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 app ropriate treatment plan for stone disease. We used decision modeling to und erstand better patient choices and decision making in the overall managemen t of recurrent nephrolithiasis. Materials and Methods: We interviewed 180 consecutive patients with active stone disease. Demographic data and historical experiences with calculi wer e recorded. Patients were presented with 6 hypothetical clinical scenarios and various treatment options. The standard gamble method was used to obtai n utility values for each option. Results: Nephrectomy had the lowest mean utility value of 0.883. Percutaneo us nephrolithotomy for severe, moderate and mild pain had utilities of 0.92 4, 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 util ity for long-term medical therapy was 0.949, which was between that of perc utaneous nephrolithotomy and shock wave lithotripsy for mild pain. Patients with a surgical history of stone removal assigned lower utilities to invas ive procedures (nephrectomy, percutaneous nephrolithotomy, p <0.05). As the incidence of spontaneous stone passage increased, a higher utility was giv en to long-term medical therapy (p <0.05). Patients on medical therapy less than 1 year did not appreciate a significant benefit of medical prophylaxi s. However, longer compliance with medical management led patients to perce ive increasing benefits of continuing such medical treatment (p <0.05). Pat ients who had undergone stone removal via endoscopic or open surgery also h ad a higher preference for medical therapy (p <0.05). Conclusions: Patients who had undergone stone removal wanted to avoid futur e invasive procedures. They ranked long-term medical therapy below shock wa ve lithotripsy but above invasive procedures, such as percutaneous nephroli thotomy. Most importantly, patients appreciated the benefits of medical the rapy the longer that they complied with specific recommendations. These res ults support the concept that patients perceive long-term medical therapy t o prevent recurrent nephrolithiasis as a desirable treatment option.