in the
methodologies used, even at the higher 1990 estimate,
these figures suggest that the total direct costs
associated with treating BPH have almost doubled
over the past 20 years. It would also seem likely that
expenditure on BPH will continue to escalate due to
our ageing population, adding an increasing burden on
NHS resources, therefore any potential for managing the
condition more cost effectively should be considered.
14
Summary
•
This report estimates that £180,797,430 is
spent on BPH treatments each year
•
60% of this is incurred in secondary care
as a direct result of managing complications
in BPH
•
Improving the quality and consistency of
BPH management in primary care could
lead to reductions in BPH complications and
their associated costs for the NHS
Improving the ProState of the Nation: a call to action
Improving the ProState of the Nation:
a call to action
• The NHS must recognise effective BPH management and treatment as a key health
priority and make every effort to educate and encourage primary care to manage this
condition appropriately.
• More can be done at a primary care level to improve current management of this
highly prevalent condition. Inclusion of BPH on the Quality Outcomes Framework
(QOF) would provide additional resource to GPs to enable this to happen.
• PCTs and secondary care urology departments must work together to establish local
shared-care referral and treatment pathways designed to provide more clinically
effective and cost effective treatment for men with BPH. This is in-line with the
‘Community and Care Services White Paper’, aimed at providing care closer to home
in speciality areas such as urology.37
• Men must be proactively educated through awareness campaigns, dedicated health
clinics and their primary care practitioners so that they are aware that urinary
symptoms are not a normal part of ageing and that treatment is available from
their GP.
15
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GSK sponsorship has included payment for a medical writer, honoraria
to the editorial board and payment to a public relations agency in
respect of project management support