App-Based Treatment of Urinary Incontinence: Is the Time Now?

Michael E. Johansen; Christal M. Clemens

doi:10.1370/afm.2683

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RE: Commentary for" App-Based Treatment of Urinary Incontinence: Is the Time Now? "
Mariaelana Brenner, Madelyn Dulin, William Graft, Aaron Hezeltine, Rebecca Hezeltine and Paul J. Pecorin

Published on: 17 July 2021
RE: Commentary for" App-Based Treatment of Urinary Incontinence: Is the Time Now? "
Shalini Kumar, Lucendia Adams, Robert Ayres, Joshua Dein, Titus Hou, Jesseca Pirkle, Jairo R Garcia, Trever Troutman and Tanya Magana

Published on: 03 May 2021

Published on: (17 July 2021)
Page navigation anchor for RE: Commentary for" App-Based Treatment of Urinary Incontinence: Is the Time Now? "
RE: Commentary for" App-Based Treatment of Urinary Incontinence: Is the Time Now? "
Mariaelana Brenner, Medical Student, Univesity of Illinois College of Medicine Rockford
Other Contributors:
Madelyn Dulin, Medical Student

William Graft, Medical Student

Aaron Hezeltine, Medical Student

Rebecca Hezeltine, Medical Student

Paul J. Pecorin, Medical Student
The overall purpose of this study was to determine whether an app-based treatment was as effective as “usual care” for treating urinary incontinence (UI) [1]. Usual care consisted of pelvic floor muscle training or bladder training, pessary placement, drugs, absorbent products, or referral to a pelvic physical therapist. The researchers examined all types of UI including stress, urgency, and mixed-type. As the primary outcome, they used the International Consultation on Incontinence Modular Questionnaire Urinary Incontinence Short Form (ICIQ-UI-SF) to assess the change of UI severity from baseline to 4 months following treatment. They compared the results of this questionnaire between groups. As secondary outcomes, they looked at the change in UI-specific lower urinary tract symptoms quality of life, the number of UI episodes per day, and the overall feeling of improvement of urinary incontinence.
This study used a parallel-arm, randomized, non-inferiority study design in the North of the Netherlands. Due to the nature of the treatment, participants and their clinicians were not blinded to the treatment. A total of 262 women were randomized into either the usual care group or the app-based treatment group. The study used a linear regression analysis to determine if the app-based treatment was non-inferior to usual care in reducing UI severity in a time frame of 4 months. Because there was no significant difference in severity of UI symptoms between groups, the result...
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The overall purpose of this study was to determine whether an app-based treatment was as effective as “usual care” for treating urinary incontinence (UI) [1]. Usual care consisted of pelvic floor muscle training or bladder training, pessary placement, drugs, absorbent products, or referral to a pelvic physical therapist. The researchers examined all types of UI including stress, urgency, and mixed-type. As the primary outcome, they used the International Consultation on Incontinence Modular Questionnaire Urinary Incontinence Short Form (ICIQ-UI-SF) to assess the change of UI severity from baseline to 4 months following treatment. They compared the results of this questionnaire between groups. As secondary outcomes, they looked at the change in UI-specific lower urinary tract symptoms quality of life, the number of UI episodes per day, and the overall feeling of improvement of urinary incontinence.
This study used a parallel-arm, randomized, non-inferiority study design in the North of the Netherlands. Due to the nature of the treatment, participants and their clinicians were not blinded to the treatment. A total of 262 women were randomized into either the usual care group or the app-based treatment group. The study used a linear regression analysis to determine if the app-based treatment was non-inferior to usual care in reducing UI severity in a time frame of 4 months. Because there was no significant difference in severity of UI symptoms between groups, the results suggest that the app-based treatment was indeed non-inferior, but also non superior, to usual care in the treatment of UI symptoms.
Global impression of UI symptom improvement was a secondary outcome and statistical significance was not calculated for each category of improvement. Our group discussed how there was a greater proportion of patients in the usual care group who rated their improvement as “very much better” as compared to the app-based group. This suggests that analyzing the data stratified by levels of improvement may show differences at various levels. A standardized approach to the “care as usual” treatment would have eliminated the variety of care approaches to UI. The study was performed at 31 practices in the Netherlands which leads to the potential for inconsistent care, weakening the study results. Although the 31 practices were following guidelines, different amounts of time may have been spent counseling each patient. This may impact the effectiveness of treatments such as pelvic floor exercises if less time was given to teaching proper technique. In addition, severity of UI was not stratified and was defined as women with two episodes of UI per week, meaning that women with varying levels of incontinence severity were compared. Efficacy of treatment methods could differ by incontinence severity and this was not captured in the analysis. Finally, risk factors for UI including number of births, family history of UI and patient weight were not considered.
