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Internet-based treatment of stress urinary incontinence: treatment outcome, patient satisfaction, and cost-effectiveness
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background Stress urinary incontinence (SUI) is the leakage of urine when coughing, sneezing, or on exertion. It affects 10-35% of women, and can impair quality of life (QOL). First-line treatment is pelvic floor muscle training (PFMT). However, access barriers and embarrassment may prevent women from seeking care. There is a need for new, easily accessible ways to provide treatment.

Aim To evaluate the treatment outcome, patient satisfaction, and cost-effectiveness of an Internet- based treatment programme for SUI.

Methods We recruited 250 community-dwelling women aged 18-70 years, with SUI ≥1/week via our website. Participants were randomised to 3 months of PFMT with either an Internet-based programme (n=124), or a programme sent by post (n=126). We had no-face-to face contact with the participants, but the Internet group received individually tailored e-mail support from an urotherapist. Treatment outcome was evaluated after 4 months with intention-to-treat analysis. After treatment, we telephoned a strategic selection of participants (Internet n=13, postal n=8) to interview them about their experiences, and analysed the results according to grounded theory principles. We also performed a cost-utility analysis with a 1-year societal perspective, comparing the treatment programmes with each other and with a no-treatment alternative. To scrutinize our measure of QOL, we performed a reliability study of the ICIQ-LUTSqol questionnaire.

Results Participants in both intervention groups achieved highly significant improvements (p<0.001) with large effect sizes (>0.8) in the primary outcomes symptom score (ICIQ-UI SF: mean change Internet 3.4 [SD 3.4], postal 2.9 [3.1]), and condition-specific QOL (ICIQ-LUTSqol: mean change Internet 4.8 [SD 6.1], postal 4.6 [SD 6.7]); however, the differences between the groups were not significant. Compared with the postal group, more participants in the Internet group perceived they were much or very much improved after treatment (40.9%, vs. 26.5%, p=0.01), reduced their use of incontinence aids (59.5% vs. 41.4%, p=0.02), and indicated satisfaction with the treatment programme (84.8% vs. 62.9%, p<0.001).

Results from the interviews fell into three categories: about life with SUI and barriers to seeking care; about the treatments and the patient-provider relationship; about the sense of empowerment many women experienced. A core category emerged: “Acknowledged but not exposed.”

The extra cost per quality-adjusted life year (QALY) gained through use of the Internet-based programme compared with the postal programme was €200. The extra cost per QALY for the Internet-based programme compared with no treatment was €30,935.

The condition-specific questionnaire ICIQ-LUTSqol is reliable in women with SUI, with high degrees of agreement between overall scores (Intraclass correlation coefficient 0.95, p<0.001).

Conclusion Internet-based treatment for SUI is a new, effective, and patient-appreciated treatment alternative, which can increase access to care in a sustainable way.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2014. , 86 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1621
Keyword [en]
Stress urinary incontinence, Internet, randomised controlled trial, pelvic floor muscle training, self care, quality of life, qualitative research, cost-utility analysis, validation study
National Category
Family Medicine
Research subject
Family Medicine
Identifiers
URN: urn:nbn:se:umu:diva-84405ISBN: 978-­91-­7459-­778-­3 OAI: oai:DiVA.org:umu-84405DiVA: diva2:684299
Public defence
2014-01-31, Hörsalen Snäckan (Aulan), hus 16, ingång 6, Östersunds sjukhus, Östersund, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2014-01-10 Created: 2014-01-06 Last updated: 2015-04-29Bibliographically approved
List of papers
1. Internet-based treatment of stress urinary incontinence: a randomised controlled study with focus on pelvic floor muscle training
Open this publication in new window or tab >>Internet-based treatment of stress urinary incontinence: a randomised controlled study with focus on pelvic floor muscle training
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2013 (English)In: BJU International, ISSN 1464-4096, E-ISSN 1464-410X, Vol. 112, no 3, 362-372 p.Article in journal (Refereed) Published
Abstract [en]

Objective To compare two treatment programmes for stress urinary incontinence (SUI) without face-to-face contact: one Internet-based and one sent by post.

Patients and Methods Randomised, controlled trial conducted in Sweden 2009-2011. Computer-generated block-randomisation, allocation by independent administrator. No 'blinding'. The study included 250 community-dwelling women aged 18-70 years, with SUI >= 1 time/week. Consecutive online recruitment. The women had 3 months of either; (i) An Internet-based treatment programme (124 women), including e-mail support and cognitive behavioural therapy assignments or (ii) A treatment programme sent by post (126). Both programmes focused mainly on pelvic floor muscle training.

