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. 2016 Jul 8;11(1):147–153. doi: 10.1177/1557988315617527

The Informed Patient

An Analysis of Information Seeking Behavior and Surgical Outcomes Among Men With Benign Prostatic Hyperplasia

Haidar Abdul-Muhsin 1,✉, Mark Tyson 1, Santanam Raghu 2, Mitchell Humphreys 1
PMCID: PMC5675171  PMID: 26614445

Abstract

The Internet has placed considerable information at the disposal of patients, but the sources for credible and accurate information may be difficult for a layperson to discern. Benign prostatic hyperplasia (BPH) in elderly men can be treated with different surgical interventions. The purpose of this research was to determine information seeking behaviors (ISB) of BPH patients before and after each type of surgery. All patients who underwent surgical intervention for BPH at a tertiary training center between January 2007 and January 2013 were included in this study. A comprehensive questionnaire regarding their ISB was sent through a third-party survey center. The following areas were examined: (1) the patient’s opinion regarding information sources of BPH and its treatment, (2) the extent of ISB for each patient and its relation to the type of surgical intervention he eventually underwent, and (3) the relationship between the extent of ISB and the patient’s final satisfaction. The results indicated that the majority of patients felt that it is relatively easy to find information about BPH and its treatment. Most of the patient started with either general online search engines or used the hospital website. Patients who explored more sources of information ended up choosing a more specific and sophisticated procedure. Generally, patients used fewer sources postoperatively regardless of the procedure they underwent. There was no correlation between the extent of ISB and overall satisfaction (r = −0.0719, p = .1610) and regret (r = −0.0436, p = .3945).

Keywords: benign prostatic hyperplasia (BPH), information seeking behavior, holmium laser enucleation of the prostate (HoLEP), transurethral resection of the prostate (TURP)

Introduction

Benign prostatic hyperplasia (BPH) is one of the most common health conditions affecting aging males in the world today; it is the most common cause of urologic office visits in men older than 50 years and is the most common benign neoplasia in males (Wei, Calhoun, & Jacobsen, 2008). There is a wide array of surgical interventions for the treatment of symptomatic BPH that differ significantly in their advantages, disadvantages, and efficacy. There is no clear consensus on the single best treatment option (Lee, Xue, & Lerner, 2012).

The American Urological Association (AUA) Clinical Practice Guidelines on BPH encourage “shared decision making” where the patient actively participates in the choice of therapy. Because of the multitude of treatment options available, not all urologists have the time, training, or expertise to offer every treatment option to the patient, and thus, they tend to offer the procedure that they are most comfortable performing (Lee et al., 2012). From the patient’s perspective, the choice is mainly skewed by the nature of available information resources.

While it is the role of the physician to fully educate patients, the adoption and mainstreaming of the Internet has enabled patients to become more medically savvy and seek out information directed toward their specific medical conditions. The Internet has placed considerable information at the disposal of patients, but sources for credible and accurate information may be difficult for the layperson to discern, and interpretation of online information can be overwhelming (Hart, Henwood, & Wyatt, 2004). It is of paramount importance to understand the current available information sources and drivers or motivation for information seeking behavior (ISB) and how that may affect surgical outcomes. Regarding prostatic diseases, there are numerous studies that examine the ISB of prostate cancer patients and the different factors that affect their decision making (Gulavita, Sinnott, Setliff, & Sellick, 2000). However, there are no data regarding information sources and ISB associated with BPH patients.

The purpose of this research was to describe the ISB of BPH patients and to determine the correlation between their behavior and their postoperative satisfaction and regret. The data reported here is unique in that it was obtained directly from patients through a third-party survey center independent of investigators’ influences. We believe that this is the first study of this type ever reported.

Materials and Methods

The study population consisted of all patients who underwent a surgical intervention for the treatment of BPH at a tertiary training institution between January 2007 and January 2013. The following were the surgical interventions performed during this period: holmium laser ablation of the prostate (HoLAP), holmium laser enucleation of the prostate (HoLEP), photoselective vaporization of the prostate (PVP), transurethral incision of the prostate (TUIP), transurethral resection of the prostate (TURP), and open simple prostatectomy (OSP). Patients were identified using the Current Procedural Terminology (CPT®) and were queried through a structured institutional review board–approved survey questionnaire. No patients were excluded from this survey. The survey was sent to the identified patients by a third-party independent survey center. A predetermined termination date was set when no response was obtained after two separate mailings. No incentives were used to enhance the response rate. The Mayo Clinic Institutional Review Board approved this project. Responses were then collected and data entered into a single database via the survey center.

