Bladder diaries, recommended for use in lower urinary tract symptoms (LUTS) clinical guidelines, are now becoming available in the form of Apps for self-completion. To be clinically useful, health related Apps require appealing layouts, ease of navigation and data content sufficient to support diagnosis and management strategies. Electronic diaries offer potential benefits over paper diaries including the option to export, share data with physicians, and potential ease of use. We found a lack of standardized analyses of current electronic bladder diary Apps. Therefore, we used the APPLICATIONS scoring system, which aims to provide unbiased and objective assessment of Apps and generates a quantitative score. Higher scores represent better quality Apps assessing 10 domains (Figure 1). Hypothesis: Electronic bladder diary Apps will meet moderate framework analysis scores and will allow tracking for 3 or more days to meet clinical guideline recommendations. Aim: to conduct a formal framework analysis review of application-based electronic bladder diaries for tracking lower urinary tract symptoms (LUTS) to evaluate their suitability for clinical decision making.

An online search identified English language bladder diary Apps. This framework analysis assessed the domains of: accuracy, functionality, and features using a modified version of the validated APPLICATIONS Scoring System used for App evaluation. The search used a combination of the terms: bladder, voiding, tracker, diary, incontinence. The APPLICATIONS system scores points for defined parameters including accuracy, comprehensiveness, subjective presentation, navigation ease, and security, to provide a score from 0-19. Apps were excluded if they could not track LUTS for at least 3 days, required a medical device to use the App, or indicated they were for use by medical professionals only. 

In October 2023, we downloaded these apps and modified the APPLICATIONS scoring system to meet the needs of apps looking at LUTS (Figure 1). Apps were assessed by 4 independent reviewers and scores were averaged (Figure 2). Apps have been anonymized in Figure 2.

N=13 Apps were identified. 3 Apps were excluded, leaving N=10 Apps with the ability to track LUTS for 3 or more days. The Apps have been available to the public for a median of 3.66 years (range 1-11 yrs). No Apps had multi-language capabilities in addition to English; 90% were freely available. All Apps scored poorly. The two with the highest scores were 9.75/19. The mean score was 7.6 (range 9.75 - 5.25). Identified deficiencies were: Only 20% had health professional oversight; 10% had literature cited; 3 had health education incorporated, and 1 included a medical disclaimer. None had combined bowel/bladder tracking. 70% had the ability to export data. Only 50% had password protection and 40% had the ability to create a custom reminder for data entry.

For the publicly available electronic diaries assessed, domains identified with poor compliance included difficult navigation systems and a lack of associated medical literature and education. A lack of multi-language capability was identified, which limits equitable usability. Importantly, the data security domain frequently did not meet current recommendations for health data collection and transfer. For example, in half of the Apps, no password or personal security identifier was required, allowing any person to open, enter, or change health data. Given that one benefit of electronic diary use is the ability to transfer data to electronic medical records, further attention to details of data acquisition and transfer are indicated.

The majority of bladder tracking Apps are unsuited to clinical use based on low scores using the modified APPLICATIONS scoring system, with most applications being poorly designed and lacking important domains. Our findings provide actionable changes that can be incorporated into future App development to meet patient demand for this form of data collection while conforming to clinical guidelines. This will enable Apps to be of higher quality and maximize their utility for diagnosis and management of LUTS.

Continence 12S (2024) 101356
DOI: 10.1016/j.cont.2024.101356