The responsiveness of the Overactive Bladder Questionnaire (OAB-q)

Assessment of treatment outcomes in patients with overactive bladder: importance of objective and subjective measures

Overactive bladder (OAB) is a highly prevalent symptom syndrome that negatively affects health-related quality of life (HRQL). In clinical practice, the diagnosis and treatment of OAB are largely driven by a patient's reporting of symptoms, often in combination with objective assessment. Thus, OAB provides the opportunity to examine the relations between objective (eg, urodynamic studies, bladder diary variables) and subjective (eg, symptom bother, HRQL) outcomes. We compared objective and subjective results from 27 trials recently evaluated in a systematic review and meta-analysis of antimuscarinic agents used to treat OAB. Many studies demonstrated concurrent improvements in both types of outcomes. However, several reports showed that although pharmacotherapy may reduce micturition frequency or increase bladder capacity, treated patients may not perceive a significant benefit to HRQL. We conclude that objective assessments can help determine the underlying causes of OAB symptoms and assess the effects of treatment, but that these results are not always predictive of subjective outcomes, which are influenced by a patient's priorities and lifestyle, and thus highly individualized. A patient's perception of treatment success should be regarded as an important measure of efficacy because a patient considers the trade-offs between symptom improvement, adverse events, and effects on daily life when assessing overall treatment benefit. We recommend that subjective measures become standard considerations in the initial evaluation and treatment of patients with OAB.

Development and validation of patient-reported outcomes measures for overactive bladder: a review of concepts

Patient-reported outcome (PRO) measures are a valuable means for determining how a disease and its treatment affect patients, including effects on health-related quality of life (HRQL). To ensure that the results obtained with PROs are clinically useful, data must be gathered using valid and reliable instruments. Developing such instruments requires a multistep, structured process that incorporates cognitive psychology, psychometric theory, and patient and clinician input. The process begins by determining the intent and purpose of the PRO and culminates in studies that demonstrate the measure's validity, reliability, and responsiveness. Several valid and reliable PROs are available for assessing the effects of treatment on symptom severity, symptom bother, and HRQL in patients with overactive bladder.

Symptom assessment tool for overactive bladder syndrome--overactive bladder symptom score

OBJECTIVES

Overactive bladder (OAB) is a common symptom syndrome with urgency, urinary frequency, and urgency incontinence. To collectively express OAB symptoms, we developed the overactive bladder symptom score (OABSS).

METHODS

Four symptoms--daytime frequency, nighttime frequency, urgency, and urgency incontinence--were scored. The weighing score was based on a secondary analysis of an epidemiologic database. Psychometric properties were examined in five patient groups: OAB (n = 83), asymptomatic controls (n = 34), stress incontinence (n = 29), benign prostatic hyperplasia (n = 28), and other diseases with urinary symptoms (n = 26).

RESULTS

The maximal score was defined as 2, 3, 5, and 5 for daytime frequency, nighttime frequency, urgency, and urgency incontinence, respectively. The sum score (OABSS 0 to 15) was significantly greater in the patients with OAB (8.36) than in the other patient groups (1.82 to 5.14). The distribution of the OABSS showed a clear separation between those with OAB and asymptomatic controls. The OABSS correlated positively with the individual scores (Spearman's r = 0.10 to 0.78) and quality-of-life scores assessed by the King's Health Questionnaire (Spearman's r = 0.20 to 0.49). The weighted kappa coefficients were 0.804 to 1.0 for each symptom score and 0.861 for OABSS. The posttreatment reduction in the OABSS was consistent with the global impression of patients of the therapeutic efficacy.

CONCLUSIONS

The OABSS, the sum score of four symptoms (daytime frequency, nighttime frequency, urgency, and urgency incontinence), has been developed and validated. OABSS may be a useful tool for research and clinical practice.