The questionnaire contained 39 items that were presented in two formats that covered the following main areas:

  1. Patient’s urinary, sexual, and quality-of-life outcomes after the procedure: These were measured using standardized and validated questionnaires. The urinary outcomes were measured using the International Prostate Symptom Score and the International Continence Society–Short Form questionnaires. The sexual outcomes were measured using the Sexual Health Inventory for Men questionnaire.

  2. Satisfaction and regret after the intervention: Overall satisfaction was assessed by a Likert-type scale that measured the agreement with the following statements “I am satisfied with the outcomes of my surgical procedure” and regret rates were measured by their agreement with this statement “If I were to do all over again, I would have the same surgical procedure.”

  3. ISB of patients before and after surgery: The survey included questions about ease of obtaining information about BPH, ease of obtaining information about BPH surgical treatments, patient’s opinion regarding the importance of having information regarding BPH prior to treatment and the specific information sources utilized before and after the operation.

The information sources that were examined included the online general search utilities (such as Google or Yahoo, etc.), the AUA website, the Mayo Clinic website, online patient discussion forums or boards, online BPH support groups, medical journals, and others. A composite score was generated, and this represented the sum of the number of the resources each patient utilized. Patients who utilized more sources were considered to have more extensive ISB.

At the end of the study, the following outcomes were examined:

  1. Patient’s opinion regarding information sources of BPH and its treatment.

  2. The extent of ISB in relation to the type of surgical intervention.

  3. The relationship between the extent of ISB and satisfaction.

Descriptive data were reported as frequency distributions and simple percentages for categorical variables. Continuous variables were expressed as the mean ± the standard deviation and the median with interquartile range. Univariate analysis of discrete variables was accomplished by chi-square analysis or the Fisher exact test (if the expected value in any cell was less than 5 with the appropriate degrees of freedom). Comparisons of continuous variables were conducted using a two-tailed Student’s t test. Pearson product moment correlation was used to assess the relationship between the extent of preoperative ISB and postoperative satisfaction. Patients were then analyzed based on their specific surgical intervention and corresponding resources utilized.

Results

There were 862 living patients who underwent surgical treatment for BPH during this study interval. Among this cohort, 479 patients (55.6%) responded to the survey. Respondents were classified by the type of surgical intervention and included 214 HoLEP (44.6%), 210 TURP (43.8%), 21 HoLAP (4.3%), 18 PVP (3.7%), 9 TUIP (1.8%), and 7 OSP (1.4%). Since the numbers of patients who underwent HoLAP, PVP, TUIP, and OSP were small, these cases were excluded from this analysis.

Among the remaining respondents, the majority had neutral opinions regarding the ease of obtaining information about BPH (Figure 1) and its various treatment options (Figure 2). In both of these domains, there was a general trend to agree that it was easy to find disease or treatment-specific information. Most of the patients (145 patients, 41.8%) had neutral opinions regarding the importance of discussing their condition with other BPH patients. Overall, 115 patients (33.67%) did not find such an endeavor important, whereas 92 (25.5%) reported such communication important (Figure 3).

Figure 1.

Figure 1.

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Patients’ opinion regarding easiness of obtaining general information about benign prostatic hyperplasia (BPH).

Figure 2.

Figure 2.

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Patients’ opinion regarding easiness of obtaining information about benign prostatic hyperplasia (BPH) treatment.

Figure 3.

Figure 3.

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Patients’ opinion regarding the importance of discussing their condition with other benign prostatic hyperplasia (BPH) patients.

Preoperatively, when ISB was analyzed based on the procedure performed, the most commonly utilized source of information was general online search engines for TURP and the Mayo Clinic institutional website for HoLEP. The least utilized source was the online BPH support groups for both interventions. With the exception of online discussion boards and BPH support groups, there was a significant difference in the frequency of utilization of all other websites between the two groups, where there was a higher tendency for HoLEP patients to utilize these resources (Table 1).

