Chapter 4: Treatment of overactive bladder in men: Is it really different?

Trends in Overactive Bladder Therapy: Associations Between Clinical Care Pathways, Practice Guidelines, and Therapy Utilization Patterns

INTRODUCTION

Overactive bladder (OAB) is a chronic condition with significant financial and health-related consequences. Guidelines and treatment pathways were created to optimize care and provide a clinical framework for diagnosing and managing OAB. However, the impact of these efforts and patterns of medical treatment for OAB are poorly understood. Therefore, we sought to evaluate overall trends in therapy utilization before and after the 2014 American Urological Association (AUA)/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) OAB guideline amendment and publication of the OAB clinical care pathway in 2016.

METHODS

In this retrospective cohort study, we analyzed data from Optum, a national administrative health and pharmacy claims database, between 2013 and 2018. All adult patients diagnosed with idiopathic OAB were identified by the International Classification of Diseases 9th and 10th Revision codes. Oral OAB therapies were identified using National Drug Codes, while third-line therapy procedures, onabotulinumtoxinA (BTX), sacral neuromodulation (SNM), and percutaneous tibial nerve stimulation (PTNS), were identified using Current Procedural Terminology (CPT) codes. The study's primary outcome was the annual number of OAB prescriptions filled by pharmacotherapy class and the number of minimally invasive therapies performed during the study period. The secondary outcome was the association between OAB therapy utilization and various clinical and sociodemographic factors. Patterns of care were analyzed from 2013 to 2018, and initial treatment with each therapy was collected, excluding repeat procedures from the analysis.

RESULTS

1 825 782 patients were included in the study. The mean age was 61.1 ± 16.7 years, and 1 071 420 patients were female (58.7%). The number of new OAB diagnoses increased by 369% from 2013 to 2017. During the 6-year study period, 347 052 (19%) patients were treated with oral and/or third-line therapies. The overall number of oral medications prescribed peaked in 2016, followed by a 17% decline between 2016 and 2018. In 2013, the two most prescribed oral medications were oxybutynin (46%) and solifenacin (31.8%). By 2018, mirabegron (18.5%) surpassed solifenacin (16.5%), with oxybutynin still accounting for most prescriptions written (55%). Eighty percent of all initial mirabegron prescriptions were filled by patients over the age of 65. The rate of third-line therapy procedures almost doubled between 2013 and 2018 (9-17 procedures per 1000 OAB patients, p < 0.001).

CONCLUSIONS

Following the publication of the first OAB guidelines, there was an increase in OAB diagnoses, followed by a decrease in anticholinergic medication use, and a rise in beta-3 agonist utilization in patients over 65 years old. Additionally, there was greater adoption of third-line OAB therapies. These trends indicate that OAB therapy guidelines and clinical practice pathways may influence treatment patterns. Given the recent publication of the OAB guidelines, further studies are necessary to assess their impact on therapy utilization patterns.

Exploring lifelong overactive bladder: Transitions, evidence, and clinical implications; A modified Delphi process

INTRODUCTION

Overactive bladder (OAB) is a prevalent urological condition characterized by urinary urgency, with or without urgency urinary incontinence, accompanied by increased daytime frequency and nocturia. However, the current definition of OAB lacks a specified time frame, hindering our understanding of the temporal aspects and transitions that occur within the OAB spectrum.

METHODS

A modified Delphi study was conducted in three rounds, involving a panel of international experts in functional urology, urogynaecology, geriatrics, transitional medicine, and pediatric urology. The study took place between February 2023 and June 2023 and employed two sequential rounds of online surveys, followed by a final hybrid group discussion session in June 2023.

RESULTS

The Delphi process resulted in a consensus definition of lifelong OAB as a persistent and continuous condition that may manifest differently from birth and evolve over time, with varying levels of clinical perception. The course of its progression is influenced by transition periods and modifying factors, mainly anatomical, hormonal, and psychosocial/stressors. Three main transition periods were identified: achievement of daytime continence, adulthood to elderly, and transition to frail elderly. The panel also considered the therapeutic and diagnostic implications of lifelong OAB, as well as future research prospects in terms of importance and feasibility.

CONCLUSIONS

Future longitudinal research is needed to develop this concept and further identify transitions and temporal dynamics.