YungFu Chen 陳永福 PhD Professor Department of Healthcare Administration Central Taiwan University of Science and Technology Taichung Adjunct Professor Health Services Administration China Medical University Taichung ID: 912077
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Slide1
1
Development and evaluation of an E-health system to care for patients with bladder pain syndrome/interstitial cystitis (BPS/IC)
Yung-Fu Chen (
陳永福
), Ph.D.
Professor, Department of Healthcare Administration, Central Taiwan University of Science and Technology, Taichung;
Adjunct Professor, Health Services Administration, China Medical University, Taichung
Slide2Introduction
MethodsPreparation of health educational materials
Management of symptom flares
Participants and protocolExperimental designStatistical analysisResultsDiscussionsConclusionFuture Works
Outline
2
Slide3Introduction
3
Slide4Acquisition of diseases and causes of their mortality and morbidity are related to behavior (
Parkin
, Boyd & Walker 2011)
Appropriate interventions administrated to change behavior are essential in preventing occurrences or recurrences of diseasesClearly identifying the active components when designing, evaluating, and reporting interventions is important for understanding principles of behavior change (Michie & Johnson 2012)
Behavior Change
4
Slide5Regarding the 7 behavior topics, i.e., unintentional injury, peer violence, dating/intimate partner violence (IPV), mental health, smoking, alcohol/substance use, and safe sex, patients are interested in receiving technology-based behavior interventions, including computer, Internet, social networking, mobile phone, and text messaging, on each topic (
Renney et al. 2012).
89.6% reported preference for at least one behavior topic
>50% reported preference for each specific topicThe effectiveness of Internet-based interventions was enhanced by additional communicating techniques, especially the short message service (SMS) or text messaging (Webb et al. 2010)
Behavior Change Intervention
5
Slide6BPS/IC is a poorly defined chronic bladder disease characterized by pelvic pain and urinary storage symptoms (e.g. urgency and frequency) in the absence of proven urinary infection or other definable pathological etiology (Hanno et al. 2011).
The etiologies of the disease are multifocal, whether it has originated from the bladder or other pelvic organs, or is a systematic disease is still not elucidated (
Moutzouris
& Falagas 2009)
Bladder Pain Syndrome/
Interstial
Cystitis (BPS/IC)
膀胱擴張術黏膜出血情形
黏膜受損
6
Slide7Currently, no single therapy has been found to be effective for the majority of patients (Hanno et al. 2011)
Clinically, the patients have been bothered by the disease for a long time, making them feel frustrated when receiving further therapies.Recently, environmental factors, such as dietary, physical activity, smoking and drinking behaviors, attributed substantially to the occurrence of BPS/IC based on the twin studies (Altman et al.2011;
Tunitsky et al.2012)
BPS/IC
7
Slide8When the symptoms flare up, most patients cannot follow the regiments of self-management and usually seek help by visiting the emergency department without receiving effective treatment, resulting in a waste of medical resources and degradation of quality of life.
Intervention by sending simple messages through cellular telephones and the Internet can effectively decrease blood pressure, reduce bodyweight and waist circumference, decrease blood glucose levels of obese type 2 diabetes patients, and promote safer sex and sun safety (Kim & Kim 2008; Gold et al. 2011).
SMS Intervention
8
Slide9It
is currently impossible to completely cure BPS/IC disease because of unclear pathogenesis; the treatment is mainly to alleviate symptoms or to improve QOL Treatment of BPS/IC needs a lot of healthcare resources and might cause a great burden for the country as a result of its
chronicity
; Intervention using mobile telephone and the Internet is effective in caring for patients with chronic diseases in outpatient settings. The objective is to develop an E-health system by integrating mobile telephone and the Internet to through weekly health education by asking patients to check their daily foods, activities and living habits.
Motivations & Objectives
9
Slide1010
Methods
Slide11Materials and Methods
Preparation of health educational materials (1)
Please check “Yes” or “No” based on your experience during the past week
Y
N
Item
Description
1
Do you follow the suggested diets?
2
Do you drink 1500 c.c. of water or so daily?
3
Do you eat banana, pineapple, citrus fruit, or other food containing a great amount of potassium.
4
Do you drink any beverage that contains alcohol, coffee, vinegar or tea?
5
Do you smoke?
6
Have you done mild aerobic exercise, such as yoga, hiking, jogging, etc,?
7
Do you wear cozy, loose clothes, and put on underwear mainly made of cotton?
Appendix I
: Weekly check for consolidating good habits promoted by health education
11
Slide12Materials and Methods
Preparation of health educational materials (2)
If you don’t have pain or sexual intercourse, please check “NA”, otherwise check “Y” or “N” based on your personal experience.
