Copyright © Taylor & Francis Group, LLC ISSN: 0092-623X print
DOI: 10.1080/00926230600835361
Treating Erectile Dysfunction through
Electronic Consultation: A Pilot Study
P. M. LEUSINK
Department of Sexology Groene Hart Ziekenhuis, Gouda, The Netherlands E. AARTS
Faculty of Natural Sciences, Mathematics and Computing Science, Department of Science Communication, Nijmegen, The Netherlands
We investigated a group of men suffering from electric dysfunction (ED) who visited the website www.erectie.info and who had re-ceived consultation through the Internet (n= 219). We measured the treatment’s effectiveness using the 5-item version of the Interna-tional Index of Erectile Function (IIEF-5; Rosen et al., 1996; Rosen, Cappelleri, Smith, Lipsky, & Pena, 1999) and a global assessment question (GAQ). We investigated the motives and characteristics of the users of electronics consultation using a questionnaire. Af-ter a few months, the consultation group showed a considerably higher IIEF-5 score compared with their baseline score. Eighty-one percent replied in the affirmative to the GAQ. E-consultation is likely to be effective when treating ED, especially among men who find the medium convenient and for men who experience much embarrassment.
Within Europe, the Netherlands has the largest number of Internet users, after the Scandinavian countries (Raad voor de Volksgezondheid en Zorg, 2002). Some 70% of Dutch users of the Internet (approximately 6 million Dutch people) would prefer to be able to contact their family doctor or specialist through the Internet. In order to safeguard the quality and safety of such contacts, the Royal Netherlands Medical Association has recently drawn up guidelines (KNMG, 2005). There are few investigations into the effectiveness of electronic consultation (e-consultation).
Controlled studies of e-consultations, without any doctor-patient physi-cal interaction and without face-to-face contact, have shown that they can be
Address correspondence to P. M. Leusink, Department of Sexology, Groene Hart Zieken-huis, Post Box 1098, 2800 BB Gouda, The Netherlands. E-mail: [email protected]
effective for several complaints treatable by behavior therapy (Andersson, Stromgren, Str¨om, & Lyttkens, 2002; Carlbring, Westling, Ljungstrand, Ekselius, & Andersson, 2001; Christensen, Griffiths, & Jorm, 2004; Lange et al., 2003; Lange, van de Ven, Schrieken, & Emmelkamp, 2001; Str¨om, Petterson, & Andersson, 2000). In Europe, there are no known investigations into e-consultation in which medication is also provided. One study was car-ried out in the United States into the supplying of sildenafil through the Internet for the treatment of erectile dysfunction (ED; Jones, 2001). How-ever, this study only carried out a follow-up of those patients who asked for a repeat prescription through the website. Moreover, this follow-up did not consist of standardized questions, which made measurements before and after treatment impossible.
ED affects 16% of Dutch males over 18 years of age; only 10.4% of those men suffering from ED receive treatment (de Boer et al., 2004). This may be due to factors on the part of both doctors and patients. Because of the anonymity that it provides, Internet treatment could well reach ED sufferers who are too embarrassed to seek help. Theoretically, e-consultation could be a good form of ED treatment because, according to the Dutch Guideline for the Diagnosis and Treatment of Erectile Disorders, physical examinations or laboratory investigations are Saldom required to treat ED (Meuleman, Drenth, van Driel & Lycklama a Nijeholt, 1995; Meuleman et al., 2001). Our study aims to answer the following questions: (a) does e-consultation effectively improve erectile function and (b) what are the characteristics and motives of the men who suffer from ED and who use e-consultation.
METHODS
The group under investigation consisted of men who had used the e-consultation on the website Erectie.info (http://www.erectie.info) during March 1, 2003–December 1, 2003. In addition to information about ED, this website also offers e-consultation, which consists of a questionnaire contain-ing twenty questions about medical history and sexological complaints. After the consultation, a prescription may, if necessary, be faxed by a doctor to a dispensing pharmacist. In some cases, basic exercises based on Masters & Johnson’s are provided, especially if there is a psychogenic or mixed cause for ED. If necessary, the consultant recommends sex therapy or psychother-apy, providing specialist contact information.
