Determining the importance of change in the overactive bladder questionnaire

Effects of tolterodine extended release on patient perception of bladder condition and overactive bladder symptoms*

OBJECTIVE

To evaluate the efficacy of tolterodine extended release (ER) versus placebo at 1 and 12 weeks using questionnaires and diary measures.

RESEARCH DESIGN AND METHODS

Subjects with overactive bladder (OAB) were randomized to receive tolterodine ER (4 mg) or placebo for 12 weeks. This double-blind study is registered with ClinicalTrials.gov (identifier: NCT00143377).

MAIN OUTCOME MEASURES

Subjects completed the Patient Perception of Bladder Condition (PPBC) and 3-day bladder diaries at baseline and weeks 1 and 12, and the Overactive Bladder Questionnaire (OAB-q) at baseline and week 12. PPBC score changes were analyzed using 2-category (improvement, no improvement), 3-category (improvement, no change, deterioration), and 4-category (>or=2-point improvement, 1-point improvement, no change, deterioration) stratifications. Categorical change in PPBC scores from baseline to week 12 was the primary endpoint.

RESULTS

A total of 617 subjects were randomized (tolterodine ER, n = 410; placebo, n = 207). At week 1, a significantly higher percentage of subjects receiving tolterodine ER reported improvement on the PPBC compared with placebo (p < 0.05). Subjects receiving tolterodine ER also had a significantly greater reduction in all OAB symptoms versus placebo (all p < 0.05). At week 12, a higher percentage of tolterodine ER subjects reported PPBC improvement versus placebo subjects. This was significant in the 3- and 4-category analyses (both p < 0.05) but not in the 2-category analysis (the prespecified method of analysis; p = 0.098). Compared with the placebo group, the tolterodine ER group reported significantly greater week 12 improvements in all bladder diary variables (all p < 0.01) as well as in OAB-q Symptom Bother, total Health-Related Quality of Life, Coping, and Concern scores (all p <or= 0.02).

CONCLUSIONS

Compared with placebo, subjects receiving tolterodine ER reported significantly greater improvements in nondiary patient-reported outcomes and OAB symptoms at week 12. Improvements in subjects' perception of their bladder-related problems and in OAB symptoms were observed as early as week 1. Further research is required to assess which aspects of subjects' bladder-related problems were improved. A large placebo effect may have prevented the prespecified 2-category analysis of PPBC improvement from reaching statistical significance at week 12, which was the primary endpoint.

Psychometric equivalence of the OAB-q in Danish, German, Polish, Swedish, and Turkish

OBJECTIVE

Patient-reported outcomes (PROs) are measures of patients' health status provided directly by patients and when utilized in clinical trials, multiple language versions may be needed. The overactive bladder questionnaire (OAB-q), a self-administered PRO assessing symptom bother and health-related quality of life (HRQL) in patients with OAB, was developed in US English and has been translated into more than 40 languages. This analysis evaluated the psychometric equivalence of five language versions of the OAB-q.

METHODS

The Disease Management Study (DMS) was a multicenter, double-blind, placebo-controlled, parallel group, randomized study in adults with OAB. Participants completed the OAB-q, 3-day micturition diaries, and the patient's perception of bladder condition (PPBC) at baseline and weeks 1 and 12 of treatment.

RESULTS

Data from 398 patients from five countries were analyzed: Denmark (N = 71), Germany (N = 127), Poland (N = 60), Sweden (N = 94), and Turkey (N = 46). Participants were a mean of 57.4 years old; 31% were male; and almost all were Caucasian. Cronbach alphas for the OAB-q symptom bother subscale = 0.71 to 0.83 and 0.82 to 0.94 for the HRQL subscales (concern, coping, sleep, and social) across all five languages. OAB-q subscales were significantly correlated with PPBC in all languages. Mean baseline to week 12 change scores = -21.4 to -30.3 for symptom bother and 5.2 to 36.0 for the HRQL subscales. Effect sizes for the symptom bother subscale = 0.92 to 2.79 and 0.21 to 1.30 for the HRQL subscales.

CONCLUSION

OAB-q language versions of Danish, German, Polish, Swedish, and Turkish demonstrated acceptable psychometric characteristics, including internal consistency reliability, construct validity, and responsiveness.

Subjective measures of efficacy and quality of life in overactive bladder syndrome

In recent years, more attention has turned to the use of patient-reported outcomes in clinical trials to assess treatment efficacy in overactive bladder syndrome (OAB). The challenge for investigators and clinicians is how to choose among the many available health-related quality-of-life questionnaires. This article provides an overview of the patient-reported outcome instruments available specific to OAB and their validation for clinical use.

