6 How to implement NICE's guidance on the UroLift system

6 How to implement NICE's guidance on the UroLift system

The experiences of these NHS trusts have been used to develop practical suggestions for how to implement NICE guidance on the UroLift system.

Project management

In order to gain maximum benefit, the technology should be adopted using a project management approach. NICE has produced the Into Practice guide which includes a section on what organisations need to have in place to support the implementation of NICE guidance.

Project team

The first step is to form a local project team who will work together to implement the technology and manage any changes in practice.

Individual NHS organisations will determine the membership of this team and how long the project will last. In order to implement this guidance in an effective and sustainable way, consider the following membership of the team:

  • Clinical champion: could be the clinical director for urology or a consultant urological surgeon with an interest in the surgical management of BPH. They should have the relevant knowledge and understanding to be able to drive the project, answer any clinical queries and champion the project at a senior level.

  • Project manager: could be someone in a clinical or managerial role who will be responsible for the day‑to‑day running of the project, co‑ordinating the project team and ensuring the project is running as planned.

  • Management sponsor: could be the directorate manager, directorate accountant or directorate business manager. They will be able to help assess the financial viability of the project, drive the formulation of a business case and help to demonstrate the cost savings achieved. It is the experience of both trusts that respect and support from the managerial teams for the clinician's aims and goals facilitated adoption of the UroLift system.

  • Key stakeholders: consultant urological surgeons, deputy directorate manager, nurse specialists and theatre scrub nurses will be valuable members of the project team because they are directly involved in the management and provision of the service.

  • Clinical audit facilitator: to help set up mechanisms to collect and analyse local data related to the project metrics and audit needs. A nurse specialist or medical fellow with interest or a project in this area could fulfil this role.

Early questions that the team may wish to consider are:

  • How will the project be funded? Can local payment arrangements be implemented with the clinical commissioning group in order support adoption? (See resource impact.)

  • How will local metrics be identified and measured?

  • Who will be responsible for collecting clinical data?

  • How will the required education be provided?

  • How to ensure all eligible men are informed of this procedure and offered the choice where appropriate?

  • Are there any obvious challenges and how can these be overcome?

Care pathway mapping

NICE has produced advice on mapping care pathways to help organisations through the technology adoption process. The 2 sites involved in the production of this resource identified the key steps needed:

  • Patient identification and choice: it is estimated that the UroLift procedure will be appropriate for up to 1 in 4 men needing surgery for lower urinary tract symptoms of BPH.

    • Men referred to secondary care for BPH should be given information about all the surgical options available in the trust which may be suitable for them.

    • The UroLift system offers particular benefits for those men who wish to preserve sexual function, have blood clotting disorders or for whom general anaesthetic would be unsuitable.

    • Men for whom the UroLift procedure is thought suitable should be referred to a trained consultant urological surgeon in the trust.

  • Assessment: by cystoscopy (or in some cases ultrasound) to establish the size of the prostate and the presence of a middle lobe. This means an additional outpatient appointment and it is not part of the routine pathway for men with BPH.

  • Follow up: at 3–4 weeks, with final follow‑up and discharge at 3 months. Follow up appointments were either in outpatients or by phone.

Measuring success

In order to demonstrate the benefits of adopting the UroLift system it is important to take measurements before, during and after implementation. Some of these measures will not be routinely collected and sites must consider a data collection methodology that is appropriate to the service. NICE interventional procedure guidance on insertion of prostatic urethral lift implants to treat lower urinary tract symptoms secondary to benign prostatic hyperplasia recommends that reported outcomes should include the effects of the procedure on symptoms and quality of life, the duration of benefits, the need for further procedures and complications.

Because the UroLift system offers an additional option for men with BPH, the sites involved in developing this resource suggested that outcome measures should include patient satisfaction scores. These could include:

  • IPSS

  • Sexual function scores including:

    • IIEF

    • ejaculatory function score

    • sexual health inventory for men (SHIM)

  • total number of surgical interventions for BPH

Other outcome measures could include:

  • length of stay

  • procedure time

  • use of catheter and duration of catheterisation

  • flow rate

  • Male Sexual Health Questionnaire for Ejaculatory Dysfunction (MSHQ‑EjD)

  • length of benefit

  • readmission rates and the need for further procedures

Overcoming implementation challenges.

