Stoevelaar H J, McDonnell J, Bosch J L, Kahan J P
Institute for Health Care Policy and Management, Erasmus University, PO Box 1738, NL-3000 DR Rotterdam, The Netherlands.
Eur Urol. 2001;39 Suppl 3:13-9. doi: 10.1159/000052562.
To perform a systematic analysis of clinical expertise on treatment for benign prostatic hyperplasia (lower urinary tract symptoms (LUTS) suggestive of benign prostatic obstruction (BPO)) and to investigate the usefulness of these data in further guideline development.
A modified Delphi method was used to analyse the opinions of a panel of 15 European urologists on the appropriateness of 4 common treatments for 1,152 "indications" (hypothetical cases) for LUTS suggestive of BPO. Each indication consisted of a unique combination of 9 diagnostic variables, found to be relevant in treatment choice in previous research. The study population was restricted to patients for whom current guidelines do not provide clear indications on the most appropriate treatment. The panellists individually rated the appropriateness of three active treatments (surgery, alpha(1)-adrenoceptor antagonists, finasteride) using a 9-point scale, all in comparison with "watchful waiting". Aggregate panel judgements were calculated from individual ratings for each indication (appropriate, inappropriate, and uncertain). The relationship between diagnostic characteristics and panel opinions was analysed using logistic regression methods. The results were compared to those of an identical panel study including 12 Dutch urologists.
Strong agreement existed for 42.5% of the indications, while strong disagreement was found in only 0.1%. For patients who had not previously been treated for LUTS, surgery was considered appropriate in 44% of the indications. For alpha(1)-adrenoceptor antagonists and finasteride these percentages were 56 and 6 respectively. Strong contra-indications were found only for finasteride (34%). Logistic regression analysis demonstrated consistent panel opinions, indicating a strong cumulative impact of almost all diagnostic variables on the panel judgement "appropriate". The figures on appropriateness were highly comparable to the results of the Dutch study (overall agreement 84%, kappa 0,76). A computer program was constructed to facilitate the implementation and evaluation of the panel recommendations in daily clinical practice.
Given the consistency of the panel opinions, the results may be useful in complementing evidence-based guidelines for LUTS suggestive of BPO in the grey area of treatment choice.
对良性前列腺增生（提示良性前列腺梗阻（BPO）的下尿路症状（LUTS））治疗方面的临床专业知识进行系统分析，并研究这些数据在进一步制定指南中的实用性。
采用改良的德尔菲法，分析15名欧洲泌尿外科医生组成的专家小组对1152例提示BPO的LUTS“适应症”（假设病例）的4种常见治疗方法的适用性的意见。每个适应症由9个诊断变量的独特组合构成，这些变量在先前的研究中被发现与治疗选择相关。研究人群仅限于当前指南未就最合适治疗方法提供明确适应症的患者。专家小组成员使用9分制分别对三种积极治疗方法（手术、α1肾上腺素能受体拮抗剂、非那雄胺）的适用性进行评分，所有评分均与“观察等待”进行比较。根据每个适应症的个体评分计算专家小组的总体判断（合适、不合适和不确定）。使用逻辑回归方法分析诊断特征与专家小组意见之间的关系。将结果与包括12名荷兰泌尿外科医生的相同专家小组研究结果进行比较。
42.5%的适应症存在强烈共识，而只有0.1%存在强烈分歧。对于先前未接受过LUTS治疗的患者，44%的适应症认为手术是合适的。对于α1肾上腺素能受体拮抗剂和非那雄胺，这些百分比分别为56%和6%。仅发现非那雄胺有强烈的禁忌症（34%）。逻辑回归分析表明专家小组意见一致，表明几乎所有诊断变量对“合适”的专家小组判断都有强烈的累积影响。适用性数据与荷兰研究结果高度可比（总体一致性84%，kappa值0.76）。构建了一个计算机程序，以促进专家小组建议在日常临床实践中的实施和评估。
鉴于专家小组意见的一致性，这些结果可能有助于补充在治疗选择灰色区域中提示BPO的LUTS的循证指南。