Determining the importance of change in the overactive bladder questionnaire

PURPOSE

The overactive bladder questionnaire assesses symptom bother and health related quality of life in patients with overactive bladder. It has been shown to be reliable, valid and responsive. We established the minimally important difference of the overactive bladder questionnaire.

MATERIALS AND METHODS

Post hoc analyses from 2 clinical trials were performed. Distribution based, eg effect size, and anchor based analyses using perception of treatment benefit and clinical variables were used.

RESULTS

The mean age of the 2 study populations was 58.8 and 58.7 years, respectively. Patients were predominantly female (51.8% and 75.1%) and white (83.9% and 87%, respectively). Half SD of the overactive bladder questionnaire symptom bother subscale was 9.1 to 9.3, and half SD of the overactive bladder questionnaire health related quality of life subscales (coping, concern, sleep and social interaction) was 9.8 to 13.2. Questionnaire subscales had moderate to large effect sizes with the largest effect sizes for symptom bother (-0.85 to -1.09). Anchor based analyses showed that significantly greater change scores were associated with greater patient perceived treatment benefit and satisfaction. The difference between change scores in patients perceiving no and little benefit was 7.4 to 16.5 for all questionnaire scales except social interaction with the majority greater than 10 points. Greater change scores were consistently associated with greater improvements in micturition diary variables.

CONCLUSIONS

Multiple methodologies provide strong justification for the recommendation of a 10-point minimally important difference for all overactive bladder questionnaire subscales. This minimally important difference may be conservative for some subscales, although a uniform minimally important difference is recommended to facilitate interpretation of the overactive bladder questionnaire.

The effects of antimuscarinics on health-related quality of life in overactive bladder: A systematic review and meta-analysis

The objective of this study was to review the effects of antimuscarinic treatments on health-related quality of life (HRQL) in patients with overactive bladder (OAB). MEDLINE, EMBASE, the Cochrane Controlled Trials Register, and the Cumulative Index to Nursing and Allied Health Literature databases were searched from 1966 through August 2004 for randomized controlled trials of antimuscarinic agents. HRQL data from included trials were extracted, and meta-analysis was performed where possible. Of 56 trials included, 25 (45%) reported HRQL and/or patient-reported outcomes. The most commonly used instruments were the Incontinence Impact Questionnaire (3 trials), the King's Health Questionnaire (KHQ; 5 trials), the Medical Outcomes Study Short Form-36 (2 trials), the Gaudenz Appraisal Questionnaire (3 trials), and the Urogenital Distress Inventory (2 trials). Results from the meta-analyses of placebo-controlled trials showed statistically significant differences in favor of antimuscarinic therapy. Differences in HRQL as assessed using the KHQ were also clinically meaningful. The meta-analysis results of active-controlled trials did not show significant differences among antimuscarinic agents. This review provides evidence that antimuscarinics provide an HRQL benefit to patients with OAB. HRQL outcomes using validated instruments are recommended for inclusion in active-controlled trials, and agreement on the most appropriate HRQL instrument is now required.

Correlation Between the Overactive Bladder Questionnaire (OAB-q) and Urodynamic Data of Parkinson Disease Patients Affected by Neurogenic Detrusor Overactivity During Antimuscarinic Treatment

INTRODUCTION

Parkinson disease (PD) patients present urinary symptoms during the course of the disease, very often suggestive of overactive bladder and sustained by neurogenic detrusor overactivity. These symptoms cause a severe lowering of quality of life determining social withdrawal and they need to be early diagnosed to restore social interaction and prevent urinary tract complications. Today overactive bladder diagnosis is easier, thanks to the availability of new investigative tools, particularly voiding questionnaires. The aim of the present study was to evaluate the reliability of the Overactive Bladder screener (OAB screener/OAB-questionnaire), a new voiding questionnaire specifically developed for the overactive bladder diagnosis in PD subjects suffering from overactive bladder symptoms. Clinical data obtained by the questionnaire were compared with urodynamic outcomes, at basal conditions and after antimuscarinic treatment, to better explorate the questionnaire reliability.

