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May 27, 1988, Vol 259, No. 20 >
ARTICLE | May 27, 1988

Watchful Waiting vs Immediate Transurethral Resection for Symptomatic Prostatism: Title and subTitle BreakThe Importance of Patients' Preferences FREE

Michael J. Barry, MD; Albert G. Mulley, Jr, MD, MPP; Floyd J. Fowler, PhD; John W. Wennberg, MD
[+] Author Affiliations

Reprint requests to the General Internal Medicine Unit, Massachusetts General Hospital, Bulfinch 1, Fruit St, Boston, MA02114 (Dr Barry).


JAMA. 1988;259(20):3010-3017. doi:10.1001/jama.1988.03720200032029
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References

The rate of resection for benign prostatic hypertrophy shows considerable variability among small geographic areas. To help inform the decision to recommend prostatectomy to men with prostatism without signs of chronic retention, we performed a decision analysis to compare the expected outcomes with immediate transurethral resection and watchful waiting. Data used in the model originated from the medical literature, Medicare claims data, and patient interview studies. In our base-case analysis for 70-year-old men, immediate surgery resulted in the loss of 1.01 months of life expectancy, but when adjustments were made for quality of life, immediate surgery was favored with a net utility benefit of 2.94 quality-adjusted life-months. However, the analysis was particularly sensitive to the degree of disutility attributed to the index symptoms of prostatism. We conclude that patient preferences should be the dominant factor in the decision whether to recommend prostatectomy.

(JAMA 1988;259:3010-3017)

