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					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                ADT/MAM/09/43437/1
please see the back cover page of the report                       Date of preparation September 2009
ProState of the Nation Report



Forewords
Professor Roger Kirby                                        Amanda McLean
Consultant Urologist, The Prostate Centre                    CEO, Prostate UK

                When I trained as a Urologist during the                       At Prostate UK, we receive calls every
                1980s, the only effective treatment                            day from, and on behalf of, men who
                option for Benign Prostatic Hyperplasia                        are suffering with BPH. It is a condition
                (BPH) was surgery; usually by                                  that can, in the most severe and
                Transurethral Resection of the Prostate                        untreated cases, have a devastating
                (TURP). Gradually, during the 1990s,                           effect on a man’s quality of life. This
                medical therapy with alpha-blockers and                        ProState of the Nation report lays out
5 alpha-reductase inhibitors (5ARI) grew in popularity,      clearly what the issues are for men and the treatments
and now very few patients with uncomplicated BPH             that are available to them. It demonstrates how, with
are treated by surgery in the first instance – many men      appropriate training, support and resources, GPs can
now avoid surgery altogether. This ProState of the           do much to effectively manage and alleviate the
Nation report is a call to action; not only for men who      condition. It is also a wake-up call to policy makers who
need to be more proactive in maintaining their prostate      have shied away from confronting BPH and makes a
health, but also for GPs who, with a little education,       compelling case for the need for proactive diagnosis
can care more effectively for the many individuals           and intervention.
whose quality of life is negatively affected by this most
prevalent and bothersome of conditions.

Dr John Nash                                                 Denis Gizzi
GPwSI Urology, Buckinghamshire                               Executive Director for System Reform and Service
                                                             Innovation, NHS Oldham
               As a GP and hospital practitioner in
               Urology, I am fortunate in seeing men                        In an era characterised by continuous
               with BPH, both in primary and                                improvement in condition management,
               secondary care. Due to the ageing                            patient choice and economic
               population, the prevalence of BPH is                         constriction, the opportunity for
               increasing. The adverse effects of BPH,                      conditions such as BPH (for which
               potential subsequent acute urinary                           office based medicine methods clearly
retention and hospitalisation for TURP, on quality of life                  apply) to be offered closer to patients’
have long been underestimated.                               homes via economically grounded models of care
                                                             should be explored.
The assessment and management of men with BPH is
straightforward in General Practice. With an average         The findings from research direct us to a model of care
list size, each GP will have 50 men between the ages         which is in the most part, observation and diagnostic
of 60–80 years suffering with urinary symptoms, of           based. The continuous drive to improve population
moderate and severe degree, from BPH – for whom              health, individual experience and economic viability has
there is effective drug treatment. I hope that the           led to new, bespoke shared care models of urology
ProState of the Nation report will encourage my fellow       service delivery. These pathfinder services, located
GPs to manage BPH in the community and I am                  within communities, allow for rapid access to expert
enthusiastic and eager to help facilitate this process.      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.




2
                                                                                             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 GP’s,
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
                                                             What does BPH mean for men?
    In the UK, about 3.2 million men – over one
    third of those aged over 50 years – suffer from          Men suffer varying degrees of BPE and BOO, so BPH
    the symptoms of benign prostatic hyperplasia             presents as a wide spectrum of clinical symptoms.
    (BPH).*1–3 The troublesome and unpleasant                These are categorised as either storage (irritative) or
    urinary symptoms associated with BPH do not              voiding (obstructive).4
    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              Storage symptoms
    acute urinary retention (AUR), hospitalisation
    and surgery.4                                              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. non-
cancerous – enlargement of the prostate gland, a               Urgency             Sudden urge to urinate
walnut-shaped gland located beneath the bladder. In            Incontinence        Involuntary leakage of urine
BPH, benign prostatic enlargement (BPE) causes
narrowing of the urethra where it passes through the           Voiding symptoms
prostate, leading in turn to bladder outlet obstruction
(BOO) and lower urinary tract symptoms (LUTS).5                Hesitancy           Difficulty in beginning to urinate
                                                               Poor stream         Weak, dribbling stream of urine
                                                               Intermittency       Urine stream stops and restarts
     Bladder                                                   Abdominal           Needing to push or strain to pass
                                            Seminal            straining           urine, increasing the risk of
                                            vescile
         Vas                                                                       micturition syncope (temporary
    Deferens                                Prostate gland
                                                                                   loss of consciousness)
     Urethra                                                   Prolonged           Taking a long time to urinate
       Penis                                Epididymus
                                                               voiding

