Prevalence of Lower Urinary Tract Symptoms and Associated Resource Utilization among VA Primary Care Patients

Yano E, Lanto AB, Wilt T, Rubenstein LV. Prevalence of Lower Urinary Tract Symptoms and Associated Resource Utilization among VA Primary Care Patients. Paper presented at: VA HSR&D National Meeting; 1999 Feb 24; Washington, DC.

Objectives: In 1997, nearly 750,000 male veterans had outpatient diagnoses of benign and malignant prostate disease, yet little is known about their presenting symptoms in primary care or associated resource utilization, information that would be useful in the design of programs to systematically screen and treat them. We assessed the prevalence of lower urinary tract symptoms consistent with the presentation of prostate disease among VA primary care patients and assessed their VA healthcare utilization. Methods: These data were drawn from a longitudinal cohort of randomly sampled male veterans in no acute distress who were visiting the Primary Ambulatory Care and Education (PACE) Center from March-June 1993. Using the Survey of Health and Medical Care designed for the evaluation of PACE, a primary care firm system, we conducted a telephone survey of 1,849 veterans with 3+ primary care visits regarding their health status and symptoms. Lower urinary symptoms (e.g., nocturia) were queried using items developed by a national panel of academic urologists. Cutpoints were selected to identify the most clinically meaningful symptom burden. Survey data were linked with VA administrative data to evaluate general medicine and subspecialty outpatient visits (particularly urology), and admission rates during the following year. We used logistic regression to evaluate the predictors of symptom burden among primary care patients.Results: For specific symptoms, 24.4% of men reported sometimes-to-frequently having urinary urgency (11.2% frequently), 12.1% reported sometimes-to-often having problems urinating in the previous month (4.0% often), and 24.1% reported urinating 1+ times/hour (4.4% > 2 times/hour). Nearly half of those surveyed (47.5%) reported that they urinated 2+ times/night (22.2% with 3+ trips), while over half (56.2%)reported moderate-to-slow streams (11.2% slow and strained). Taking the most severe category for each symptom, we found that 32.9% had 1+ clinically meaningful lower urinary tract symptoms (21.0% with 1, 6.7% with two symptoms). As clinically expected, hypertensives were 53% more likely to report 1+ symptoms (1.53, 95%CI 1.18-1.98), diabetics were 75% more likely (1.75, 95%CI 1.32-2.31), and men reporting shortness-of-breath at rest (1.80, 95%CI 1.28-2.52) or on exertion (2.03, 95%CI 1.49-2.77) were more likely to report 1+ lower urinary tract symptoms (p < .0001). Adjusting for these comorbid conditions, men with 1+ symptoms had significantly more general medicine (p < .01) and urology visits (p < .00001) in the following year compared to men without urinary symptoms. The more symptoms reported, the higher the general medicine (p < .005), subspecialty (p < .0001) and urology (p < .0001) visit rates, as well as medical-and-surgical admission rates (p < .0001).Conclusions: Male primary care patients have a significant lower urinary tract symptom burden consistent with underlying prostate disease that is associated with significantly higher utilization of VA healthcare resources. Clinical guidelines and pathways that address the optimal role of primary care practitioners and urologists in a coordinated system of care are needed. Impact: VHA has identified prostate disease as a high impact target condition for QUERI. These analyses are helpful in quantifying the needs of veterans and in assessing how to manage patients in primary and specialty care