Transcript References

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
1
Outline

Introduction

Methods

Preparation of health educational materials

Management of symptom flares

Participants and protocol

Experimental design

Statistical analysis

Results

Discussions

Conclusion

Future Works
2
Introduction
3
Behavior Change

Acquisition 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 diseases

Clearly identifying the active components when
designing, evaluating, and reporting interventions is
important for understanding principles of behavior
change (Michie & Johnson 2012)
4
Behavior Change Intervention

Regarding 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 topic

The effectiveness of Internet-based interventions was enhanced
by additional communicating techniques, especially the short
message service (SMS) or text messaging (Webb et al. 2010)
5
Bladder Pain Syndrome/Interstial Cystitis
(BPS/IC)

BPS/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)
黏膜受損
6
膀胱擴張術黏膜出血情形
BPS/IC

Currently, 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)
7
SMS Intervention

When 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).
8
Motivations & Objectives

It 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.
9
Methods
10
Materials 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
Materials 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
12
imagery, such as meditation or listening to music.
Preparation of health educational materials (1)




Items 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)
13
Preparation of health educational materials (2)




Items 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)
14
Materials and Methods
ICT Intervention (1)
♥
♥
Mobile Phone
Management of
Emergent Symptom Flares
Web Service
Weekly Health
Education
♥
Pre- & Post-test
Survey by Questionnaires
15
Materials and Methods
ICT Intervention (2)
Intervention
Weekly Education
Urgent Message
Independent Variable
Demographic Information
Sex
Age
Marriage Status
Education
Disease Status
Dependent Variable
Survey
SF-36 QOL
O’Leary-Sant Index
VAS Pain & Urgency Scale
Anesthetic Bladder Volume
16
Materials and Methods
Management of symptom flares




An 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.
17
Materials and Methods
Management of Symptom Flares
Question
Internet
Mobile
phone
Base
Station
Message Center
（China Telecom）
Internet
Web
Application
手機
先喝大量水
xxxxxx
Response
Internet
Base
Station
Message Center
（China Telecom）
Web
Server
Internet
18
Event
Question
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.
Answer
19
Materials and Methods
Participants and protocol
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.
Study
40 Patients
Group
7 were excluded
40 Patients
Control
Group
8 were excluded
1. Traditional treatment
1. Traditional treatment
2. Weekly health education
2. None
3. Urgency Management
3. None
20
Materials and Methods
Experimental Paradigm (1)
Baseline
Control
W8
Group
BPS/IC
Patients
F1~F3
Study
Group
Baseline
E
R
W1
R
E
W2
F: Questionnaires
F1：SF-36
.....
R
W3
R
W4
R+F1~F3
W8
R: Weekly Health Education
E：Emergency Intervention
F2：O’Leary-Sant Symptom Index
and Problem Index Scale
F3：VAS scale of Pain & Urgency
Baseline: F1-F3 & Cytoscopic Hydrodistension
(Anesthetic Bladder Volume)
21
Materials and Methods
Experimental Paradigm (2)
 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
Materials and Methods
Experimental Paradigm (3)
SF-36 Survey
23
Materials and Methods
Experimental Paradigm (4)
O’Leary-Sant Index
附錄三
間質性膀胱炎症狀及問題指數評分表
(O’Leary-Sant Symptom Index and Problem Index Scale)(F3)
姓名：
症 狀 指 數
1.過去二個月來，您突然有強烈
的尿意感？
0 ╴ 完全沒有
1 ╴ 五次中小於一次
2 ╴ 小於一半次數
3 ╴ 約一半的次數
4 ╴ 大於一半的次數
5 ╴ 幾乎總是如此
填表日期：
問 題 指 數
過去二個月來，下列問題對您困擾
的情況。
1.白天常常小便的情況。
0 ╴ 沒有困擾
1 ╴ 很輕微困擾
2 ╴ 輕微困擾
3 ╴ 中度困擾
4 ╴ 嚴重困擾
2.過去二個月來，您有沒有在小
便之後的 2 小時內又需再次小
便？
0 ╴ 完全沒有
1 ╴ 五次中小於一次
2 ╴ 小於一半次數
3 ╴ 約一半的次數
4 ╴ 大於一半的次數
5 ╴ 幾乎總是如此
3.過去二個月來，半夜必須起床
小便的次數。
0 ╴ 沒有
1 ╴ 1次
2 ╴ 2次
3 ╴ 3次
4 ╴ 4次
5 ╴ 5 次以上
4.過去二個月來，您感覺到漲尿
或未漲尿時膀胱有疼痛或燒灼
的情況?
0 ╴ 完全沒有
2 ╴ 少數幾次
3 ╴ 常常如此
4 ╴ 次數頻繁
5 ╴ 幾乎總是如此
2.晚上起床小便的情況。
0 ╴ 沒有困擾
1 ╴ 很輕微困擾
2 ╴ 輕微困擾
3 ╴ 中度困擾
4 ╴ 嚴重困擾
VAS Pain & Urgency Scale
痛及尿急評量表(VAS scale of Pain & Urgency) (F4)
姓
名 : ╴╴╴╴╴╴╴╴
日期: ╴╴╴╴
請圈選您現在膀胱疼痛的程度（非最痛）:
膀胱疼痛
輕
0
中等
1
2
3
4
5
嚴重
6
7
8
9
10
請圈選您現在尿急的程度（非最嚴重）:
3.沒有預警徵兆就急著想小便。
0 ╴ 沒有困擾
1 ╴ 很輕微困擾
2 ╴ 輕微困擾
3 ╴ 中度困擾
4 ╴嚴重困擾
4.膀胱有燒灼感、疼痛、不舒服、
或壓力的感覺。
0 ╴ 沒有困擾
1 ╴ 很輕微困擾
2 ╴ 輕微困擾
3 ╴ 中度困擾
4 ╴ 嚴重困擾
尿急
輕
0
中等
1
2
註：
3
4
5
嚴重
6
7
8
9
10
膀胱疼痛：下腹部區域
尿急：突然之間有強烈尿意，忍不住
總分╴╴╴╴
總分╴╴╴╴╴
24
Materials and Methods
Statistic Analysis