Table 1.

Preoperative Information Seeking Behavior.

Type of information seeking behavior TURP (%) HoLEP (%) p
Online search (Google, Yahoo, Bing, etc.) 31.82 54.84 <.0001
American Urological Association website 3.42 14.74 .001
Mayo Clinic website 31.55 56.11 <.001
Online patient discussion boards 4.76 8.00 .254
Online BPH support groups 1.5 4.08 .196
Other medical websites 14.18 30.41 .001
Medical journals 27.96 43.00 .002
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Abbreviations: BPH, benign prostatic hyperplasia; TURP, transurethral resection of the prostate; HoLEP, holmium laser enucleation of the prostate.

Postoperative source consideration was uniformly less for all websites for both procedures in comparison to the preoperative period. The most commonly utilized source of information was the Mayo Clinic institutional website for both procedures. There were no differences in the utilization of sources except for AUA and the Mayo Clinic institutional website (Table 2). HoLEP patients were more likely to use these resources after the procedure as well.

Table 2.

Postoperative Information Seeking Behavior.

Type of information seeking behavior TURP (%) HoLEP (%) p
Online Search (Google, Yahoo, Bing, etc.) 16.03 24.03 .078
American Urological Association website 0.75 6.67 .010
Mayo Clinic website 17.81 27.39 .047
Online patient discussion boards 3.65 6.02 .364
Online BPH support groups 0.96 0.84 .924
Other Medical websites 6.93 13.56 .111
Medical journals 16.57 17.28 .857
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Abbreviations: BPH, benign prostatic hyperplasia; TURP, transurethral resection of the prostate; HoLEP, holmium laser enucleation of the prostate.

When the relationship between ISB and overall satisfaction and regret were utilized, there was no correlation between the extent of ISB and overall satisfaction (r = −0.0719, p = .1610). Additionally, there was no correlation between the extent of ISB and regret (r = −0.0436, p = 0.3945).

Discussion

The Internet provides a major source of information for patients seeking specific answers to their medical questions (Andreassen et al., 2007). It is estimated that 40% to 60% of the adult population has access to the Internet (Ayantunde, Welch, & Parsons, 2007) and approximately 5% of Internet utilization is for health-related information (Eysenbach & Kohler, 2003). Bastian (2003) reported that 40% of the people included in their survey sought online health information before meeting their physicians, and one third of respondents thought that this information affected their decisions. With that being said, a large number of patients come to doctor visits with prior knowledge about their medical conditions (Baker, Wagner, Singer, & Bundorf, 2003). This, in turn, resulted in a dramatic impact on the patient-doctor relationship because there are innumerable sources of health-related information with varying degrees of credibility (McMullan, 2006).

A meta-analysis for health-related website content identified that 70% of websites were found to be of poor quality (Eysenbach, Powell, Kuss, & Sa, 2002). All of these facts collectively mandate the real and pressing need to examine the health ISB of patients. This health ISB should be individualized to the specific diseases being studied because each disease affects a certain group of patients with certain demographic characteristics that may affect their specific ISB (Kummervold et al., 2008; Lorence, Park, & Fox, 2006; Wangberg et al., 2008; Ybarra & Suman, 2008).

The abundance of health information resources dedicated to a certain disease is expected to be related to the prevalence and chronicity of that specific condition. BPH is a very common disease in elderly males and is considered the most frequent cause of outpatient clinic visits in the United States and the most frequent benign neoplasia in males. It is estimated that there are more than 210 million individuals are affected with BPH worldwide. Such chronically ill patients may spend long amounts of time on the Internet to seek information, and they are more likely to have a more extensive health ISB compared with patients with acute illnesses (Kalichman et al., 2006; Wagner, Baker, Bundorf, & Singer, 2004). Despite the prevalence of BPH and the numerous medical and surgical treatments available, there are no studies that examined the information sources or ISB in those patients.