Y
N
NA
Item
Description
8
I have bathed the whole lower abdomen with warm water (40°C) more than once a day, each lasting for 15 min, or placed a heat pad over the abdomen to keep it warm to relieve uncomfortable symptom, especially after sexual intercourse.
9
Before or after menstruation, I used a heat pad to relieve uncomfortable symptoms.
10
I have used lubricant (ointment) to relieve uncomfortable feeling during intercourse.
11
When feeling uncomfortable during intercourse, I have changed the position to the top position to maneuver the force exerted and alleviate the pain.
12
I have washed and cleaned the vulva and keep them dry after intercourse.
13
When I experienced flare up of symptoms without definite causes, I have tried to relief the symptoms with guided imagery, such as meditation or listening to music.
12
Slide13Items 1, 3, & 4
: The BPS/IC patients are generally sensitive to foods containing vitamin C, potassium, or spices, as well as beverages containing caffeine or alcohol (Friedlander et al. 2012)
Item 2
: To reduce the recurrence of BPS/IC symptoms, the patients are encouraged to drink 1500 cm3 water daily (ICA: http://www.ichelp.org/).Item 5
: Smoking is associated with a higher risk of BPS/IC (
Tettamanti et al. 2011)
Items 6 & 7: Certain types of exercise, such as pelvic floor muscle exercise, and wearing of tight-fitting
clothes might worsen BPS/IC symptoms in some patients (
Hanno PM, et al. 2011). Yoga can be carried out as a complementary and alternative therapy for patients with anxiety (Sharma &
Haider
2013)
Preparation of health educational materials (1)
13
Slide14Items 8 & 13
: The patients are encouraged to bath their whole lower abdomen with warm water (40°C) more than once a day, each time lasting for 15 min. A heat pad can also be placed over the abdomen to relieve uncomfortable symptoms (
ICA
).Item 9: More than 80% of premenopausal IC women have symptoms flare up before, within, and after the menstrual cycle, and 35% of IC women choose heating bag to relieve pain (Peters et al. 2008). Items 10–12
: Treatment and care of the vagina and genital area might affect sexual and reproductive morbidities for women (
Hilber et al. 2010)
Item 13: Guided imagery or meditation was shown to be effective in pain and symptom management for BPS/IC patients (
Carrico et al. 2008)
Preparation of health educational materials (2)
14
Slide15Materials and Methods
ICT Intervention (1)
15
Mobile Phone
Management of
Emergent Symptom Flares
♥
Web Service
Weekly Health
Education
♥
Pre- & Post-test
Survey by Questionnaires
♥
Slide16Materials and Methods
ICT Intervention (2)
Demographic Information
Sex
Age
Marriage Status
Education
Disease Status
Anesthetic Bladder Volume
Survey
SF-36
QOL
O’Leary-
Sant
Index
VAS Pain & Urgency Scale
Intervention
Weekly Education
Urgent Message
Independent Variable
Dependent Variable
16
Slide17An SMS application was designed to provide a Q/A service to handle the cases of symptom flares.
When an emergent symptom occurred, the patient was encouraged to send a message by typing the event number (Appendix II) to the SMS server through a designated mobile phone number. The template contains the questions (symptoms) and their corresponding answers.
The SMS server responded to the question by sending its corresponding answer to guide the patient on how to relieve the symptom.
Materials and Methods
Management of symptom flares
17
Slide18Materials and Methods
Management of Symptom Flares
Mobile phone
Base Station
Internet
Message Center
（
China Telecom
）
Question
Internet
Web Application
Web
Server
手機
Base Station
Internet
Response
Internet
先喝大量水
xxxxxx
Message Center
（
China Telecom
）
18
Slide19Event
Question
Answer
1
Pain or urgency after eating specific food.
Drink a great amount of water to dilute urine concentration. If the symptom is severe and cannot be relieved, visit your physician.
2
Feeling of bladder pain is gradually deteriorating.
Bath the whole lower abdomen with warm water (40
°
C) more than once every day, each time lasting for 15 min. You can also place a heat pad over the abdomen to keep it warm. If the symptom cannot be relieved, visit your physician.
3
Pain or uncomfortable feeling caused by allergy induced by, for example, weather change or drugs.
Take anti-allergic medication for alleviation of the symptom. If the symptom has lasted for a few days without any improvements, visit your physician.
4
Pain or uncomfortable feeling of abdomen after menstruation.
You can place a heat pad over the abdomen to keep it warm to alleviate uncomfortable symptom.
5
Suspected urethral infection after intercourse.
