Characterising the quality of clinical guidelines, epidemiology and healthcare resource utilisation of neurogenic bladder

Jaggi, Ashley (2019) Characterising the quality of clinical guidelines, epidemiology and healthcare resource utilisation of neurogenic bladder. Doctoral thesis (PhD), Manchester Metropolitan University.

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Abstract

Background and Aims: Knowledge on several key aspects of the neurogenic bladder (NGB) patient journey remain unknown. Accordingly, the aim of this research was to conduct an in-depth analysis of the prominent NGB clinical guidelines (CGs) and characterise the descriptive epidemiology and healthcare resource utilisation (HRU) of NGB in the UK. Methods: (1) The AGREE II tool was used to appraise the quality of the National Institute for Health and Care Excellence (NICE), European Association of Urology (EAU) and International Consultation on Incontinence (ICI) CGs for NGB and the concordance of their recommendations were assessed. (2) Adults (≥19 years) with a definitive or probable diagnosis of NGB between 1st January 2004 and 31st December 2016 were included into a study using the Clinical Practice Research Datalink (CPRD) GOLD and Hospital Episode Statistics (HES) databases in order to determine their real-world patient characteristics and drug utilisation patterns. Furthermore, the level of HRU over 12 months and associated costs were calculated via a bottom-up approach (ISAC protocol number 17_207RMn). Results: NICE scored 92%, the EAU scored 83% and the ICI scored 75% in the AGREE II appraisal. The CGs place differing emphasis on costs and expert opinion, which translated in notably different recommendations. Amongst many important findings, the CPRD study revealed evidence of diagnosis error in NGB, a high level of comorbidities 8.6 (SD,7.6), polypharmacy 5.2 (SD,4.8), an Anticholinergic Cognitive Burden (ACB) score of 6.6 (SD,5.9), and substantial HRU (overall costs £2,395 per annum). Conclusions: Improving the applicability and incorporation of comparative effectiveness research (CER) is crucial to ensure uptake of CGs and efficiency in clinical practice. It is also imperative that the underlying evidence base is strengthened, and cross-speciality interactions enhanced in order to guide more robust and consistent recommendations in future publications. Furthermore, policy makers should be aware of the substantial burden of complications, polypharmacy, comorbidity, anticholinergic burden and HRU associated with NGB, and modifications to CGs should be introduced to aid in optimal management of these issues.