REFERENCES

1 +
Wennberg JE, Barnes BA, Zubkoff M:  Professional uncertainty and the problem of supplier-induced demand. Soc Sci Med 1982;;16:811-824.
2 +
Barnes BA, O'Brien E, Comstock C, et al:  Report on variation in rates of utilization of surgical services in the Commonwealth of Massachusetts. JAMA 1985;;254:371-375.
3 +
Wennberg JE, Gittelsohn A:  Health care delivery in Maine: I. Patterns of use of common surgical procedures. J Maine Med Assoc 1975;;66:123-130, 149.
4 +
McPherson K, Wennberg JE, Hovind OB, et al:  Small-area variation in the use of common surgical procedures: An international comparison of New England, England, and Norway. N Engl J Med 1982;;307:1310-1314.
5 +
Wennberg JE, Roos N, Sola L, et al:  Use of claims data systems to evaluate health care outcomes: Mortality and reoperation following prostatectomy. JAMA 1987;;257:933-936.
6 +
Beck JR, Pauker SG:  The Markov process in medical prognosis. Med Decis Making 1983;;3:419-458.
7 +
Ransohoff DF, Gracie WA, Wolfenson LB, et al:  Prophylactic cholecystectomy or expectant management for silent gallstones: A decision analysis to assess survival. Ann Intern Med 1983;;99:199-204.
8 +
Sonnenberg A:  Endoscopic screening for gastric stump cancer—would it be beneficial? A hypothetical cohort study. Gastroenterology 1984;;87:899-895.
9 +
Hillner BE, Hollenberg JP, Pauker SG:  Postmenopausal estrogens in the prevention of osteoporosis: Benefit virtually without risk if cardiovascular effects are considered. Am J Med 1986;;80:1115-1127.
10 +
Matchar DB, Pauker SG:  Endarterectomy in carotid artery disease: A decision analysis. JAMA 1987;;258:793-798.
11 +
Fowler FJ, Wennberg JE, Timothy RP, et al:  Symptom status and quality of life following prostatectomy. JAMA 1988;;259:3018-3022.
12 +
Woodward R, Boyarsky S, Barnett H:  Discounting surgical benefits: Enucleation vs resection of the prostate. J Med Syst 1983;;7:481-493.
13 +
Kleinbaum DG, Kupper LL, Morgenstern H: Epidemiology Research . London, Life Learning Publications, 1982;, pp 106-111.
14 +
Hollenberg JP:  Markov cycle trees: A new representation for complex Markov processes, abstracted. Med Decis Making 1984;;4:529A.
15 +
Weinstein MC, Feinberg HV: Clinical Decision Analysis . Philadelphia, WB Saunders Co, 1980;.
16 +
Dunn VH, Pauker SG:  An ambiguous renal cyst in a patient with prior nephrectomy: What to do when there is only one more to lose. Med Decis Making 1986;;6:49-62.
17 +
Bloor MJ, Venters GA, Samphier ML:  Geographic variations in the incidence of operations on the tonsils and adenoids: An epidemiologic and sociologic investigation. J Laryngol Otol 1978;;92:791-801.
18 +
Krumins PE, Fihn SD, Kent DL:  Symptom severity and patients' values in the decision to perform a transurethral resection of the prostate. Med Decis Making 1988;;8:1-18.
19 +
Wennberg JE, Mulley AG, Hanley D, et al:  An assessment of prostatectomy for benign urinary tract obstruction: Geographic variations and the evaluation of medical care outcomes. JAMA 1988;;259:3027-3030.
20 +
McNeil BJ, Pauker SG, Sox HC, et al:  On the elicitation of preferences for alternative therapies. N Engl J Med 1982;;306:1259-1262.
21 +
Muller A:  When is prostatectomy indicated? Br J Surg 1965;;52:744-745.
22 +
Birkoff JD, Weiderhorn AR, Hamilton ML, et al:  Natural history of benign prostatic hypertrophy and acute urinary retention. Urology 1976;;7:48-52.
23 +
Spiro LH, Labay G, Orkin LA:  Prostatic infarction: Its role in acute urinary retention. Urology 1974;;3:345-347.
24 +
Ball AJ, Feneley RC, Abrams PH:  The natural history of untreated 'prostatism.' Br J Urol 1981;;53:613-616.
25 +
Resnick M, Jackson JE, Watts LE, et al:  Assessment of the antihypercholesterolemic drug, probucol, in benign prostatic hyperplasia. J Urol 1983;;129:206-209.
26 +
Hedlund H, Andersson KE, Ek A:  Effects of prazocin in patients with benign prostatic obstruction. J Urol 1983;;130:275-278.
27 +
Castro JE, Griffiths JH, Edwards DE:  A double-blind, controlled clinical trial of spironolactone for benign prostatic hypertrophy. Br J Surg 1971;;58:485-489.
28 +
Geller J, Nelson CG, Albert JD, et al:  Effect of megestrol on uroflow rates in patients with benign prostatic hypertrophy. Urology 1979;;14:467-474.
29 +
Faber JF, Wade AH: Life Tables for the United States: 1900-2050 (actuarial study No. 89). Dept of Health and Human Services, Social Security Administration, Office of the Actuary (SSA publication 11-11536), 1983;.
30 +
Craigen AA, Hickling JB, Saunders CR, et al:  Natural history of prostatic obstruction. J R Coll Gen Pract 1969;;18:226-232.
31 +
Jensen KM, Madsen PO:  Candicidin treatment of prostatism: A prospective double-blind placebo-controlled study. Urol Res 1983;;11:7-10.
32 +
Gleckman RA:  Community-acquired urosepsis , in Gleckman RA, Gantz NM (eds): Infections in the Elderly . Boston, Little Brown & Co Inc, 1983;, pp 265-281.
33 +
Sach R, Marshall VR:  Prostatectomy: Its safety in an Australian teaching hospital. Br J Surg 1977;;64:210-214.
34 +
Melchior J, Valk WL, Foret JD, et al:  Transurethral prostatectomy: Computerized analysis of 2223 consecutive cases. J Urol 1974;;112:634-642.
35 +
Chilton CP, Morgan RJ, England HR, et al:  A critical evaluation of the results of transurethral resection of the prostate. Br J Urol 1978;;50:542-546.
36 +