Selection bias may be present with the study group more adherent to treatment than the general population. The participants selected for the study had already brought up urinary incontinence to their physician and were seeking treatment. Therefore, they may be more motivated to adhere to treatment. Inclusion criterion for the study may have favored those who had increased access to health care due to the requirement of a smartphone or tablet and recruitment through social media. This may affect the generalizability of the study to the general population where access to healthcare varies widely. The inability to blind the participants in the study was another issue because women who were randomized to the treatment they desired, may be more adherent than those who did not receive their desired treatment. Also, although study participants were randomized, there may have been a selection bias of participants more receptive to app-based treatments. Those that were not technologically advanced or those who were weary of app-based treatments may not have signed up for the study. Some women may prefer a “hands-on” approach from their physicians and be less willing to adhere to an app-based treatment. These women would have poor outcomes with an app-based treatment. In this study, women were all inclined to try an app-based treatment so the positive outcomes may be artificially inflated.
The applicability of this study to populations outside of the Netherlands is questionable due to the demographic and healthcare system differences. The Netherlands is a European country with a population of 17.5 million people [2] with individuals of Dutch descent making up 75.8% of the population and other Europeans making up an additional 10.3% [2]. This is drastically different from the 331-million-person population of the United States of America (USA) that is much more ethnically diverse [3]. Variation in receptiveness to app-based care makes it difficult to translate this study to a patient population in the USA. Additionally, the Netherlands and the USA have substantially different healthcare systems which may impact physicians' willingness to incorporate app-based treatment into their care plans. Insurance coverage is an additional variable that is present in the USA, but less so in the study population. Differences in internet access presents another barrier to applying app-based UI treatment to patients in the USA, as a higher percentage of the Netherland population reports using the internet [4].
The difference in applicability of this study to rural and urban areas was also discussed. The development of app-based treatment options could greatly benefit both populations, however, it could also lead to unique challenges. In rural areas, patients may face barriers to healthcare such as physician shortages, limited access to specialists, and lack of transportation [5]. App-based treatment could be a valuable resource to this population. It would give them a treatment option that could be accessed from home, eliminating the need to travel long distances and would allow them to bypass long wait times to schedule an appointment with a provider. A common misconception is that people in rural areas may not be as technologically advanced, however, a 2021 survey found that 80% of people who live in rural areas use a smartphone, compared to 84% in suburbs and 89% in urban areas [6]. App-based treatment options could also benefit underserved urban areas, as they also face physician shortages. However, we felt that the most impact could be made in rural areas where some of these issues are more prevalent.
Overall, this study presents a comparison between physician-led usual care treatment and app-based treatment for urinary incontinence. As the world continues to become more technologically advanced, it is important that healthcare follows this trend. In more sensitive subject areas such as urinary incontinence, women may feel shame or embarrassment to seek treatment which could hinder their ability to receive care. An app-based approach would allow for a more discrete method to treat urinary incontinence in the privacy of her own home without needing to visit a physician. This study demonstrated that app-based treatment is a non-inferior option to usual care and is a viable option in treating urinary incontinence.