Anticholinergic drugs, bladder retraining and their combination for urge urinary incontinence: a pilot randomised trial

Bladder retraining and anticholinergic drugs in women with urge urinary incontinence need to be compared. Women with urge urinary incontinence were recruited by advertisements, from primary care and from a urogynaecology clinic. Women were randomised using a web page to bladder retraining, anticholinergic drugs or both and followed up at 3 and 12 months. No blinding was attempted. The primary outcomes were the trial process and the Overactive Bladder Questionnaire (OAB-q) quality-of-life measure. Recruitment was much slower than anticipated. There were no differences in the OAB-q at 12 months (87.9 SD 11.6 bladder retraining, 81.6 SD 19.3 drug therapy and 88.9 SD 9.9 combination) but dry mouth was more common in those taking drugs. It is feasible to run a pragmatic randomised trial with 12-month follow-up for women with urinary urge incontinence. This will require about 500 participants per arm.

Impact of solifenacin on resource utilization, work productivity and health utility in overactive bladder patients switching from tolterodine ER

OBJECTIVE

Assess changes in resource utilization, work and activity impairment, and health utility among OAB patients continuing to have urgency symptoms with tolterodine ER 4 mg and willing to try solifenacin 5/10 mg.

RESEARCH DESIGN AND METHODS

This was an open-label, non-comparative, flexible-dosing, multicenter, 12-week study assessing the efficacy and safety of solifenacin 5/10 mg/day. Patients receiving tolterodine ER 4 mg/day for >/=4 weeks but continuing to experience residual urgency symptoms (>/=3 urgency episodes/24 h) were enrolled into the study. After a 14-day washout, patients began treatment with solifenacin 5 mg/day with dosing adjustments allowed at Weeks 4 and 8.

MAIN OUTCOME MEASURES

Outcomes were assessed using the Work Productivity and Activity Impairment Questionnaire - Specific Health Problem (WPAI-SHP), Health Utilities Index (HUI), and a resource utilization questionnaire administered at Pre-Washout and Week 12.

RESULTS

Patients (n=440) reported significantly fewer physician office visits (p<0.0001), UTIs (p<0.0001), and pads/diapers (p=0.0009) during the study period while receiving solifenacin 5/10 mg/day, compared with the Pre-Washout period when receiving tolterodine ER 4 mg/day. After 12 weeks of treatment with solifenacin 5/10 mg/day, patients reported a reduction in work time missed (p=0.0017), less impairment while working (p<0.0001), less overall work impairment (p<0.0001) and a reduction in activity impairment (p<0.0001) compared to Pre-Washout. There was no significant difference in health utility scores. Treatment-emergent adverse events were mostly anticholinergic in nature, and were mild to moderate in severity.

CONCLUSION

Overall, solifenacin 5/10 mg/day improved work productivity, activity participation, and reduced medical care use in OAB patients who continued to have urgency symptoms with tolterodine ER 4 mg/day and wished to switch to solifenacin 5/10 mg. This was an open-label, non-comparative study; therefore, further research is needed to confirm these results.

Solifenacin treatment for overactive bladder in Hispanic patients: patient-reported symptom bother and quality of life outcomes from the VESIcare Open-Label Trial

OBJECTIVE

The primary goal of overactive bladder (OAB) treatment is to reduce symptoms and improve health-related quality of life (HRQoL). Although trials open enrolment to everyone, most OAB studies feature Caucasians. Here we present Hispanic data.

METHODS

VESIcare Open-Label Trial was a 12-week, open-label, flexible-dosing study in patients with OAB symptoms for >or=3 months. All patients started on solifenacin 5 mg/day, with a dosing option of 5 or 10 mg/day at weeks 4 and 8. Three patient-reported outcome (PRO) measures assessed symptom improvement and treatment satisfaction: the Patient Perception of Bladder Condition (PPBC) scale, a Visual Analogue Scale (VAS), the Overactive Bladder Questionnaire (OAB-q).

RESULTS

94/2205 patients in the full population were Hispanic. Urgency was most frequently reported at baseline (93.6%), followed by frequency (91.5%), nocturia (84.0%) and urge incontinence (UI) (67.0%). Frequency was reported as the most bothersome symptom (MBS) by a higher proportion of Hispanics than the full population (40.4% vs. 28.1%). UI was reported as the MBS by a smaller proportion of Hispanics (18.1% vs. 27.3%). Patients reporting moderate-to-severe problems related to bladder condition at baseline reported improvement to 'some minor problems' at week 12. Over 72.0% of patients experienced PPBC score improvement. Both groups reported significant improvements in urgency, UI, frequency and nocturia on the VAS (all p<0.001) and all OAB-q domains (all p<0.001) at week 12.

