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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.