MATERIALS AND METHODS

Forty PD patients have been enrolled in the protocol, and submitted to the OAB screener, voiding diary and urodynamic investigation before and after antimuscarinic treatment. OAB-score and urodynamic parameters were statistically analyzed and compared.

RESULTS

The OAB-q well correlated with voiding diary and urodynamic data of Parkinson subjects either at baseline or after the antimuscarinic treatment. The study suggests that this clinical tool might be used for neurogenic overactive bladder diagnosis and that it seems to be a useful outcome measure for treatments of neurogenic OAB.

The Validation of the Patient Perception of Bladder Condition (PPBC): A Single-Item Global Measure for Patients with Overactive Bladder

OBJECTIVES

The purpose of this study was to evaluate the validity and responsiveness of a global measure for overactive bladder (OAB), the Patient Perception of Bladder Condition (PPBC).

METHODS

Post-hoc analyses were conducted on two 12-wk clinical trials for OAB (Study 1: n = 865; Study 2: n = 520). In addition to the PPBC, patients completed two condition-specific health-related quality of life (HRQL) measures, the Overactive Bladder Questionnaire (OAB-q) and King's Health Questionnaire (KHQ), and bladder diaries at baseline and 12 wk. Validity of the PPBC was evaluated through correlations with baseline diaries, OAB-q, and KHQ. The responsiveness of the PPBC was evaluated using correlations and general linear models to assess the degree of association between change in PPBC and change in the diaries, OAB-q, and KHQ.

RESULTS

Both samples were primarily women and white with mean ages of 61.0 and 58.8 yr. The majority of patients were incontinent (75.3% and 80.4%) with the greatest proportion of patients indicating that they had "moderate problems" (47.5% and 51.2%) on the PPBC at baseline. Significant correlations were present at baseline and among change scores between the PPBC and the bladder diaries (p < 0.001), OAB-q (p < 0.001), and KHQ (p < 0.01). In both studies, patients with major PPBC improvement had significantly greater reductions in frequency, urgency episodes, incontinence episodes, and Symptom Bother and significantly greater improvements in HRQL than patients with only a minor PPBC improvement.

CONCLUSION

The PPBC, a global patient-reported measure of bladder condition, demonstrated good construct validity and responsiveness to change. These findings support the use of the PPBC as a global assessment of bladder condition among patients with OAB.

The effect of cannabis on urge incontinence in patients with multiple sclerosis: a multicentre, randomised placebo-controlled trial (CAMS-LUTS)

OBJECTIVE

To test whether cannabinoids reduce urge incontinence episodes without affecting voiding in patients with multiple sclerosis. This was part of the multicentre trial of the Cannabinoids in Multiple Sclerosis (CAMS) study.

SUBJECTS AND METHODS

The CAMS study randomised 630 patients to receive oral administration of cannabis extract, Delta(9)-tetrahydrocannabinol (THC) or matched placebo. For this substudy subjects completed incontinence diaries.

RESULTS

All three groups showed a significant reduction, p<0.01, in adjusted episode rate (i.e. correcting for baseline imbalance) from baseline to the end of treatment: cannabis extract, 38%; THC, 33%; and placebo, 18%. Both active treatments showed significant effects over placebo (cannabis extract, p=0.005; THC, p=0.039).

CONCLUSION

The findings are suggestive of a clinical effect of cannabis on incontinence episodes in patients with MS. This is in contrast to the negative finding of the CAMS study, where no difference was seen in the primary outcome of spasticity.