Table 3 shows the challenges reported by NHS sites that have implemented the UroLift system.

Table 3 Reported implementation challenges when using the UroLift system

Implementation challenge

Solution

Capital and ongoing revenue costs in the absence of an appropriate tariff.

Securing the necessary funding will require a collaborative approach between the provider and commissioner.

Prepare a business case including full cost considerations for the UroLift system compared with current procedures across a complete service budget.

Clinical acceptance of a new procedure.

Securing engagement from all members of the urology team can be challenging and can pose a risk to successful adoption of the technology.

Select appropriate metrics to demonstrate clinical benefits, safety and demand.

Provide adequate training, information and evidence base for the use of the technology.

It is anticipated that the UroLift procedure may be suitable for up to 25% of men with BPH voiding symptoms, so it would not be essential for all surgeons to be trained. However, all will need to be able to identify suitable men and refer them as appropriate.

Abbreviations: BPH, benign prostatic hyperplasia.

Resource impact

NICE has published a costing statement that can be used by NHS commissioners and providers to better understand the local costs associated with adopting the UroLift system.

The NICE statement for a UroLift procedure identifies the unit cost of 1 UroLift procedure (including 4 implants) to be £2,405.

At the time of guidance publication (September 2015), the UroLift procedure (irrespective of the number of implants used) was expected to map to the Healthcare Resource Group (HRG) LB26Z (Intermediate Endoscopic Prostate or Bladder Neck Procedures). The 2016/17 elective tariff for LB26Z was £1,231 (2016/17 national tariff).

From 1 April 2017 the procedure code in OPCS 4.8 which corresponds to the Urolift system is M68.3 (Endoscopic Insertion of prosthesis to compress lobe of prostate). The UroLift procedure (irrespective of the number of implants used) is therefore expected to map to HRG LB70C (Complex Endoscopic, Prostate or Bladder Neck Procedures (Male and Female) with CC Score 2+) or LB70D (Complex Endoscopic, Prostate or Bladder Neck Procedures (Male and Female), with CC Score 0–1). The 2017/18 elective tariffs for LB70C and LB70D are £2,538 and £2,107 respectively) (2017/18 national tariff).

Business case

Developing a business case should be a priority for the implementation team. Local arrangements for developing and approving business plans will vary from trust to trust, and each organisation is likely to have its own process in place.

NICE has produced advice on building a business case to help organisations with technology adoption.

The business case will need to demonstrate how the UroLift system can lead to cost savings in terms of reduced beds days, simpler pre‑operative processes and increased capacity. It should also demonstrate an improved quality of service offered to men in terms of enhanced choice.

Sites reported that having a senior managerial 'champion' to present the business case to the board was beneficial.

Trusts may also explore offering the UroLift procedure as a pilot and seeking approval for adoption from their research and development committee or through a 'new technology' process.

Education

The manufacturer provides all training needed for the UroLift system. For surgeons, this involves:

  • observing a number of cases (3–5 on average)

  • practising on a simulator and model

  • doing the procedure under the mentorship of a manufacturer representative or mentor surgeon (1 site said that, on average, a surgeon should be competent to work independently after doing 6 procedures).

The surgeons obtained study leave and professional development leave (2 days) in order to visit off‑site lecturers and procedures.

As the surgeons become more confident they can move from doing the procedure under general anaesthetic with urinary catheter to sedation or local anaesthetic and no urinary catheter. This will shorten procedure times and may lead to lower procedure costs.

If a nurse specialist is responsible for post‑procedure follow‑up and discharge if no complications are reported, plans will need to be in place to meet their training needs.

It is important that all healthcare professionals assessing men at the surgical stage of the BPH pathway are able to identify those in whom the UroLift procedure would be of benefit and provide information on all the options available.


This page was last updated: 27 April 2017