Holtgrewe HL, Valk WL:  Late results of transurethral prostatectomy. J Urol 1964;;92:51-55.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Wennberg JE, Barnes BA, Zubkoff M:  Professional uncertainty and the problem of supplier-induced demand. Soc Sci Med 1982;;16:811-824.
2 +
Barnes BA, O'Brien E, Comstock C, et al:  Report on variation in rates of utilization of surgical services in the Commonwealth of Massachusetts. JAMA 1985;;254:371-375.
3 +
Wennberg JE, Gittelsohn A:  Health care delivery in Maine: I. Patterns of use of common surgical procedures. J Maine Med Assoc 1975;;66:123-130, 149.
4 +
McPherson K, Wennberg JE, Hovind OB, et al:  Small-area variation in the use of common surgical procedures: An international comparison of New England, England, and Norway. N Engl J Med 1982;;307:1310-1314.
5 +
Wennberg JE, Roos N, Sola L, et al:  Use of claims data systems to evaluate health care outcomes: Mortality and reoperation following prostatectomy. JAMA 1987;;257:933-936.
6 +
Beck JR, Pauker SG:  The Markov process in medical prognosis. Med Decis Making 1983;;3:419-458.
7 +
Ransohoff DF, Gracie WA, Wolfenson LB, et al:  Prophylactic cholecystectomy or expectant management for silent gallstones: A decision analysis to assess survival. Ann Intern Med 1983;;99:199-204.
8 +
Sonnenberg A:  Endoscopic screening for gastric stump cancer—would it be beneficial? A hypothetical cohort study. Gastroenterology 1984;;87:899-895.
9 +
Hillner BE, Hollenberg JP, Pauker SG:  Postmenopausal estrogens in the prevention of osteoporosis: Benefit virtually without risk if cardiovascular effects are considered. Am J Med 1986;;80:1115-1127.
10 +
Matchar DB, Pauker SG:  Endarterectomy in carotid artery disease: A decision analysis. JAMA 1987;;258:793-798.
11 +
Fowler FJ, Wennberg JE, Timothy RP, et al:  Symptom status and quality of life following prostatectomy. JAMA 1988;;259:3018-3022.
12 +
Woodward R, Boyarsky S, Barnett H:  Discounting surgical benefits: Enucleation vs resection of the prostate. J Med Syst 1983;;7:481-493.
13 +
Kleinbaum DG, Kupper LL, Morgenstern H: Epidemiology Research . London, Life Learning Publications, 1982;, pp 106-111.
14 +
Hollenberg JP:  Markov cycle trees: A new representation for complex Markov processes, abstracted. Med Decis Making 1984;;4:529A.
15 +
Weinstein MC, Feinberg HV: Clinical Decision Analysis . Philadelphia, WB Saunders Co, 1980;.
16 +
Dunn VH, Pauker SG:  An ambiguous renal cyst in a patient with prior nephrectomy: What to do when there is only one more to lose. Med Decis Making 1986;;6:49-62.
17 +
Bloor MJ, Venters GA, Samphier ML:  Geographic variations in the incidence of operations on the tonsils and adenoids: An epidemiologic and sociologic investigation. J Laryngol Otol 1978;;92:791-801.
18 +
Krumins PE, Fihn SD, Kent DL:  Symptom severity and patients' values in the decision to perform a transurethral resection of the prostate. Med Decis Making 1988;;8:1-18.
19 +
Wennberg JE, Mulley AG, Hanley D, et al:  An assessment of prostatectomy for benign urinary tract obstruction: Geographic variations and the evaluation of medical care outcomes. JAMA 1988;;259:3027-3030.
20 +
McNeil BJ, Pauker SG, Sox HC, et al:  On the elicitation of preferences for alternative therapies. N Engl J Med 1982;;306:1259-1262.
21 +
Muller A:  When is prostatectomy indicated? Br J Surg 1965;;52:744-745.
22 +
Birkoff JD, Weiderhorn AR, Hamilton ML, et al:  Natural history of benign prostatic hypertrophy and acute urinary retention. Urology 1976;;7:48-52.
23 +
Spiro LH, Labay G, Orkin LA:  Prostatic infarction: Its role in acute urinary retention. Urology 1974;;3:345-347.
24 +
Ball AJ, Feneley RC, Abrams PH:  The natural history of untreated 'prostatism.' Br J Urol 1981;;53:613-616.
25 +
Resnick M, Jackson JE, Watts LE, et al:  Assessment of the antihypercholesterolemic drug, probucol, in benign prostatic hyperplasia. J Urol 1983;;129:206-209.
26 +
Hedlund H, Andersson KE, Ek A:  Effects of prazocin in patients with benign prostatic obstruction. J Urol 1983;;130:275-278.
27 +
Castro JE, Griffiths JH, Edwards DE:  A double-blind, controlled clinical trial of spironolactone for benign prostatic hypertrophy. Br J Surg 1971;;58:485-489.
28 +
Geller J, Nelson CG, Albert JD, et al:  Effect of megestrol on uroflow rates in patients with benign prostatic hypertrophy. Urology 1979;;14:467-474.
29 +
Faber JF, Wade AH: Life Tables for the United States: 1900-2050 (actuarial study No. 89). Dept of Health and Human Services, Social Security Administration, Office of the Actuary (SSA publication 11-11536), 1983;.
30 +
Craigen AA, Hickling JB, Saunders CR, et al:  Natural history of prostatic obstruction. J R Coll Gen Pract 1969;;18:226-232.
31 +
Jensen KM, Madsen PO:  Candicidin treatment of prostatism: A prospective double-blind placebo-controlled study. Urol Res 1983;;11:7-10.
32 +
Gleckman RA:  Community-acquired urosepsis , in Gleckman RA, Gantz NM (eds): Infections in the Elderly . Boston, Little Brown & Co Inc, 1983;, pp 265-281.
33 +
Sach R, Marshall VR:  Prostatectomy: Its safety in an Australian teaching hospital. Br J Surg 1977;;64:210-214.
34 +
Melchior J, Valk WL, Foret JD, et al:  Transurethral prostatectomy: Computerized analysis of 2223 consecutive cases. J Urol 1974;;112:634-642.
35 +
Chilton CP, Morgan RJ, England HR, et al:  A critical evaluation of the results of transurethral resection of the prostate. Br J Urol 1978;;50:542-546.
36 +
Holtgrewe HL, Valk WL:  Late results of transurethral prostatectomy. J Urol 1964;;92:51-55.

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