Unwilling Versus Unable: Therapy Compliance And Patient Engagement With Remote Therapy Monitoring

Patient compliance with treatment is at the forefront of every healthcare professional’s mind as noncompliance can lead to worsening conditions and increased healthcare costs.¹ But are we thinking about compliance/non-compliance correctly? 

Frank Aviles Jr., PT, CWS, FACCWS, CLT, posed a provocative thought in Today’s Wound Clinic on whether most patients were truly noncompliant or if they simply lack the necessary resources for compliance.² Taken further, should we stop grouping all noncompliant patients and start thinking of them as unwilling versus unable?

Over the past 2 years, we have endeavored to better understand what makes some patients compliant and others not. In an internal retrospective evaluation of over 1,800 patients, we found an increase in the average negative pressure wound therapy (NPWT) usage was associated with an increased reduction in wound volume and area (unpublished data, 2017). From this, we formulated a hypothesis. What if patient adherence to NPWT could be influenced through active patient engagement? This led to the development of a proprietary remote therapy monitoring (RTM) system (iOn Progress^™ Remote Therapy Monitoring; KCI, an Acelity Company, San Antonio, TX) and Care Network for use with the NPWT units for patients in the home care setting. The premise was that maximizing the daily use of NPWT would result in better clinical and ultimately economic outcomes. 

The RTM system works in conjunction with the NPWT device (ACTIV.A.C.^™ Therapy System; KCI, an Acelity Company) to collect and transmit therapy usage information. The Care Network consists of Virtual Therapy Specialists (VTSs) who monitor the NPWT use data and engage with the patient. A relationship is initiated with the patient through the welcome call. Here, the VTS provides education on NPWT and the monitoring program and answers any initial questions the patient might have regarding therapy. More importantly, the VTS establishes a rapport with the patient, seeking to understand each patient’s “goal” beyond healing. This becomes a shared objective for the patient and the VTS to overcome the obstacles to staying adherent to therapy.

Through RTM, we’ve engaged with over 10,000 patients and have learned that patients are willing to be adherent to their care plans, but often lack the resources, education or support needed to be compliant. Therapy obstacles can be small and obvious, like a leak alarm that kept a patient up all night, or impossible to predict, such as a patient’s pet tapping the touch screen and changing the settings.  

Some issues can be resolved in a single interaction with a patient, while others may persist throughout therapy, requiring several interactions. On average, a patient requires 5 to 6 engagements per period of NPWT use. However, not every patient is willing to engage. In cases of consistent noncompliance, an escalation to the patient’s caregiver or treating clinician to discuss therapy usage or barriers to therapy compliance occurs, though this is not the norm. An analysis of 4,450 RTM patients revealed that during the course of therapy, 83.1% of the patients required at least one low compliance call and 31.8% had an escalation call made to their treating clinician.³ 

Since its implementation, RTM has been shown to help increase patient compliance to NPWT. In the first findings from 198 RTM patients, therapy usage increased the day following a low compliance call in 70.3% of the patients contacted.⁴ An analysis of 4,450 RTM patients revealed that RTM patient engagement resulted in 18.6 hours of mean therapy time the day following patient engagement with increased therapy usage in 84.1% of patients contacted.³ A retrospective analysis of 2,072 patients compared those who received RTM (n=1,065) to those who did not (n=1,007) between May 2018 and October 2018.⁵ On average, patients who received RTM used their NPWT 2.6 hours more each day (P < .0001) than patients without RTM. Additionally, 93.6% of RTM patients used their therapy more than 16 hours a day compared to 75.3% of the non-RTM patients.⁵ 

Patient engagement drives therapy compliance, which in turn can contribute to improved wound outcomes and reduced wound care costs. A study of 510 RTM patients reported that as compliance to NPWT increased, the rate of daily wound volume and area reduction also increased.⁶ This result was confirmed in the 2,072 patient retrospective study, where increased daily rate of wound volume and area reduction was observed in RTM patients.⁵ Patients who received RTM displayed a trend toward lower median number of therapy days (27 vs. 29 days, P = .0581).⁵ A significant reduction length of therapy was also observed in a 90-day wound-related cost study of 431 patients (27 days RTM vs. 32 days without RTM, P = .0394).⁷ Subsequently, wound-related costs were reduced for RTM patients ($10,515 vs. $12,158 non-RTM). When the wound-related costs were further examined, RTM patients had reduced costs compared to non-RTM patients in both NPWT and non-NPWT costs ($3,622 vs. $3,856 NPWT; $6,893 vs. $8,302 non-NPWT).⁷

Summary

The implementation of RTM into the NPWT care plan has revealed that we should be a bit more optimistic about a patient’s intentions. The ability to engage with patients to better understand their obstacles and help them find solutions may lead to improved clinical and economic outcomes. 

Leah Griffin is Director of Health Economics and Outcomes Research at KCI, an Acelity Company, San Antonio, TX.

Chris Sandroussi is the Senior Director of Strategic Planning and Business Development at KCI, an Acelity Company, San Antonio, TX.

1. Chisholm-Burns MA, Spivey CA. The 'cost' of medication nonadherence: consequences we cannot afford to accept. J Am Pharm Assoc. 2012;52(6):823-826.

2. Aviles F Jr. Throw everything at diabetes … but don't throw in the towel. Today's Wound Clinic. 2019;13(2):20-21.

3. Griffin L, Leyva L. A large cohort study evaluating adherence to negative pressure wound therapy with a remote therapy monitoring program. Poster presented at: SAWC Spring; May 7-11, 2019; San Antonio, TX.

4. Griffin L, Casillas LL. Evaluating the impact of a patient-centered remote monitoring program on adherence to negative pressure wound therapy. Wounds. 2018;30(3):E29-E31.

5. Griffin L, Leyva L. Comparison of therapy adherence and wound outcomes of patients receiving negative pressure therapy with or without remote therapy monitoring. Poster presented at: SAWC Spring 2019; May 7-11, 2019: San Antonio, TX.

6. Griffin L, Casillas LL. A patient-centered remote therapy monitoring program focusing on increased adherence to wound therapy: a large cohort study. Wounds. 2018;30(8):E81-E83.

7. Griffin L, Sifuentes MM. Retrospective payor claims analysis of patients receiving outpatient negative pressure wound therapy with remote therapy monitoring. Wounds. 2019;31(2):E9-E11.