CONCLUSION

Although numbers were small, Hispanics receiving solifenacin for OAB reported improvement from baseline in symptom bother and HRQoL, as assessed by three independent PRO measures.

Clinically meaningful improvement on the Self-Esteem And Relationship questionnaire in men with erectile dysfunction

PURPOSE

To estimate the minimal clinically meaningful improvement (MCMI) on the Self-Esteem And Relationship (SEAR) questionnaire.

METHODS

Using combined data from the 2 pivotal SEAR trials of men treated with sildenafil for erectile dysfunction (ED), MCMIs were estimated as the lower limit of the 2-sided 95% confidence intervals of SEAR mean change scores (from baseline to end of study) for 2 anchor groups: (1) men who improved 1 ED severity category on the Erectile Function domain of the International Index of Erectile Function, and (2) men who improved 5-60% (inclusive) on these erectile function scores.

RESULTS

Both anchors gave comparable results. A 10-point MCMI was proposed because the estimates of 95% lower bounds centered on around 10 points for most SEAR components (Sexual Relationship, Confidence, Self-Esteem, Overall Score). An exception was the Overall Relationship whose 95% lower bounds were too low to recommend them as an MCMI.

CONCLUSIONS

Two anchor-based approaches suggest that a change of about 10 points represents an MCMI on most components of the SEAR questionnaire.

Overactive bladder and women's sexual health: what is the impact?

INTRODUCTION

Overactive bladder (OAB) is quite prevalent and significantly affects health-related quality of life and daily functioning.

AIM

The impact of OAB on sexual health is currently not known. This qualitative study was conducted to gain a thorough understanding of OAB's impact.

METHODS

Sexually active women with continent or incontinent OAB were recruited from urology and urogynecology clinics. Six focus groups of women (three continent and three incontinent) were conducted to assess the sexual health of women with OAB. Data were analyzed descriptively and qualitatively.

MAIN OUTCOME MEASURES

Qualitative data, Sexual Quality of Life Questionnaire-Female, Overactive Bladder Questionnaire.

RESULTS

Thirty-four women (11 continent; 23 incontinent) participated; mean age was 48.4 years; 76% were white, 67% postmenopausal, and 88% in a long-term relationship. Continent women reported more frequent sexual activity than incontinent women; 91% reported intercourse >or=1-3 times per month vs. 50% of incontinent women. Half of the incontinent women reported a reduction in sexual desire related to OAB, aging, and menopause. Over half of continent women experienced pain with intercourse, and the majority complained of having to interrupt intercourse to void. Although not all incontinent women reported incontinence during intercourse, the majority were embarrassed by their incontinence and OAB with resulting loss of self-image. Both continent and incontinent women reported difficulty achieving orgasm because of pain, fear of incontinence, or anxiety related to intercourse. Approximately a third of the women would not initiate discussion of sexual issues with their physicians, but all women expressed concern about the impact of OAB on their sexual life.

CONCLUSION

Overactive bladder with or without incontinence negatively affects women's sexual health, reducing sexual desire and ability to achieve orgasm. Given the impact of OAB on sexual health, sexual health should be routinely assessed by clinicians and addressed by researchers.

The responsiveness of the OAB-q among OAB patient subgroups

AIMS

Although the majority of patients with overactive bladder (OAB) are continent, most patient-reported outcome measures for OAB were designed for patients with urinary incontinence. The overactive bladder questionnaire (OAB-q) was developed to assess symptom bother and HRQL among both continent and incontinent OAB patients; however, the responsiveness of the OAB-q among continent patients has not been evaluated. The purpose of this analysis was to assess the responsiveness of the OAB-q among OAB patient subgroups with a focus on continent patients.

METHODS

Post-hoc analyses were conducted from two 12-week trials of tolterodine for the treatment of OAB. Patients completed the OAB-q and daily bladder diaries (assessing frequency, urgency, and incontinence episodes) at baseline, 4 weeks, and 12 weeks. Three patient subgroups were identified on the basis of continence status at all three timepoints: (1) continent; (2) incontinent; and (3) incontinent at baseline and continent by Week 12 (ITC). General linear models were used to compare changes from baseline, and Spearman correlations assessed the association between OAB-q changes and bladder diary changes. Effect sizes were computed separately for each group.