Drink a lot of water (2000 c.c. a day) during two days after the recurrence. Take a rest by asking someone in your family to do housework for you. If the symptom lasts for a few days, visit your physician.
6
Pain after intercourse.
Bath the whole abdomen with warm water (40
°
C) for 20 min. You can also place a heat pad over the abdomen to keep it warm to alleviate uncomfortable symptom. If the symptom has lasted for a few days, visit your physician.
7
Stress caused by tedious affairs.
(1) Sit on the floor and extend your neck muscles by keeping the posture for at least 10 s. Repeat the exercise for several times. (2) Relax all of your body muscles through meditation or concentration on a certain part of your body, e.g. nose tip or fingers.
8
Others (please address your complaints)
These cases will be handled by the case manager through phone calls.
19
Slide20Materials and Methods
Participants and protocol
Traditional treatment
Weekly health education
Urgency Management
Study
Group
Control
Group
40 Patients
7 were excluded
Traditional treatment
None
None
40 Patients
8 were excluded
A total of 80 BPS/IC patients were recruited and randomly assigned to either study or control group. The study was approved by the IRB of Taichung Hospital.
20
Slide21Materials and Methods
Experimental Paradigm (1)
BPS/IC Patients
Baseline
W8
Control
Group
Study
Group
F: Questionnaires
F1
：
SF-36
F2
：
O’Leary-
Sant
Symptom Index
and Problem
Index Scale
F3
：
VAS scale of
Pain & Urgency
Baseline: F1-F3 &
Cytoscopic
Hydrodistension
(Anesthetic Bladder Volume)
Baseline
W8
R: Weekly Health Education
E
：
Emergency Intervention
F1~F3
R+F1~F3
E
E
W1 W2 W3 W4
R
R
R
R
. . . . .
21
Slide22Materials and Methods
Experimental Paradigm (2)
22
Heath management:
台灣
間質性膀胱炎關懷協會
(
Taiwan Interstitial Cystitis Association)
website (
http
://taic.hopto.org
)
.
Health Education & Management
22
Slide23Materials and Methods
Experimental Paradigm (3)
SF-36
Survey
23
Slide24Materials and Methods
Experimental Paradigm (4)
24
O’Leary-
Sant
Index
VAS Pain & Urgency Scale
Slide25Descriptive statistics were used to analyze the demographic information, disease severity and questionnaires of the recruited patients
Inferential statistics (Student’s t-test) were applied to compare the improvement of health status and symptoms between the study and control groups, as well as between pre-test and post-test for both control and study groups.
SAS (SAS Institute Inc., Cary, NC, USA) was used as the tool for statistic analysis.
Materials and Methods
Statistic Analysis
25
Slide2626
Results
Slide27Results
Comparison between study and control groups
Variable
Control
(n = 32)
Study
(n = 33)
p
-value
Age (
Mean ± SD
)
49.5
±
11.8
46.5
±
10.2
0.28
Education
(Chi-square)
High School
15 (46.9%)
19 (59.4%)
0.54
University
17 (53.1%)
14 (40.6%)
Marriage
(Chi-square)
Yes
30 (93.8%)
27 (81.2%)
0.14
No
2 (6.2%)
6 (18.8%)
Bladder Volume (
Mean ± SD
)
649.5
±
152.7
607.5
±
210.3
0.36
O’Leary-
Sant
Index
Symptom
11.34
±
4.78
11.33
±
4.14
0.99
Problem
10.47
±
4.71
11.55
±
5.03
0.38
VAS Scale
Pain
5.16
±
2.58
4.91
±
2.78
0.71
Urgency
5.06
±
2.97
5.12
±
2.60
0.93
Table 1. Comparison of demographic information, bladder volume, and disease severity
27
Slide28Results
Comparison between study and control groups
Table 1 (Cont.). Comparison of SF-36 survey
Construct
(Mean ± SD)
Control
(n = 32)
Study
(n = 33)
Statistics
t
p
Physical
function
81.88
±
18.17
72.12
±
23.19
1.88
.06
Role physical
63.28
±
38.62
48.48
±
44.61
1.43
.16
Bodily pain
63.78
±
26.31
52.24
±
24.05
1.85
.07
General health
＊
54.38
±
22.69
38.61
±
23.81
2.73
.01
Vitality
48.28
±
13.95
42.73
±
21.25
1.24
.22
Social function
66.02
±
18.58
62.88
±
25.67
0.56
.58
Role emotional
59.38
±
43.78
45.45
±
47.01
1.23
.22
Mental health
53.38
±
18.81
47.15
±
19.99
1.29
.20
28
Slide29Results
Comparison between study and control groups
Table 2. Comparison of SF-36 survey before and after ICT intervention
Control (n = 32)
Study (n = 33)
Pre-
vs
Post-test
Improvement
SF-36
Pre-test
Post-test
Improv
.