Efficacy, tolerability and safety of darifenacin, an M(3) selective receptor antagonist: an investigation of warning time in patients with OAB

This double-blind, randomised placebo-controlled, multicentre study evaluated the efficacy, tolerability and safety of 12 weeks' treatment with controlled release darifenacin 15 mg once daily (qd), in 445 patients with overactive bladder (OAB). The primary endpoint was warning time (time from first sensation of urgency to voiding), and secondary endpoints included urge incontinence episodes and volume voided. Darifenacin treatment resulted in numerical increases in warning time, but these were not significant compared with placebo -- highlighting difficulties in assessing this parameter. Significant improvements were seen with darifenacin vs. placebo in urge incontinence episodes/week, volume voided and quality of life (QoL). Darifenacin was associated with increases in urgency-free time (UFT; time between any void to the next urgency event) vs. placebo. Treatment was well tolerated; the most commonly reported adverse events were the typical antimuscarinic effects of dry mouth and constipation, both infrequently leading to discontinuation. This study demonstrated the difficulty in measuring warning time, due in part to its subjective nature; the authors believe further investigation is warranted to allow urgency to be better defined. Further investigation of UFT is required to determine its role in evaluating urgency. The study confirmed that darifenacin 15 mg qd is an effective and well-tolerated treatment for OAB, which improves QoL.

Overactive bladder

The overactive bladder is a common condition, which has significant effects on quality of life. The aetiology in most cases is unknown, and treatment outcomes have until recently been unsatisfactory. Management includes excluding pathology and implementing behavioural changes such as caffeine reduction, bladder and pelvic floor training, as well as antimuscarinic drug therapy. Compliance is often problematic, and this can be improved with some of the newer antimuscarinics with fewer side-effects, and a good therapist/patient relationship. In the majority of cases this 'treatment package' is successful, but in those where it is not, intravesical therapies have been introduced, e.g. neuromodulation, alternative drug therapies (e.g. vanilloids, botox) and surgery. With a better understanding of the aetiology and identification of risk factors better outcomes from treatment are likely.

The validation of patient-rated global assessments of treatment benefit, satisfaction, and willingness to continue--the BSW

OBJECTIVE

This study evaluated the validity of three single-item, patient-rated, interviewer-administered, global assessments of treatment benefit, satisfaction with treatment and willingness to continue treatment, collectively referred to as the BSW.

METHODS

The BSW, micturition diaries, the Overactive Bladder Questionnaire (OAB-q) and the King's Health Questionnaire (KHQ) were included in part or in total in three OAB clinical trials. Discriminant validity for full and dichotomized responses was assessed with anovas models and correlations were used to evaluate construct validity.

RESULTS

The BSW demonstrated significant differences among the majority of the response levels on all measures of micturitions in all studies. The BSW also demonstrated discriminant validity with the OAB-q and the KHQ. BSW measures demonstrated significant differences among the change scores for all subscales of the OAB-q and the majority of the KHQ domains with both full and dichotomized responses. Patients who were dissatisfied with treatment and those unwilling to continue treatment also reported significantly worse OAB-q and KHQ scores compared with those who were satisfied with treatment or willing to continue treatment. BSW measures were moderately correlated with the micturition variables, moderate to strongly correlated with the OAB-q and weak to moderately with the KHQ, providing support for the construct validity of the BSW measures.

CONCLUSIONS

The BSW is a useful tool to capture patients' global impressions of three key elements of treatment outcome: a perceived benefit, satisfaction with treatment, and the willingness to continue treatment, and can facilitate patient-physician communication as well as be informative to researchers.

A review of quality-of-life questionnaires for urinary incontinence and overactive bladder: which ones to use and why?

Overactive bladder (OAB) and stress urinary incontinence have a profound impact on patients' health-related quality of life (HRQL). The purpose of this article is to identify and describe condition-specific HRQL measures validated among patients with symptoms of OAB or stress urinary incontinence. A Medline literature search was performed to identify published articles or abstracts focusing on the development and psychometric validation of relevant instruments. Target populations and psychometric properties (reliability, validity, responsiveness to change) of 16 questionnaires are reviewed. A range of well-validated, condition-specific HRQL measures are available. Recommendations are provided regarding which measures to use in different situations. When choosing among instruments, psychometric evidence and the match of an instrument to the study population should be considered.