                                            Testicle           Incomplete          Sensation of urine remaining in
                                                               bladder             the bladder, and possibly passing
                                                               emptying            more urine after apparently
                                                                                   completing urination
Figure 1: The male reproductive system
                                                               Terminal            Urine continues to leak from the
Enlargement of the prostate occurs in response to the          dribbling           penis after urination has
androgen, or male hormone, dihydrotestosterone                                     apparently completed
(DHT). DHT is metabolised from testosterone by the
action of the 5 alpha-reductase enzyme and is the key
androgen responsible for healthy prostate growth.6           The more severe a man’s symptoms, the more likely it is
In adult men, there is normally a balance between            that his general health status and quality of life will be
prostate cell growth (proliferation) and cell death          adversely affected by BPH. BPH symptoms can have a
(apoptosis). BPH develops when this balance                  tremendous impact, affecting daily activities and quality
becomes tipped in favour of increased cell proliferation,    of life of up to 75% of men aged 50–65 years with
resulting in prostatic enlargement.                          moderate to severe symptoms.8

Beyond the age of 40 the prostate gland enlarges in
most men and by the age of 65 half of men have               * In the UK, there are 9.4 million men aged over 50 years1 of which
                                                               it is estimated that 35% experience symptoms suggestive of
symptoms of BPH.7 BPH almost exclusively affects men           BPH.2 This corresponds to an estimated 3.2 million men in the UK
aged over 40 because prostate size increases slowly.           with clinical BPH.3

4
                                                                                                  BPH: the evidence


•   As the prostate enlarges and BPH progresses, men         The possibility of AUR and surgery is a significant
    need to wake more often – in some cases up to five       concern for men with BPH. When it occurs, admission
    times a night – to urinate. This degree of nocturia is   for AUR has a serious impact on patients’ quality of life
    not a natural part of ageing, and seriously disrupts     due to the costs of additional domestic support, the
    sleep reducing daytime energy and negatively             burden of multiple visits to accident and emergency
    affecting daily activities and general well being.9      departments, and extra admissions to hospital.16 The
                                                             fear that AUR may recur and may need surgical
•   Nearly half of men with BPH have sexual problems,        treatment can also have a serious effect on a man’s
    such as difficulty in maintaining or achieving an        quality of life.17
    erection and painful ejaculation.10, 11
                                                             Older age, moderate-to-severe symptoms and decreased
•   Up to 95% of men with moderate symptoms report           flow rate are associated with an increased risk of BPH
    not being completely happy to spend the rest of          progression. But the most important risk factors are
    their lives with their current symptoms.12               prostate size and prostate-specific antigen (PSA).4

•   51% of men report that BPH interferes with at least      Prostate size
    one area of their daily lives, compared with 28%         Patients who initially present with a larger prostate tend
    without a formal diagnosis of BPH.13                     to experience greater subsequent increases in prostate
                                                             volume and more severe symptoms.18 Men with a
But BPH does not just affect men. The disease also           prostate larger than 30ml are one-and-a-half times
has a serious impact on their partners, who suffer from      more likely to have moderate-to-severe LUTS and three
‘second hand prostatism’ that affects their quality of       times more likely to experience AUR.4 Men with a
life, daily routines and relationships.14                    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?
                                                             Prostate-specific antigen (PSA)
BPH is progressive and, without treatment, the               PSA is a protein produced by the prostate. Men with
prostate continues to grow and symptoms become               baseline PSA greater than 1.4ng/ml are at approximately
more severe. In some cases, this results in complete         double the risk of progressing to AUR over four years
blockage of the urethra and a sudden inability to pass       compared to men with lower PSA levels.19
urine. This condition, known as Acute Urinary Retention
(AUR), is a medical emergency that is often unexpected       It is important to identify men with these risk factors,
and always painful, and involves treatment with              because appropriate treatment can delay or prevent BPH
catheterisation or, in some men, prostate surgery.15         progression and the risk of a patient developing AUR.20