Stat.
Pre-test
Post-test
Improv
.
Stat.
Mean ± SD
Mean ± SD
Mean ± SD
p
Mean ± SD
Mean ± SD
Mean ± SD
p
t
p
Phys.
function
81.88±18.17
83.91
±
17.21
2.03
±
3.33
.003
72.12
±
23.19
81.67
±
19.15
9.55
±
19.58
.01
-2.14
.04
＊
Role physical
63.28±38.62
72.66
±
30.69
9.38
±
17.68
.01
48.48
±
44.61
74.24
±
37.23
25.76
±
48.20
.009
-1.81
.08
Bodily pain
63.78±26.31
68.53
±
21.87
4.75
±
7.69
.002
52.24
±
24.05
69.15
±
17.92
16.91
±
22.70
<.001
-2.87
.01
＊
Gen.
health
54.38±22.69
57.59
±
18.64
3.22
±
7.25
.02
38.61
±
23.81
52.48
±
23.28
13.88
±
22.28
.005
-2.58
.01
＊
Vitality
48.28±13.95
51.41
±
13.45
3.13
±
4.88
<.001
42.73
±
21.25
60.76
±
20.35
18.03
±
22.88
<.001
-3.61
.005*
＊
Soc.
function
66.02±18.58
68.75
±
17.39
2.73
±
10.40
.15
62.88
±
25.67
75.00
±
17.68
12.12
±
19.64
.005
-2.40
.02
＊
Role emotion
59.38±43.78
75.00
±
38.80
15.63
±
26.75
.005
45.45
±
47.01
77.78
±
34.02
32.32
±
3.69
<.001
-1.85
.07
Mental health
53.38±18.81
55.00
±
18.32
1.63
±
4.41
.05
47.15
±
19.99
58.18
±
17.95
11.03
±
19.55
.007
-2.66
.01
＊
29
Slide30Control (n = 32)
Study (n = 32)
Pre-
vs
Post-test
Improvement
Pre-test
Post-test
Improv
.
Stat.
Pre-test
Post-test
Improv
.
Stat.
Mean±SD
Mean±SD
Mean±SD
p
Mean±SD
Mean±SD
Mean±SD
p
t
p
O’Leary-
Sant
Index
Symptom
11.34
±
4.78
9.19
±
4.19
-2.16
±
4.12
.01
11.33
±
4.14
7.76
±
4.22
-3.58
±
5.61
.005
1.16
.25
Problem
10.47
±
4.71
5.81
±
3.80
-4.66
±
4.86
<.001
11.55
±
5.03
9.24
±
5.43
-2.30
±
6.13
.04
-1.71
.09
VAS Scale
Pain
5.16
±
2.58
5.13
±
2.42
-0.03
±
0.86
.84
4.91
±
2.78
3.03
±
1.90
-1.88
±
3.14
.005
3.21
.006
＊
Urgency
5.06
±
2.97
4.94
±
2.66
-0.13
±
0.75
.35
5.12
±
2.60
3.27
±
2.17
-1.85
±
3.03
.005
3.12
.006
＊
Results
Comparison between study and control groups
Table 3. Comparison of disease severity before and after ICT intervention
30
Slide3131
Discussion
Slide32The prevalence in Asian countries investigated based on O’Leary-
Sant
indices is lower than the European countries (0.31-0.68%) and the USA (0.57%)
0.26% in South Korea (Choe et al. 2011), 0.27% in Japan (Inoue et al. 2009), and 0.27% in Taiwan (Lee 2009) Different diagnostic criteria might be the reason causing such a difference even investigated by the same research groups (Rosenberg and Hazzard 2005, Rosenberg et al. 2007);
Rosenberg and
Hazzard (2005) presented a prevalence of 0.57% investigated based on O’Leary-
Sant indices and Pelvic pain and Urgency/Frequency (PUF) score only, while it significantly increased to 4.3% with the diagnosis based on the patient history, PUF score, patient interview, and test results of potassium sensitivity test or anesthetic bladder challenge (Rosenberg et al. 2007).
Discussion
Prevalence
32
Slide33Dyspareunia
is widely observed in female BPS/IC patients, with pain as the most important finding significantly degrading the quality of life (
Srivastava
et al. 2011). It was estimated to occur in 49–90% of the BPS/IC patients; among them, 54% intended to avoid intercourse most of the time because of the pain incurred (Wehbe et al. 2010). Female BPS/IC patients experienced a much higher level of sexual dysfunction, such as lack of interest in sex, arousal difficulties and pain, compared with the general population (
Kellogg-
Spadt & Whitmore 2006).