References
1. Loohuis AMM, Wessels NJ, Dekker JH, van Merode NAM, Slieker-Ten Hove MCP, Kollen BJ, Berger MY, van der Worp H, Blanker MH. App-Based Treatment in Primary Care for Urinary Incontinence: A Pragmatic, Randomized Controlled Trial. Ann Fam Med. 2021 Mar-Apr;19(2):102-109. doi: 10.1370/afm.2585. PMID: 33685871; PMCID: PMC7939722.
2. Statistic Netherlands. (n.d.). CBS Statline. https://opendata.cbs.nl/statline/#/CBS/en/dataset/37325eng/table?ts=1624...
3. U.S. Census Bureau. (2020). U.S. Department of Commerce. US Census 2020. https://www.census.gov/quickfacts/fact/table/US/POP010220.
4. International Telecommunication Union (ITU ) World Telecommunication/ICT Indicators Database. Individuals using the Internet (% of population). The World Bank. https://data.worldbank.org/indicator/IT.NET.USER.ZS?end=2019&most_recent... esc=tru e&start=1960&view=chart
5. Green-Hernandez, C. (2006). Transportation Challenges in Rural Healthcare. The Nurse Practitioner, 31(12), 10. https://doi.org/10.1097/01.npr.0000393077.02176.6b
6. Pew Research Center. (2021, April 7). Demographics of Mobile Device Ownership and Adoption in the United States. Pew Research Center: Internet, Science & Tech. https://www.pewresearch.org/internet/fact-sheet/mobile/.
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Competing Interests: None declared.
Published on: (3 May 2021)
Page navigation anchor for RE: Commentary for" App-Based Treatment of Urinary Incontinence: Is the Time Now? "
RE: Commentary for" App-Based Treatment of Urinary Incontinence: Is the Time Now? "
Shalini Kumar, Medical Student, University of Illinois College of Medicine Rockford
Other Contributors:
Lucendia Adams, Medical Student