                                            Impact of BPH on quality of life
               Percentage of men affected




Figure 2: BPH symptoms affect on quality of life13

                                                                                                                     5
ProState of the Nation Report


                                                              Choosing the right treatment
    The troublesome and unpleasant symptoms of
    BPH are the main reason why men first seek                In BPH, the aim of treatment is to relieve symptoms
    help from their general practitioners. Many               and/or prevent complications (i.e. AUR and surgery),
    men can be managed in primary care, but                   and to slow/halt the disease progression. Currently
    BPH is commonly under diagnosed and under                 available options include watchful waiting, drug
    treated. Less than half of men with BPH are               treatment with alpha-blockers and 5 alpha-reductase
    diagnosed and, of those, only half receive                inhibitors (5ARIs), and surgery.
    drug treatment.21
                                                              Watchful waiting
                                                              Watchful waiting involves regular monitoring of
Diagnosing BPH                                                symptoms, and education and lifestyle advice. It is
                                                              appropriate for patients with a low risk of progression
A comprehensive initial assessment is essential when a        and mild symptoms that are not particularly
man with LUTS first consults his GP or practice nurse.        bothersome.23
A clinical history is essential to exclude other causes
of LUTS and to assess the severity of symptoms.22, 23         Alpha-blockers
Large prostate volume and a high to normal PSA level          These drugs rapidly relieve symptoms by relaxing the
predict the increased risk of disease progression, and        smooth muscle of the prostate and bladder neck:
influence decisions about treatment and referral.             symptoms are improved by 20–50% and flow rates by
Assessment should therefore also include a validated          20–30% within 6–12 weeks. Alpha-blockers do not,
symptom assessment instrument, digital rectal                 however, reduce prostate size, have little or no effect
examination (DRE) and PSA testing.4                           on disease progression, and do not lower the risk of
                                                              long-term complications such as AUR and surgery.25
•   A validated assessment instrument, such as the
    International Prostate Symptom Score (IPSS), helps        All alpha-blockers are similarly effective, but side
    to quantify a man’s symptoms. The IPSS measures           effects and ease of use vary between drugs.4 Although
    the severity of storage and voiding symptoms, and         alpha-blockers are generally well tolerated, commonly
    is also useful in assessing quality of life and disease   reported side effects include headache, dizziness,
    progression, and in predicting/establishing treatment     postural hypotension, lack of energy, drowsiness, nasal
    response.23 The questionnaire is not diagnostic –         congestion and retrograde ejaculation.23
    hence the need to first exclude other causes of LUTS.
                                                              5 alpha-reductase inhibitors
•   A DRE is an integral part of good clinical examination.   5ARIs work differently from alpha-blockers, shrinking
    Its main purpose is to assess the size, shape and         the prostate by suppressing DHT and so addressing
    consistency of the prostate and to check for any          the underlying cause of BPH. DHT is synthesised from
    rectal pathology.4                                        testosterone by two isoenzymes of 5 alpha-reductase:
                                                              type 1 and type 2.6 Two 5ARIs are currently available to
•   PSA testing is used to assess the risk of prostate        treat BPH.
    cancer. It is also a useful surrogate for prostate
    volume (the higher the PSA, the larger the                5ARIs also significantly improve symptoms. Initial
    prostate). Men undergoing PSA testing should              improvement is seen in the first few months after
    receive information and counselling, as a high level      initiation, followed by sustained, progressive benefit in
    can also be a sign of prostate cancer.4, 24               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




6
                                                                                           BPH: the evidence


Combination drug therapy
                                                            Summary
  Benefits of combining an alpha-blocker                    •   BPH is a common condition, affecting over a
  and a 5ARI                                                    third of men aged over 50 years in the UK
                                                            •   The unpleasant symptoms have a
  Benefit                    Alpha-blocker 5ARI                 considerable effect both on the patient and
                                                                their family
  Rapid improvement                 √
  in symptoms                                               •   Appropriate treatment of BPH can delay
                                                                disease progression and reduce the risk of
  Improved symptoms/flow            √             √             patients developing AUR and eventually
                                                                requiring surgery
  Maintenance of symptom/           √             √
  flow improvements
  Reduced prostate volume                         √
  Maintenance of reduced                          √
  prostate volume                                          All of my day to day activities
  Reduced long-term risk                          √        are affected by BPH. The
  of AUR and surgery                                       constant need to be near a
Treatment with a combination of an alpha-blocker and a
                                                           toilet means that I am
5ARI combines the complementary advantages of each         restricted in the work I can
class of drug, and has been shown to be more effective
than treatment with either of the individual drugs
                                                           do, I can’t do outside work –
alone.4, 26 This approach is recommended in men with       I must have a toilet nearby.
moderate- to-severe symptoms who have a high risk of
BPH progression.4
                                                           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
                                                            First published in 2004, the BAUS guidelines reflect
    Clinical guidelines, delivered by tools such as         advice contained in other international BPH guidelines,
    the Map of Medicine, are increasingly                   and their recommendations on diagnosis and treatment
    important in guiding the management of                  are specifically designed for use by GPs and practice
    common diseases and conditions, especially in           nurses in primary care. The BAUS recommendations
    primary care. This is because, by basing                have also influenced the BPH pathway in the Map of
    recommendations on the best available                   Medicine, and the 18-week Commissioning pathway
    evidence, clinical guidelines can change the            for male LUTS.
    process of healthcare, reduce variations in the
    standards of diagnosis and treatment, and               The BAUS guidelines emphasise the importance of
    improve patient outcomes.                               accurate assessment of symptoms and prostate size.
                                                            The aim is to guide decisions about initial treatment
                                                            and to determine the risk of disease progression.
What do the UK guidelines                                   Diagnosis therefore includes a comprehensive,
recommend?4                                                 evidence-based initial assessment, including symptom
                                                            assessment with the IPSS, physical examination
Evidence-based guidelines for the management of             including DRE and, when appropriate, PSA testing.
LUTS by the British Association of Urological
Surgeons (BAUS) have been available for some time.