RESULTS

A total of 262 continent, 552 incontinent, and 397 ITC patients were included in this analysis. Continent patients tended to be younger than incontinent patients, and patients were predominantly female, although continent patients had the highest percentage of male patients in both studies. Compared with continent patients, patients who were incontinent at baseline tended to have greater symptom bother and lower HRQL at baseline. All OAB-q change scores were consistently greatest for the ITC group (12.1-33.9), and greater for continent patients (10.8-28.6) than for incontinent patients (7.6-20.1). All three groups of patients experienced reductions in frequency and urgency episodes, and these changes were significantly correlated with changes in the OAB-q scales. Among all three groups, effect sizes were in the moderate-to-large range for all OAB-q subscales except Social Interaction.

CONCLUSIONS

The OAB-q is highly responsive to change between continent and incontinent patients with OAB, and is a valid tool for measuring treatment outcomes among continent OAB patients.

Symptom bother and health-related quality of life outcomes following solifenacin treatment for overactive bladder: The VESIcare open-label trial (VOLT)

BACKGROUND

Most clinical trials designed to evaluate overactive bladder (OAB) syndrome treatments have focused on measuring micturition variables from bladder diaries. However, although diaries help physicians assess symptoms objectively, they lack information on patients' subjective experience of OAB symptoms and the effects of treatment.

OBJECTIVE

The objective of this study was to assess patients' perceptions of improvements in symptom bother and health-related quality of life (HRQOL) with solifenacin succinate 5- and 10-mg treatments in patients with OAB.

METHODS

VOLT (VESIcare Open-Label Trial) was a prospective, flexible-dosing trial performed at 207 centers in the United States. Ambulatory adult (aged > or = 18 years) men and women with an established diagnosis of OAB (urgency, urge urinary incontinence, frequency, and/or nocturia for > or = 3 months) and who provided a sterile urine sample received solifenacin QD for 12 weeks. Initially, all patients received 5 mg/d, with the option of adjustment to 10 mg/d at 4 and 8 weeks. Effectiveness was assessed using the Patient Perception of Bladder Condition (PPBC) scale, a visual analog scale (VAS) for the degree of bother caused by individual OAB symptoms, and the overactive bladder questionnaire (OAB-q). Assessments were performed at study initiation and study end or study termination. Adverse events (AEs) were assessed throughout.

RESULTS

Patients (N = 2225) were enrolled between June 2004 and April 2005. Patients with baseline data (n = 2205) had a mean (SD) age of 59.7 (14.4) years; most patients were women (1813 [82.2%]) and white (1761 [79.9%]). Of the total patients enrolled, 1743 (78.3%) completed all 12 weeks of the study. After 12 weeks of solifenacin treatment, improvement was observed in the mean values of patient-reported perception of bladder condition. Significant change was observed on the PPBC scale from the mean baseline value to study end (4.4 vs 2.9; P < 0.001). All subscales of HRQOL significantly improved on the OAB-q score (mean changes, 14.7 to 29.6; all, P < 0.001). On the VAS, there was a significant reduction in the degree of bother associated with urgency, urge urinary incontinence, frequency, and/or nocturia (mean changes in VAS ratings, -36.7 to -41.8; all, P < 0.001 vs baseline). Solifenacin was well tolerated in most patients. Treatment-emergent AEs were reported by 1321 (59.4%) patients. Most reported AEs were anticholinergic in nature and of mild to moderate severity: dry mouth, 477 (21.4%); constipation, 295 (13.3%); headache, 76 (3.4%); blurred vision, 57 (2.6%); nausea, 39 (1.8%); dyspepsia, 34 (1.5%); and dry eye, 29 (1.3%). Two hundred sixteen (9.7%) patients discontinued treatment due to AEs.

CONCLUSION

Flexibly dosed solifenacin 5 and 10 mg QD was associated with reductions in patient-reported OAB symptom bother and improvements in patients' perception of bladder condition and HRQOL.

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.

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.

Tolterodine extended release improves patient-reported outcomes in overactive bladder: results from the IMPACT trial

We evaluated the effect of tolterodine extended release (ER) on patient- and clinician-reported outcomes in a primary care setting. Patients had overactive bladder (OAB) symptoms for >or=3 months and were at least moderately bothered by their most bothersome symptom, as indicated on the patient-completed OAB Bother Rating Scale. Patients completed the Overactive Bladder Questionnaire (OAB-q), American Urological Association Symptom Index (AUA-SI), and Patient Perception of Bladder Condition at each visit; investigators completed the Clinical Global Impression-Improvement at week 12. By week 12, there were statistically significant and clinically meaningful decreases on the OAB-q and AUA-SI total and subscale scores (p < 0.0001). Seventy-nine per cent of patients experienced some improvement in their overall bladder condition. Physicians reported that 68% of patients were 'much improved' or 'very much improved'. For symptom-defined conditions, patient-reported outcomes are a valuable means for determining responses to treatment.