The choice of specific pharmaceutical treatment is made by the patient himself after he has been told the characteristics of the three PDE5 inhibitors. The patient receives information through e-mail on how to use his chosen medication and is requested to present a letter to his family doctor. The letter states the diagnosis, the phosphodiesterase 5 inhibitor prescribed by the
consultant, and the consultant’s correspondence address. The family doctor does not play any further role in the e-consultation.
In January 2004, we sent the group of patients an e-mail inviting them to complete an electronic questionnaire. Through the informed consent pro-vided during their first request for a consultation, the patients had already agreed to their e-mail addresses being used for the purpose of scientific research.
We assessed the e-consultation’s effectiveness using the difference in overall scores of the 5-item version of the International Index of Erectile Function (IIEF-5; Rosen, et al., 1997; Rosen, Cappelleri, Smith, Lipsky, & Pena, 1999).
Four out of the five questions concern erectile capability; the remaining question addresses sexual contentment. Scores for each question may vary from 0 to 5. A low overall score indicates a greater degree of ED. The IIEF-5 is part of the question form to be completed at the first consultation (before treatment) and was part of the posttreatment questionnaire. We assessed effectiveness was using a global assessment question (“Have your erections become better as a result of the treatment on www.erectie.info?”).
The questionnaire also provided an exploratory study into the character-istics and motives of the group under investigation. Charactercharacter-istics concern-ing disorders, medication, and age could be inferred from the question form completed by the patient at his first consultation. We sent out two reminders by e-mail during January–February 2004.
STATISTICAL ANALYSIS
We use binary logistic regression with a Wald statistic of 0.95 and df = 1 (Hosmer & Lemeshow, 1989) to investigate a possible relationship between the number of contacts with the website physician and the patient’s response. In order to compare the results scored on the IIEF-5 before and (in the event) after treatment on the website, we used t-test for paired observations in SPSS (11.5 for Windows). We considered a difference statistically significant for p < 0.05.
RESULTS
The group under investigation consisted of 219 men using e-consultation. Of those, 98 responded to the questionnaire (response rate 45%). The re-spondents from the consultation group differed from the nonrere-spondents regarding characteristics of treatment. We were able to reject the null hy-pothesis that the number of contacts with the website physician did not affect patient responses. A binary logistic regression showed a significantly
positive rise of 0.484 ( p = 0.003). In other words, more contacts resulted in a greater likelihood for us to obtain responses form participants the consul-tation group.
Those patients who used of website consultation showed on average considerable progress with respect to the IIEF-5, compared with their base-line values. The majority of the respondents (81%) from the consultation group replied in the affirmative to the question of whether their erections had become better as a result of their website treatment (GAQ). The re-spondents who reacted positively to the GAQ showed more progress on the IIEF-5 than did those respondents who said that their erections had not be-come better as a result of their treatment. Even so, the IIEF-5 for this latter group, too, improved significantly.
With regard to the second research question about the users’ motives and characteristics, most respondents mentioned as the chief reason for their having resorted to a consultation through the Internet that it was an easy or convenient way to ask for a consultation. Many respondents also selected the motive that they felt embarrassed. Nearly one third of the respondents from the consultation group had sought help with their erection problem prior to the website consultation, 86% (n= 24) of whom had seen their general practitioner.
In contrast, only 9 respondents (9%) sought follow-up help for their erection problem after their consultation on www.erectie.info. Only 6 re-spondents (6%) informed their doctor of their website consultation through the letter that had been sent along as an appendix with the e-mail.