The aim of this study was to examine the health ISB in a large group of patients who sought surgical treatment for BPH and to gauge their opinion about the importance and the ease of obtaining this information. This presents the first study of its kind, and it was designed to specifically describe the most commonly used resources of information. Additionally, it measured the impact of the patients ISB on satisfaction because it had been previously postulated that patient health ISB may affect final satisfaction (Ayantunde et al., 2007). The results were analyzed based on the type of intervention that the patient eventually had. To avoid biases, the patients were contacted through a specially designed survey that was exclusively administered through a third-party survey center without point of care influence from the investigators. This methodology was crucial for several reasons. First, many patients do not declare their health information search to medical providers for a variety of reasons (Bylund et al., 2007; Diaz, Sciamanna, Evangelou, Stamp, & Ferguson, 2005; Hay, Strathmann, Lieber, Wick, & Giesser, 2008). Second, one of the outcomes that this study measured was the final satisfaction and regret after surgical interventions, and this may be specifically vulnerable to bias if examined by the provider herself or himself. Third, not all patients may choose to return to a provider based on specific living arrangements or because of satisfaction with that particular provider or institution. The response rate to this survey was 55.6%. The majority of respondents (88%) underwent one of two procedures, either TURP or HoLEP. Accordingly, the rest of the patients who underwent one of the other surgical interventions were excluded because of the small sample size.

This study highlighted many important facts relating to ISB. A large number of patients relied on a conventional generic source of information such as the commonly used search engines Google and Yahoo. The second most commonly used resource was the Mayo Clinic institutional website. This behavior was observed mainly before the procedure but continued to a lesser degree after the procedure. This has been previously demonstrated in larger studies where approximately one quarter of the patients used these general search engines (Sommerhalder, Abraham, Zufferey, Barth, & Abel, 2009). More than 30% of TURP patients and 50% of HoLEP patients used generic Internet searches as their sole source of information. When questioned about their opinion regarding the ease of finding BPH-related information, both groups felt that it was easy to obtain information about their disease as well as the various treatments.

When the two procedures were compared, there was a general trend for the HoLEP patients to have a more extensive ISB, and they were more likely to use specific websites such as the institutional website where they ended up having their procedure. This may indicate that patients with more extensive ISB ended up having a relatively specific urologic procedure. This was expected because HoLEP is a relatively uncommon procedure that is not performed as frequently as TURP and is offered in a limited number of centers across the United States. This extensive health ISB for HoLEP patients continued even after the procedure where HoLEP patients continued to utilize health information resources at a significantly higher rate than TURP patients. However, this was uniformly lower compared with the preoperative period in both procedures.

By comparing the preoperative and postoperative ISB, postoperative source utilization was uniformly less for all websites and for both procedures. This could be explained by the fact that patients were seeking answers from the institutions where they received their treatment. The least utilized source was the online BPH support groups for both interventions. The latter finding may indicate that patients wanted to have information from credible institutional websites instead of laypersons’ opinions or may be reflective of the information provided at time of intervention.

Many studies have reported that postprocedural utilization may be a sign of mistrust or dissatisfaction (Bell, Hu, Orrange, & Kravitz, 2011; Tustin, 2010). The overall satisfaction rate in this series was (50.5%). The satisfaction did not differ by the procedure, and a relationship between preoperative ISB and postoperative satisfaction or regret could not be identified in this cohort. This may denote that satisfaction and regret is more strongly affected by the patient’s functional outcomes after the procedure. Moreover, this relationship may be clearer in future studies as health information resources become more mature and more organized.

This study presents the first description of ISB in BPH patients. However, it is limited by the retrospective nature of the study and lack of randomization. This study could not account for time of ISB or the duration between intervention and survey, which could significantly affect outcomes. With these limitations in mind, one can conclude that the majority of patients found it easy and important to obtain information about BPH and that patients who had a more extensive seeking behavior may eventually choose a more advanced procedure. Postoperative satisfaction is multifactorial, and the weight of ISB on postoperative satisfaction requires further understanding and study. The application of this study design to other common health problems provides a valuable tool to understand how patients seek and use health-related information, which in turn can help focus discussions during actual clinical encounters and improve these information sources over time.

Acknowledgments

We would like to thank and recognize Charles A. and Anna Mae Miller for their philanthropic support and generous donation that allowed us to complete this work. They were not involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript.

Footnotes

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

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