Pain during intercourse is a strong indicator of poor QOL for BPS/IC patients (Bogart et al. 2011
). Hence, reminding the patients to use lubricant and change position during intercourse, and to clean the vulva and bath the abdomen with warm water after intercourse, is believed to be effective in reducing pain during and after
intercourse.
Discussion
Dyspareunia
33
Slide34Around 90% of the IC/BPS patients complain sensitive to diet foods, e.g. citrus fruits, tomatoes, foods containing vitamin C, drinks, e.g. coffee, tea, carbonated and alcoholic beverages, and spicy foods (Friedlander et al. 2012,
Bassaly
and
Downes 2011). Gleason et al. (2012) reported that high caffeine intake is associated with an increase in the incidence of urgency inconsistence, which is consistent to the finding of Jura et al. Smoking is associated with a higher risk of BPS (Tettamanti et al. 2011), LUTS (Maserejian et al. 2012), and overactive bladder (Dallosso
et al. 2003) in women.
Discussion
Health Education (1)
34
Slide35Certain type of exercise, such as pelvic floor muscle exercise, and wearing of tight-fitting clothes may worsen IC/BPS symptoms in some patients (Hanno et al. 2011).
A low level of physical activity was reported to be associated with 2-3 times higher likelihood of LUTS symptoms, while high level of physical activity was found to be inversely associated with total LUTS, as well as voiding but storage symptoms in women (
Maserejian
et al. 2012). Hence, regular mild aerobic exercises, such as yoga, hiking, jogging, etc., reaching a high level of PASE (physical activity scale for the elderly) score (Washburn et al. 1999) are believed to be able to reduce IC/BPS re-occurrence.Guided imagery or meditation was demonstrated to be effective in pain and symptom management for IC/PBS patients (Carrico et al. 2008).
Discussion
Health Education (2)
35
Slide36Patients who understand the information and own the knowledge related to a disease can facilitate behavior change and disease management. SMS was shown to be effective in improving healthcare processes and outcomes (Krishna et al. 2009, Liang et al. 2011)
A good habit or behavior, such as eating, drinking, or exercising behavior, will be formed in a period ranging from 18 to 254 days with a median of 66 days for participants with good fits (
Lailly
et al. 2010).
Discussion
Health Education (3)
36
Slide37It was reported that administration of daily educational text messages with SMS improved knowledge and facilitated continuous use of oral contraceptives (
Castaño
et al. 2012, Hall et al. 2012)
In contrast, face-to-face behavior counseling accompanied with phone interviews didn’t show improved adherence of oral contraceptives among young women (Berenson & Rahman 2012). Text messaging reported to be able to deliver sensitive information, such as sexual health, in an cost-effective and efficient way might be the reason causing such a discrepancy (Lim et al. 2008).
Discussion
ICT Intervention
37
Slide38In conclusion, the E-health system supporting health education and providing SMS for self-management was demonstrated to be effective in improving QOL and alleviating symptoms for the patients
with
BPS/IC.
The Internet healthcare education is useful to consolidate patients’ healthy dietary habits and life styles, as well as to self-manage their outbreak symptoms.
Conclusion
38
Slide39The intervention based on video-tailored physical activity was reported to be feasible in terms of user preference (
Vandelanotte
and Mummery 2011).
Almost all the participants in the focus group agreed with the video-tailor intervention, and around 36% of the survey participant favored a video-based over a text-based intervention. When designing a video, most survey participants preferred a role model to present the personal physical activity. Intervention based on videos with the physicians as the main role is expected to be more effective in the treatment of chronic diseases. To build all the functions in a smartphone App is expected to be more effective in health education and disease management.
Future Works
39
Slide4040
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Slide49This study was supported in part by Taichung Hospital (Grant no. CTU100-PC-002) and National Science Council of Taiwan (Grant no. NSC100-2410-H-166-007-MY3).
This study has been accepted for publication in International Journal of Urology (
doi
: 10.1111/iju.12336)Co-authors: Ming-Huei Lee (李明輝),1,3
Huei-Ching
Wu (吳惠卿),
2,3
Departments of 1
Management Information System and 2Healthcare Administration, Central Taiwan University of Science and Technology,
3
Department of Urology,
Feng
Yuan Hospital, Ministry of Health and Welfare, Taichung
Acknowledgements
Slide5050
Thanks for your attention
Q/A