Primary outcomes symptom-score (International Consultation on Incontinence Questionnaire Short Form, ICIQ-UI SF) and condition-specific quality of life (ICIQ-Lower Urinary Tract Symptoms Quality of Life, ICIQ-LUTSQoL).

Secondary outcomes (i) Patient Global Impression of Improvement, (ii) Incontinence aids, (iii) Patient satisfaction, (iv) Health-specific QoL (EQ5D-Visual Analogue Scale), and (v) Incontinence episode frequency. Follow-up after 4 months via self-assessed postal questionnaires.

Results In all, 12% (30 women) were lost to follow-up. Intention-to-treat analysis showed highly significant improvements (P < 0.001) with large effect sizes (>0.8) with both interventions, but there were no significant differences between groups in primary outcomes. The mean (SD) changes in symptom-score were: Internet 3.4 (3.4), Postal 2.9 (3.1) (P = 0.27). The mean (SD) changes in condition-specific QoL were: Internet 4.8 (6.1), Postal 4.6 (6.7) (P = 0.52). Compared with the postal-group, more participants in the Internet-group perceived they were much or very much improved (40.9% (43/105) vs 26.5% (30/113), P = 0.01), reported reduced usage of incontinence aids (59.5% (47/79) vs 41.4% (34/82), P = 0.02) and were satisfied with the treatment programme (84.8% (89/105) vs 62.9% (71/113), P < 0.001). Health-specific QoL improved in the Internet-group (mean change 3.7 (10.9), P = 0.001), but not in the postal-group (1.9 (13.0), P = 0.13). Overall, 69.8% (120/172) of participants reported complete lack of leakage or reduced number of leakage episodes by >50%.

Conclusions Concerning primary outcomes, treatment effects were similar between groups whereas for secondary outcomes the Internet-based treatment was more effective. Internet-based treatment for SUI is a new, promising treatment alternative.

Keyword
stress urinary incontinence, randomised controlled study, Internet, pelvic floor muscle training, self-management, cognitive behavioural therapy
National Category
Urology and Nephrology
Identifiers
urn:nbn:se:umu:diva-79227 (URN)10.1111/j.1464-410X.2012.11713.x (DOI)000321429800018 ()
Projects
tät.nu
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare
Available from: 2013-09-16 Created: 2013-08-13 Last updated: 2017-12-06Bibliographically approved
2. Stress urinary incontinence and quality of life: a reliability study of a condition-specific instrument in paper and web-based versions
Open this publication in new window or tab >>Stress urinary incontinence and quality of life: a reliability study of a condition-specific instrument in paper and web-based versions
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2012 (English)In: Neurourology and Urodynamics, ISSN 0733-2467, E-ISSN 1520-6777, Vol. 31, no 8, 1242-1246 p.Article in journal (Refereed) Published
Abstract [en]

Aims Quality of life is an important outcome measure in studies of urinary incontinence. Electronic collection of data has several advantages. We examined the reliability of the Swedish version of the highly recommended condition-specific quality of life questionnaire International Consultation on Incontinence Modular Questionnaire-Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTSqol), in paper and web-based formats in women with stress urinary incontinence.

Methods Women aged 1870 years, with stress urinary incontinence at least once weekly, were recruited via the project's website and answered the ICIQ-LUTSqol questionnaire. Respondents completed either the paper version twice (n?=?78), or paper and web-based versions once each (n?=?54). The ICIQ validation protocol was followed.

Results The mean interval between answers was 18.1 (SD?=?3.1) days in the paper versus paper setting and 15.0 (SD?=?7.8) days in the paper versus web-based setting. Internal consistency was excellent, with Cronbach's alpha coefficients of 0.87 for the paper version and 0.86 for the web-based version. There was a high degree of agreement of overall scores with intraclass correlations in the paper versus paper and paper versus web-based settings: 0.95 (P?<?0.001) and 0.92 (P?<?0.001), respectively. The mean of each individual item's weighted kappa value was 0.61 in both settings.

Conclusions The questionnaire is reliable in women with stress urinary incontinence, and it can be used in either a paper or a web-based version.

Neurourol. Urodynam. 31:12421246, 2012. (C) 2012 Wiley Periodicals, Inc.

