Incorporation of patient preferences in the treatment of upper urinary tract calculi: a decision analytical view.

PURPOSE: Patient preferences, or utilities, may be crucial to select an appropriate treatment plan for stone disease. We used decision modeling to understand better patient choices and decision making in the overall management of recurrent nephrolithiasis. MATERIALS AND METHODS: We interviewed 180 consecutive patients with active stone disease. Demographic data and historical experiences with calculi were recorded. Patients were presented with 6 hypothetical clinical scenarios and various treatment options. The standard gamble method was used to obtain utility values for each option. RESULTS: Nephrectomy had the lowest mean utility value of 0.883. Percutaneous nephrolithotomy for severe, moderate and mild pain had utilities of 0.924, 0.932 and 0.947, respectively. Shock wave lithotripsy for the management of mild pain was the most attractive option (mean utility 0.968). The utility for long-term medical therapy was 0.949, which was between that of percutaneous nephrolithotomy and shock wave lithotripsy for mild pain. Patients with a surgical history of stone removal assigned lower utilities to invasive procedures (nephrectomy, percutaneous nephrolithotomy, p <0.05). As the incidence of spontaneous stone passage increased, a higher utility was given to long-term medical therapy (p <0.05). Patients on medical therapy less than 1 year did not appreciate a significant benefit of medical prophylaxis. However, longer compliance with medical management led patients to perceive increasing benefits of continuing such medical treatment (p <0.05). Patients who had undergone stone removal via endoscopic or open surgery also had a higher preference for medical therapy (p <0.05). CONCLUSIONS: Patients who had undergone stone removal wanted to avoid future invasive procedures. They ranked long-term medical therapy below shock wave lithotripsy but above invasive procedures, such as percutaneous nephrolithotomy. Most importantly, patients appreciated the benefits of medical therapy the longer that they complied with specific recommendations. These results support the concept that patients perceive long-term medical therapy to prevent recurrent nephrolithiasis as a desirable treatment option.

Duke Scholars

Author David Bruce Matchar Medicine, General Internal Medicine

Author Glenn Michael Preminger Urology