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:
                                                                          One of the hardest things
•     Age over 70 years with LUTS                                         about living with BPH is
•     Moderate-to-severe LUTS (IPSS over 7)
                                                                          when my partner and I go out
                                                                          together. She has to be
•     PSA over 1.4ng/ml
                                                                          prepared for me to suddenly
•     Prostate volume over 30ml (about the size of a                      want to dart off to a toilet or
      golf ball)
                                                                          to stop the car at the first
•     Flow rate less than 12ml/sec                                        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.                 Choice of treatment is indicated by each patient’s risk of
The BAUS guidelines provide clear recommendations                         disease progression, based on PSA level/prostate size.
on indications and priorities for referral. See figure 4.                 See figure 5.

All other patients can be initially treated in primary care.              The BAUS guidelines represent best practice in the
BAUS recommends that treatment is beneficial in most                      management of BPH in primary care, but adherence to
men initially presenting with bothersome symptoms.                        the guidelines varies widely in clinical practice. Adopting
Watchful waiting and lifestyle advice are appropriate                     the BAUS guidelines throughout the UK would ensure
only for patients with very mild symptoms who are at                      that all men with BPH receive the most appropriate and
low risk of disease progression.4                                         the most effective treatment.

Indications for direct urological referral                                Treatment Recommendations

    Elevated or rising age-             Refer under two-week               Men with smaller               Alpha-blocker + lifestyle
    related PSA                         wait scheme                        prostates(<30ml or             advice, reviewed
                                                                           PSA <1.4ng/ml)                 after 6–12 weeks
    Nodule in prostate                  Refer under two-week
                                        wait scheme                        Men with larger                5ARI + lifestyle
                                                                           prostates (>30ml or            advice, reviewed
    Haematuria                          Refer under two-week               PSA >1.4ng/ml)                 after 3–6 months
    (blood in the urine)                wait scheme
                                                                           Men with moderate-to-          Combination therapy
    Acute retention                     Immediate treatment/               severe symptoms and            with alpha-blocker
                                        referral                           significant risk factors       + 5ARI, reviewed
                                                                           for progression                after 3–6 months
    Chronic retention                   Priority if creatinine is
                                        high                               Men with large                 5ARI monotherapy
                                                                           prostates with no/mildly
    Recurrent urinary                   To be seen soon                    bothersome symptoms
    tract infections                                                       but significant risk factors
                                                                           for progression
    Symptoms of possible                To be seen urgently
    prostate cancer (e.g.                                                  Men with bothersome            Consider urological
    painful urination with                                                 symptoms at follow-up          referral
    sterile pyuria*)

    *Sterile pyuria: presence of increased numbers of white cells in a    Figure 5
    urine sample that appears sterile using standard culture techniques