Descriptive 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.
25
Results
26
Results
Comparison between study and control groups
Table 1. Comparison of demographic information, bladder volume, and disease severity
Variable
Control (n = 32)
Study (n = 33)
p-value
Age (Mean ± SD)
49.5±11.8
46.5±10.2
0.28
Education High School
(Chi-square) University
15 (46.9%)
19 (59.4%)
17 (53.1%)
14 (40.6%)
Yes
Marriage
(Chi-square) No
30 (93.8%)
27 (81.2%)
2 (6.2%)
6 (18.8%)
649.5±152.7
607.5±210.3
0.36
Symptom
11.34±4.78
11.33±4.14
0.99
Problem
10.47±4.71
11.55±5.03
0.38
Pain
5.16±2.58
4.91±2.78
0.71
Urgency
5.06±2.97
5.12±2.60
0.93
Bladder Volume (Mean ± SD)
O’LearySant Index
VAS Scale
0.54
0.14
27
Results
Comparison between study and control groups
Table 1 (Cont.). Comparison of SF-36 survey
Construct
Control (n = 32)
Study (n = 33)
Physical function
81.88±18.17
Role physical
(Mean ± SD)
Statistics
t
p
72.12±23.19
1.88
.06
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
Results
Comparison between study and control groups
Table 2. Comparison of SF-36 survey before and after ICT intervention
Study (n = 33)
Control (n = 32)
Pre-test
SF-36
Post-test
Improv.
Stat.
Pre-test
Post-test
Mean ± SD
Mean ± SD Mean ± SD
Phys. function
81.88±18.17
83.91±17.21
2.03±3.33
.003
72.12±23.19
81.67±19.15
Role physical
63.28±38.62
72.66±30.69
9.38±17.68
.01
48.48±44.61
Bodily pain
63.78±26.31
68.53±21.87
4.75±7.69
.002
Gen. health
54.38±22.69
57.59±18.64
3.22±7.25
Vitality
48.28±13.95
51.41±13.45
Soc. function
66.02±18.58
Role emotion
Mental health
Improv.
Mean ± SD Mean ± SD Mean ± SD
Pre- vs Post-test
Stat. Improvement
p
t
p
9.55±19.58
.01
-2.14
.04＊
74.24±37.23
25.76±48.20
.009
-1.81
.08
52.24±24.05
69.15±17.92
16.91±22.70
<.001
-2.87
.01＊
.02
38.61±23.81
52.48±23.28
13.88±22.28
.005
-2.58
.01＊
3.13±4.88
<.001
42.73±21.25
60.76±20.35
18.03±22.88
<.001
-3.61
.005*＊
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＊
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
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＊
p
29
Results
Comparison between study and control groups
Table 3. Comparison of disease severity before and after ICT intervention
Study (n = 32)
Control (n = 32)
Pre- vs Post-test
Improv. Stat. Improvement
Pre-test
Post-test
Improv.
Stat.
Pre-test
Post-test
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＊
30
Discussion
31
Discussion
Prevalence

The prevalence in Asian countries investigated based on O’LearySant 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
32
challenge (Rosenberg et al. 2007).
Discussion
Dyspareunia

Dyspareunia 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.
33
Discussion
Health Education (1)

Around 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.
34
Discussion
Health Education (2)

Certain 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).
35
Discussion
Health Education (3)

Patients 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).
36
Discussion
ICT Intervention

It 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).
37
Conclusion

In 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.
38
Future Works

The 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.
39
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48
Acknowledgements



This study was supported in part by Taichung Hospital
(Grant no. CTU100-PC-002) and National Science
Council of Taiwan (Grant no. NSC100-2410-H-166-007MY3).
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 1Management Information System and
2Healthcare Administration, Central Taiwan University of
Science and Technology, 3Department of Urology, Feng
Yuan Hospital, Ministry of Health and Welfare, Taichung
Thanks for your attention
Q/A
50