Interpretation (in light of other evidence)
Our study findings are consistent with those from two other studies concluding that app- or internet-based treatment is a cost-effective alternative when managing UI. 10,11 These studies compared an app-based approach with either a postal-based programme or postponed treatment and assessed their cost-effectiveness for stress UI in superiority trials. However, in any such evaluation, it is recommended to use a pragmatic design with a control group that reflects usual care.24 Ours is the first study to conduct such a comparison, with the results indicating that app-based treatment is a cost-effective alternative for women with UI who present to general practice.
The UI-specific follow-up costs over 12 months in our data were comparable to other studies, while our total costs were higher for both app-based treatment and care-as-usual (\euro1520 and \euro1680, respectively) compared with the data provided by Sjöström et al. (\euro547 and \euro482, respectively) and Vermeulen et al. (\euro417 and \euro87, respectively). 11, 20Although all three studies used a societal perspective, we took into consideration a broader range of costs unrelated to UI, for example loss of productivity, to conduct the societal perspective as thorough as possible.
We consider that women recruited to our trial via (social) media represent a cohort that experience barriers to seeking help from a GP. Subgroup analysis showed that for care-as-usual, the effects and costs were lower for women recruited through (social) media. These women did visit their GP to discuss treatment options just as often, but received PFMT less often (31% compared to 50%). This leads us to question if women who experience barriers to seeking help also experience barriers to accepting help when it is offered. It is conceivable that women in this cohort prefer treatment without professional involvement, which would bring the role of app-based treatment and the importance of access via (social) media to the fore.
Our subgroup analysis showed that app-based treatment for urgency UI had higher treatment effects on the impact of incontinence on daily life (0.74 IIALYs) than did care-as-usual for urgency UI (0.60 IIALYs). This may result from the accessibility of the app, which helps women to distract from feelings of urgency and to monitor the bladder training (e.g. the pee button). The treatment of urgency UI with an eHealth approach has not been studied before, precluding meaningful comparison.