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,
                                                               I find it embarrassing when at
    where necessary, secondary-care referral. But              work as I have to regularly
    recent market research** among GPs,
    urologists and men with BPH reveals important
                                                               excuse myself mid meeting to
    barriers to the effective management of BPH,               go for a break. It also
    especially in primary care. This has important
    implications both for secondary care in terms
                                                               interrupts my wife’s sleep
    of inappropriate referrals, and for patients’              when I have to go to the loo
    quality of life and well being.
                                                               in the middle of the night
What do GPs say?27
GPs lack confidence in diagnosing LUTS and are             What do urologists say?28
concerned about missing a case of prostate cancer.
As a result, under treatment and under diagnosis of        Urologists report that they spend a large proportion of
BPH is frequent in primary care. Furthermore, although     their time seeing inappropriate BPH referrals – that is,
evidence-based BPH guidelines have been published,         men who could be diagnosed and treated in primary
GPs are either unaware of them or do not follow their      care. Reducing the number of these referrals would
recommendations.                                           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      •    68% of urologists agree that PSA results are
     use PSA and 89% who routinely perform a DRE.               difficult for GPs to interpret. 82% recognise that
                                                                GPs’ uncertainty about excluding prostate cancer is
•    Only 11% of GPs are very confident about                   a key barrier to BPH management in primary care.
     distinguishing between BPH and prostate cancer.
     57% of GPs agree that PSA results are difficult to    •    41% of BPH referrals received by urologists could
     interpret and 40% lack confidence in assessing             be managed in primary care.
     prostate size.
                                                           •    35% of urologists’ time with BPH patients is spent
•    71% of GPs say that their uncertainty in diagnosing        seeing inappropriate GP referrals.
     prostate cancer is a barrier to treating BPH in
     primary care. On average GPs seek specialist          •    Up to 30% of urologists’ time with BPH patients
     advice in 37% of cases of men with LUTS.                   could be saved if GPs were confident in prescribing
                                                                alpha-blockers and 5ARIs alone, or in combination.
•    54% of GPs refer men with BPH before
     maximising drug treatment in primary care (i.e.       •    74% of urologists say that avoiding inappropriate
     before initiating combination treatment with an            BPH referrals could reduce costs to the NHS and
     alpha-blocker and 5ARI).                                   86% say that it would reduce waiting times.

•    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 with formal BPH diagnosis.
                                                              Representative geographical spread in both surveys.

10
                                                                              BPH: recommendations versus reality


What do men with BPH say?29                                •       78% of men prescribed a BPH treatment would be
                                                                   keen to take an additional tablet that reduced
Patients bear the burden of late diagnosis and under               prostate symptoms and the risk of needing surgery.
treatment of BPH. As a result, their condition continues
to have a serious impact on their daily lives. Men with    Independent market research has highlighted the
BPH say that they are happy to take additional             negative effects on the quality of life of men with BPH,
treatments to alleviate their symptoms, and that           but there are wider implications of under management
receiving a diagnosis of BPH was reassuring and            and under treatment of the condition, in particular in
improved their quality of life.                            increased costs to the NHS.

•   75% of men with BPH report waking to urinate
    more than once a night and that this symptom in            Summary
    particular had an important impact on family life.         •     GPs lack confidence in diagnosing LUTS
                                                                     due to concerns about missing a case of
•   46% of men wait more than one year after the start               prostate cancer
    of their symptoms before seeking help from their GP.
                                                               •     Clinical guidelines are available for the
•   64% of men with BPH are referred to secondary                    management of BPH however, awareness of
    care when they first present to their GP. Only                   them at a primary care level is low
    28% are prescribed treatment while waiting to see          •     Urologists are currently spending a
    the specialist.                                                  considerable proportion of their time seeing
                                                                     BPH cases which could be effectively
•   61% of men are reassured when they are diagnosed                 managed by GPs
    with BPH.
                                                               •     The late diagnosis and under treatment of
•   27% of men wait at least six months for treatment                BPH has a serious effect on both the patient
    after seeking help from their GP. Only 26% of men                and their families quality of life
    are ever prescribed a 5ARI.