Robert Ayres, Medical Student

Joshua Dein, Medical Student

Titus Hou, Medical Student

Jesseca Pirkle, Medical Student

Jairo R Garcia, Medical Student

Trever Troutman, Medical Student

Tanya Magana, Medical Student
A randomized control trial was conducted to compare app-based treatment with standard care for urinary incontinence. Standard care was defined as any treatment deemed necessary by the PCP including medications, exercise etc. The app included exercises, reminders, and step-by-step instructions for treatment of urinary incontinence. The study took place in the Netherlands, and participants were recruited via primary care clinicians, the lay press, and social media. The diagnosis of urinary incontinence was confirmed with the Three Incontinence Questions questionnaire. All types of urinary incontinence- stress, overflow, and mixed, were included. As we discussed, this was a huge clinical implication for this study. Most previous studies focused on one type of urinary incontinence.
Adult women who experienced at least 2 episodes of urinary incontinence per week, had access to a device such as a smart phone or tablet, and had not undergone treatment could participate. Women were randomized and 102 women were assigned to the standard care group and 93 were assigned to the app- treatment group. The primary outcome was the difference in urinary incontinence severity from baseline to 4 months. The secondary outcomes were the change in lower urinary tract symptoms quality of life and the change in urinary incontinence episodes per day from baseline to 4 months. In an intention-to treat analysis, the mean difference between both groups in change scores for urinary incon...
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A randomized control trial was conducted to compare app-based treatment with standard care for urinary incontinence. Standard care was defined as any treatment deemed necessary by the PCP including medications, exercise etc. The app included exercises, reminders, and step-by-step instructions for treatment of urinary incontinence. The study took place in the Netherlands, and participants were recruited via primary care clinicians, the lay press, and social media. The diagnosis of urinary incontinence was confirmed with the Three Incontinence Questions questionnaire. All types of urinary incontinence- stress, overflow, and mixed, were included. As we discussed, this was a huge clinical implication for this study. Most previous studies focused on one type of urinary incontinence.
Adult women who experienced at least 2 episodes of urinary incontinence per week, had access to a device such as a smart phone or tablet, and had not undergone treatment could participate. Women were randomized and 102 women were assigned to the standard care group and 93 were assigned to the app- treatment group. The primary outcome was the difference in urinary incontinence severity from baseline to 4 months. The secondary outcomes were the change in lower urinary tract symptoms quality of life and the change in urinary incontinence episodes per day from baseline to 4 months. In an intention-to treat analysis, the mean difference between both groups in change scores for urinary incontinence severity was 0.058 points, -2.16 in the app-based treatment group, and -2.56 in the usual care group. The per-protocol analysis showed similar results. Therefore, neither treatment was found to be better than the other, but both significantly improved outcomes.
We discussed the overall advantages and disadvantages of the app-based treatment and compared the applicability in rural and urban settings. In a rural setting, where doctors may be miles away, it is convenient to have an app-based treatment that can be accessed from home. Pelvic floor therapists are even harder to find in a rural area compared to primary care physicians, making the app even more beneficial. A disadvantage is decreased internet access. If patients don’t have internet access, it would make accessing the app and utilizing it as treatment virtually impossible.
We focused our discussion on convenience when we talked about urban settings. In a world where everyone always has their phone with them, it is easy to get reminders and undergo a treatment through an app, regardless of location. This is especially true in urban settings where everyone often has busy schedules. Internet access is usually available, so this does not pose a barrier.
Some advantages and disadvantages we discussed apply to both settings. One advantage we talked about was that an app preserves privacy. Without having to go to any primary care provider, symptoms can be improved and managed in the comfort of one’s home. It is also a big help for individuals who do not have means of transportation to the doctor’s office due to disability, low socioeconomic status, etc.
Some disadvantages we discussed were that elderly patients may not be as comfortable with technology, so it might be hard for them to know how to use the app and benefit from it. However, we discussed the fact that many elderly individuals in the present time are more comfortable with technology. They just may require direct instruction first. Time for this may be limited in an urban setting with a large patient volume but may be possible in a rural setting. A helpful alternative in an Urban setting is a multidisciplinary approach in which other health care providers, such as nurse practitioners or physician assistants, can assist in instruction in clinics with a large patient volume. The other disadvantage we discussed is the resistance of older physicians, who might be set in their ways and are not as open to exploring new means of treatment. They are also not as familiar and open to technology, often choosing more traditional approaches. The group also brought up the fact that the app-based treatment takes away the personal connection with the patients. A strong doctor-patient relationship can go a long way in terms of keeping patients motivated to continue treatment. As a group, we also considered cost. It isn’t likely that insurance companies will pay for the app at this time; however, insurance does cover visits to a primary care physician. Since this study was done in the Netherlands with universal health care, it may be possible that there might be better national funding in the country.
The group discussed some suggestions to improve this study. We discussed the idea of standard care and how that would be controlled amongst different providers with different treatment styles. We would have liked some background on if there was any training given to physicians prior as to what classified as standard care. It also would have been interesting to know how many patients who used the app still chose to see their primary care physician, since they were allowed to do this. It would give us an idea if the app alone was sufficient for improvement. Also, the study mentions that 96% of people used the app at least once, but more user data would have been helpful on how many people used the app 2 times, 3 times etc. This would also give us a better idea on how many times the app needed to be accessed for improvement.
For future studies, we discussed increasing the sample sizes of the groups and repeating the sub-group analyses for recruitment type, type of urinary incontinence, and previous physical therapy for urinary incontinence. We would like to see if an increased sample size makes a difference in terms of statistical significance. Additional sub-groups we believe would be interesting to examine are number of vaginal deliveries, number of prior pelvic surgeries, and various age group. It would also be interesting to compare the efficacy of this urinary incontinence app to other urinary apps. Finally, a helpful follow-up to this study would be to ask participants about the barriers they experienced. This would provide us with valuable information that can be considered and incorporated into development of the next generation of health-care apps in the future.

Reference: Loohuis, Anne M., et al. “App-Based Treatment in Primary Care for Urinary Incontinence: A Pragmatic, Randomized Control Trial.” Annals of Family Medicine, vol. 19, no. 2, Mar. 2021.
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Competing Interests: None declared.