Hypothesis / aims of study
Overactive bladder (OAB) is one of the most common lower urinary tract symptoms, with urinary urgency as an essential symptom. It is one of the most common diseases that afflict many elderly people, increasing with age and strongly contributing to a decreased quality of life (QOL).
In a recent epidemiological study of 10 million patients in Japan aged 40 years and older, the prevalence of OAB is estimated to be 12.4%, and since the prevalence tends to increase with age, the number of patients is expected to further increase with the aging of the population(1).
The Japanese guidelines for the treatment of OAB [3rd edition] recommend behavioral therapy as the primary treatment method because there is little risk. However, many patients do not partake in behavioral therapy.
The "USAPO" (You-Support) smartphone personal health record (PHR) application provided by Welby, which is also included in the second edition of the Guidelines for Nocturia, records diet, alcohol and caffeine intake on the application, provides advice on lifestyle, and offers comprehensive behavioral therapy, which can help patients to improve their urinary frequency within a short time in an outpatient setting. We hypothesized that this would improve the effectiveness of outpatient behavioral therapy, for which short-term guidance alone is insufficient.
In this study, we retrospectively evaluated the estimated salt intake, alcohol and caffeine intake, and the change in OABSS scores before and after the use of "USAPO" in patients who used it.
Study design, materials and methods
All scores and information recorded in USAPO were used. The protocol for this study passed the ethical review board of Chiba university.
Among 1507 patients with a chief complaint of urinary urgency and overactive bladder who used the USAPO smartphone application, 267 who entered their OABSS score into the application at least twice (between 2019-2021) were analyzed. For dietary records, 158 subjects with three dietary records were included, they all had traceable OABSS. Subjects who reported 0 g salt content were excluded.
The primary endpoint was an examination of the change in OABSS scores before and after behavioral therapy in post-usage patients. The secondary endpoint was an examination of age, gender, BMI, height, OAB severity, and number of OABSS recordings in the responder group as background factors.
Data were extracted from the smartphone application U-Support (Welby, Tokyo, Japan).
Results
Patient characteristics are shown in Figure #1.
The OABSS score of 102 and 56 patients were defined as responders and non-responders, respectively, when the change in OABSS score improved by at least 1 point, and 144 and 14 patients, respectively, when it improved by at least 3 points (MCIC).
Characteristics of the responder group included predominantly males, older age, and higher OAB severity.
The median number of days of analysis, was 4 (3,15) days; and that of OABSS recording institutions, was 11.5 (4,8) days, concentrated within 2 weeks.
With regard to salt, caffeine, and alcohol intake, the group was classified as responder (n=56) if the OABBS score decreased by one point for at least one of the four categories, and otherwise classified as non-responder (n=102). With regard to salt intake, the median values were 4.6 g (3.6-6.5 g) and 4.8 g (3.0-6.0 g) for the responders and non-responders, respectively. The Wilcoxon rank sum test showed no statistically significant difference (p=0.6997). For caffeine intake, the median was 27.9 mg (0-77.4 mg) and 43.2 mg (27.0-93.3 mg), respectively. The Wilcoxon rank sum test showed statistically higher caffeine intake for responders (p=0.03). For alcohol intake, median values were 0 mL (0-9.2 mL) and 0mL (0-4.5 mL), respectively; the Wilcoxon rank sum test could not be conducted due to limited responses.
When classified as non-responders and responders with decrease of 3 or more points for at least one of the four categories, the former had 144 and the latter had 14 patients. With regard to salt intake, the median values were 4.5 g (3.0-6.0 g) and 5.4 g (4.4-6.2 g) for non-responders and responders , respectively. The Wilcoxon rank sum test showed no statistically significant difference (p=0.17). For caffeine intake, median values were 34.3 mg (0-81 mg) and 42.0 mg (28.3-129.9 mg), respectively. The Wilcoxon rank sum test showed no statistically significant difference at (p=0.20). For alcohol intake, the median values were 0 mL (0-8.7 mL) and 0 mg mL (0-3.9 mL), respectively. There were not enough entries to perform.
Interpretation of results
The "USAPO" PHR application provided by Welby Corporation provides feedback to patients on their salt intake, caffeine intake, and alcohol intake by having them enter their dietary records and OABSS into the application, thereby encouraging behavioral changes in their eating and drinking habits, with the goal of improving symptoms of overactive bladder and nocturnal polyuria(Figure #2).
In this study, there was no improvement in OABSS with dietary recording. Possible reasons for this include the following: improvement of OABSS scores is difficult to achieve with diet records and diet therapy alone, the evaluation period for diet records was short, and many patients only recorded their diet and did not receive medical examinations or feedback from physicians.
On the other hand, this study has revealed what kind of patient population should be approached to promote lifestyle improvement through the application.
Regarding the number of times the OABSS was recorded, younger patients had more minor cases, while whereas older patients had more severe cases. The results also showed that the more severely ill patients had a lower number of recordings.
Responders in the OABSS were more likely to be elderly, male, and patients with higher OABSS severity.
The use of a smartphone application in this study undeniably lowered the age range of those who were described. In this study, it was the elderly who were more likely to have OABSS severity, and the use of the application was required for life transformation, however, the hurdle for using the application is higher for the elderly, which is an issue for the future.
However, it is expected that the hurdle for smartphone application use will be eliminated in the future, considering that the age group of smartphone users will become older.
Further improvement in behavioral changes can be expected if physicians approach such an age group with recommending the use of PHR applications.
PHR applications are believed to promote patient-centered care as a behavioral change tool.
In fact, several studies have been conducted using mobile PHRs, it has been reported that mobile PHR intervention groups have prolonged survival rates(2), and in patients with arrhythmia and heart failure in regular outpatient visits, those with PHR intervention have improved life outcomes (compared to those without) due to earlier detection of arrhythmias(3).
There have been no previous studies investigating the behavioral changes after using smartphone applications to record OABSS scores or dietary records, and the clarification of the approach layer in the present study is a significant development for future prospective studies. We are considering developing analyses that account for additional items such as underlying disease, current medication status, cognitive function, and urinary and drinking water records. In addition, patients should not only record their own information, but also provide feedback from their physicians, which may lead to improved lifestyle changes and treatment of OAB and nocturnal polyuria.