•   Over 90% of men still experience symptoms and
    52% report little or no improvement despite their
    initial BPH treatment.
                                                               Men don’t know a thing about
•   52% of men are disappointed and 22% dissatisfied           this disease. If I was speaking
    that they still experience symptoms following their
    initial treatment. Over 80% of men report that BPH
                                                               to other men with BPH I
    still affects their daily lives.                           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
                                                           In this estimated cost analysis
  quality of life of patients and their families; the      the cost of GP consultations
  condition is also expensive for the NHS, in
  terms of costs both for GP practices in primary
                                                           for BPH for 2007/2008 in the
  care and for urology services in secondary               UK was more than £44 million
  care. This current economic burden can only
  increase with the rising numbers of men with
                                                           UK primary care GP consultation cost
  BPH in the UK population, and urgent action is
  needed to improve the cost-effectiveness of
  the diagnosis and treatment of BPH.                         All-cause GP consultation rate of 5.3
                                                              Multiplied by UK population of 61 million =
                                                              323,300,000 consultations
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
                                                              Of which 0.51% or 1,648,830 are for BPH
for BPH represents the tenth most commonly
                                                              Multiplied by the cost of a GP consultation at £27
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               Gives a total primary care GP consultation
associated with managing BPH in primary and in                cost of £44,518,410
secondary care. The review uses a range of data
sources. These estimates are indicative, not
authoritative.                                             Cost of drug treatment for BPH in
                                                           the UK
The costs of BPH in primary and
secondary care                                             According to cost data provided by IMS (an
                                                           independent company providing pharmaceutical and
Although there are published estimates for the number      healthcare market intelligence to pharmaceutical and
of men affected by BPH symptoms in the UK, accurate,       biotech companies along with government agencies,
up-to-date data regarding the number of men that visit     policymakers, researchers and financial analysts
their GP to discuss these symptoms are limited to          around the world) the annual drug cost for BPH in
local, practice-based surveys. The latest published        the UK in 2008/2009 is £69,228,637.*35 This consists
national data are from the Third National Morbidity        of £40,058,187 for alpha-blockers and £29,170,450
Survey (1983) which reported that 0.51% of all GP          for 5ARIs.35
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
                                                           In this estimated cost analysis
this data with current all-cause consultation rates and    the cost of drug treatment for
population data to estimate the average number and
cost of primary care consultations related to BPH each
                                                           BPH for 2008/2009 in the
year. Using an all-cause consultation rate of 5.332 per    UK was more than £69 million
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      * IMS RSA data for G4C products 07/2008–06/2009.35 This
£44,518,410.                                                 excludes the alpha-blocker doxazosin as it is assumed that this drug
                                                             is primarily prescribed to treat hypertension.


12
                                                                                 BPH: counting the cost for the NHS


Cost of treating BPH-related                                 Cost of treating BPH complications in the UK
complications in the UK
                                                               An AUR treatment tariff cost for England
Using HES data for 2007/2008, which are based on               of £29,702,780 x 19% (factor up to UK
all hospital treatments in England, an estimate of the         population) = £35,346,308
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              A BPH-related surgery tariff cost of
admitted to hospital with AUR at a total tariff cost of        £55,357,650 x 19% (factor up to UK
£29,702,780 and 26,618 patients were admitted to               population) = £65,875,604
hospital for BPH-related surgery (for example
transurethral resection of the prostate – TURP) at a
cost of £55,357,650.36 Adding these costs together
and applying an uplift factor of 19% to reflect the
                                                               An AUR follow-up urology consultation cost of
whole UK population gives a total cost for treating
                                                               £80 x 28,499 admissions = £2,279,920 x19%
these major complications of BPH in secondary care of
                                                               (factor up to UK population) = £2,713,105
£101,221,912.36

It seems reasonable to assume that additional costs
are incurred as a result of patients requiring review in       BPH-related surgery pre-operative and follow-
urology clinic, either before their admission for surgery      up urology consultation costs of [£80 + £161]
or following their discharge after surgery or AUR.             x 26,618 admissions x 19% (factor up to UK
It is standard practice and therefore assumed that all         population) = £7,633,776
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            The total cost of treating BPH in secondary
AUR have a follow-up review at a tariff of £80. This           care is therefore estimated to be £111,568,793
equates to an additional cost of £10,346,881 directly
attributable to the costs of treating key BPH
complications in the UK.
                                                             In this estimated cost analysis
Using these costs, based on HES tariff data for
England and factored up to reflect the whole UK
                                                             the secondary care cost related
population, it is estimated that the total UK secondary      to AUR and BPH-related
care cost associated with these BPH-related
complications is £111,568,793.
                                                             surgery is £111,568,793
                                                             ** According to HES data 96% of BPH-related surgery admissions
                                                                are elective.




                                                                                                                          13
ProState of the Nation Report


Conclusions
                                                              Summary
According to this illustrative cost analysis the secondary    •   This report estimates that £180,797,430 is
care costs associated with managing AUR and BPH-                  spent on BPH treatments each year
related surgery, which are common complications of
BPH, stands at £111,568,793. This is almost 60%               •   60% of this is incurred in secondary care
more than the amount spent on drugs to treat BPH                  as a direct result of managing complications
(£69,228,637)35 and more than 3.5 times the                       in BPH
expenditure on the 5ARI class of drugs (£29,170,450),35       •   Improving the quality and consistency of
which are proven to reduce the risks of both AUR and              BPH management in primary care could
BPH-related surgery.26                                            lead to reductions in BPH complications and
                                                                  their associated costs for the NHS
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
                                           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

				
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