Place, publisher, year, edition, pages
Wiley-Blackwell, 2012
Keyword
Internet, quality of life, stress urinary incontinence, validation study
National Category
Urology and Nephrology
Identifiers
urn:nbn:se:umu:diva-61768 (URN)10.1002/nau.22240 (DOI)000310062700009 ()
Projects
tät.nu
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare
Available from: 2012-11-27 Created: 2012-11-26 Last updated: 2017-12-07Bibliographically approved
3. Women's Experiences of Internet-Based or Postal Treatment for Stress Urinary Incontinence
Open this publication in new window or tab >>Women's Experiences of Internet-Based or Postal Treatment for Stress Urinary Incontinence
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2014 (English)In: Qualitative Health Research, ISSN 1049-7323, E-ISSN 1552-7557, Vol. 24, no 4, 484-493 p.Article in journal (Refereed) Published
Abstract [en]

Stress urinary incontinence is common and sometimes embarrassing. New, simple, and easily accessible treatments are needed. We telephone interviewed 21 women who participated in a randomized controlled study comparing two treatment programs based on instructions for pelvic floor muscle training. One program was Internet-based and included email support by a urotherapist; the other was sent by post. There was no face-to-face contact in either program. Our main aim was to explore the women's experiences of the Internet-based treatment. Grounded theory analysis revealed three categories: hidden but present, at a distance but close, and by myself but not alone. These were incorporated in a core category: acknowledged but not exposed. The leakage was often a well-hidden secret, but the study treatments lowered the barrier for seeking care. In the Internet group, a supportive patient-provider relationship developed despite the lack of face-to-face contact. Internet-based treatment programs can increase access to care and empower women.

Keyword
grounded theory, health seeking, Internet, interviews, relationships, self-care, women's health
National Category
Family Medicine
Identifiers
urn:nbn:se:umu:diva-90457 (URN)10.1177/1049732314524486 (DOI)000333655200004 ()
Available from: 2014-07-07 Created: 2014-06-23 Last updated: 2017-12-05Bibliographically approved
4. Cost-effectiveness of an Internet-based treatment program for stress urinary incontinence
Open this publication in new window or tab >>Cost-effectiveness of an Internet-based treatment program for stress urinary incontinence
2015 (English)In: Neurourology and Urodynamics, ISSN 0733-2467, E-ISSN 1520-6777, Vol. 34, no 3, 244-250 p.Article in journal (Refereed) Published
Abstract [en]

AIMS: To perform a deterministic cost-utility analysis, from a 1-year societal perspective, of two treatment programs for stress urinary incontinence (SUI) without face-to-face contact: one Internet-based and one sent by post. The treatments were compared with each other and with no treatment.

METHODS: We performed this economic evaluation alongside a randomized controlled trial. The study included 250 women aged 18-70, with SUI ≥ 1 time/week, who were randomized to 3 months of pelvic floor muscle training via either an Internet-based program including e-mail support from an urotherapist (n = 124) or a program sent by post (n = 126). Recruitment was web-based, and participants were self-assessed with validated questionnaires and 2-day bladder diaries, supplemented by a telephone interview with a urotherapist. Treatment costs were continuously registered. Data on participants' time for training, incontinence aids, and laundry were collected at baseline, 4 months, and 1 year. We also measured quality of life with the condition-specific questionnaire ICIQ-LUTSqol, and calculated the quality-adjusted life-years (QALYs) gained. Baseline data remained unchanged for the no treatment option. Sensitivity analysis was performed.

RESULTS: Compared to the postal program, the extra cost per QALY for the Internet-based program ranged from 200€ to 7,253€, indicating greater QALY-gains at similar or slightly higher costs. Compared to no treatment, the extra cost per QALY for the Internet-based program ranged from 10,022€ to 38,921€, indicating greater QALY-gains at higher, but probably acceptable costs.

CONCLUSION: An Internet-based treatment for SUI is a new, cost-effective treatment alternative.

Place, publisher, year, edition, pages
John Wiley & Sons, 2015
Keyword
cost-effectiveness, Internet, pelvic floor muscle training, self-management, stress urinary incontinence
National Category
Medical and Health Sciences Family Medicine
Research subject
Family Medicine
Identifiers
urn:nbn:se:umu:diva-84401 (URN)10.1002/nau.22540 (DOI)000352152900008 ()24347521 (PubMedID)
Available from: 2014-01-05 Created: 2014-01-05 Last updated: 2017-12-06Bibliographically approved

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