DISCUSSION
We deduce from the increase of the IIEF-5 score and the largely positive replies to the GAQ among the consultation group that the website consulta-tion appears to have been effective in improving erectile funcconsulta-tion. However, there are some limitations. First, it should be taken into account that there is no randomized control group. We therefore do not know whether the erec-tion would have spontaneously improved with the passing of time or with the use of self-sought medication. Second, the self-selection of participants means that these conclusions only apply to this group of men who used the Internet to seek help. Third, we also encountered a degree of self-selection among the respondents. Within the consultation group, the respondents dif-fered from the nonrespondents by the higher frequency with which they requested prescriptions. This raises the question of whether the measure of efficacy that we have found is not, in fact, a measure of the effectiveness pharmaceutical treatment rather than of the website consultation. Even so, treatment whereby medication is prescribed can still be said to be effec-tive, even though it has been supplied through e-consultation. The present
study does not allow any statements regarding the effectiveness of the e-consultation compared with a personal, face-to-face e-consultation.
The characteristics of the present population under investigation fairly resemble those of the participants in the Enigma study (de Boer, et al., 2004). The use of Internet, which is more popular among younger people, probably accounts for the striking difference in ages of the participants (Centraal Bu-reau voor de Statistiek, 2004). One could, moreover, argue that the Internet offers assistance to young men suffering from ED. Apart from differences that cannot be explained—such as a higher percentage of disorders like anxiety and depression or the greater prevalence of drug use among the respon-dents suffering from ED in the Enigma study—there is another difference between the present study and the Enigma study. Many men suffering from ED also suffer from a chronic disorder and thus contact a physician regularly. The possible negative effect on erectile function is well known for the most frequently mentioned physical disorders in the two studies, cardiovascular diseases and diabetes. The Enigma study shows that a only 10.4% of the patients suffering from ED received help. In contrast, our study revealed that such patients apparently turn to the Internet. The general practitioner does not always bring relief, as apparently demonstrated by the 29% of the re-spondents who did seek help before they resorted to a website consultation. Over half of those seeking e-consultation had been suffering from ED for over 1 year, whereas a third had a chronic disorder or used chronic medi-cation. Nevertheless, the problem was not discussed with the physician, and the patients still turned to the website for help.
It is the consensus opinion of Dutch urologists, family doctors, and sex-ologists, that ED only requires physical examination on specific medical grounds (Meuleman et al., 1995). When a questionnaire indicates somatic complaints (pointing to diabetes or angina pectoris, for instance), physical examination consultant refers a patient to his family doctor. In other words, it is not always necessary for a consultant to carry out a physical examina-tion prior to issuing a prescripexamina-tion, a point where Dutch practice differs from European and U.S practice. The Koninklijke Maatschappij ter Bevordering van de Geneeskunst (KNMG, or the Royal Netherlands Medical Association, the umbrella organization of physicians in the Netherlands that particularly occupies itself with medical-ethical affairs) has finally made a case for not requiring a face-to-face meeting before an e-consultation. This in particu-lar helps the Internet retain its features of anonymity and easy accessibility, which are of great importance to people who feel ashamed of their sexual problems.
The ultimate goal of the website is for men to personally approach a general practitioner or a sexologist to deal with their erection problem. This goal does not seem to have been achieved, considering the very small number of men who sought follow-up help and the small number of men who actually sent or gave the letter to their general practitioner. This may
well be explained by the patients’ motives. Most respondents responded that they found the e-consulation an easy, convenient way of addressing their problem. Embarrassment may still prevent patients from seeking further help. And the fact that online treatment has proved to be effective may also imply that people will continue to opt for an e-consultation.
CONCLUSION
We conclude provisionally from this first European study of distributing drugs through the Internet that the men who went through an e-consultation on the website www.Erectie.info likely benefited from the treatment. Respondents were men who find consultation through the Internet handy and whose em-barrassment talking about their erection problem prevents them from seeking personal contact with a physician. Our study also included men whose doc-tors did not address their ED or offer a solution for it. The existence of an effective alternative like e-consultation is thus important, especially for these last two groups.
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