Benefits of a Patient-centered Remote Therapy Monitoring Program Focusing on Increased Adherence to Wound Therapy

Introduction. Patient nonadherence to wound care protocols may impact the efficacy of modalities, such as negative pressure wound therapy (NPWT). Recently, a remote therapy monitoring (RTM) system has been devised for use with NPWT for home care patients. Objective. Three home care patients receiving NPWT are presented to examine the relationship between patients using the RTM system and Virtual Therapy Specialists (VTS). Materials and Methods. Consent was secured from patients with either multiple comorbidities and/or wounds of varying complexity. Wounds were assessed as per their initial presentation, and all patients were discharged home with an RTM-equipped NPWT system to apply continuous subatmospheric pressure to their wound. Dressings were changed every 2 to 3 days. Results. All 3 patients were women (age range, 53–72 years), who presented with the following wound types: recalcitrant abdominal wound, acute wound following ventral hernia repair, and dehisced wound following a hysterectomy. Patient 1 was treated with RTM-equipped NPWT for a duration of 88 days (6 nonadherent vs. 82 adherent days) and was adherent to the therapy 93.2% of the time. Patient 2 was treated with RTM-equipped NPWT for a duration of 57 days (8 nonadherent vs. 49 adherent days) and was adherent to the therapy 86.0% of the time. Patient 3 was treated with RTM-equipped NPWT for a duration of 16 days (2 nonadherent vs. 14 adherent days) and was adherent to the therapy 87.5% of the time. Each patient presented with a barrier to therapy adherence (eg, lack of access to residential clinical support, technical issues, or work demands) that was managed by VTS interactions. Conclusions. In these 3 cases, RTM-equipped NPWT and the patient-centric exchanges with the VTS through adherence calls helped promote consistent usage of RTM-equipped NPWT to address the patients’ therapeutic needs and increase therapy adherence. 

Patient nonadherence to wound care protocols may impact the efficacy of modalities such as negative pressure wound therapy (NPWT).^1,2 Recently, a remote therapy monitoring (RTM) system has been devised for use with NPWT for patients receiving home care (Figure 1).² The authors present 3 cases of home care patients undergoing NPWT to examine the relationship between patients using the RTM system and Virtual Therapy Specialists (VTS).

Consent (verbal and written) was secured from patients with either multiple comorbidities and/or wounds of varying complexity (Table 1). Wounds were assessed as per their initial presentation, and all patients (n = 3) were discharged home with an RTM-equipped NPWT system (ACTIV.A.C. Therapy System with iOn PROGRESS Remote Therapy Monitoring; KCI, an Acelity Company, San Antonio, TX). If applicable, patients were administered antibiotics for infections and received selective debridement with dressing changes. The RTM-equipped NPWT treatment entailed the application of continuous subatmospheric pressure. Dressings were changed every 2 to 3 days. Acceptability of the therapy was assessed via qualitative exit surveys to document the patient experience and capture data related to user engagement.

Patient 1
A 72-year-old woman was provided with a RTM-equipped NPWT unit for at-home management of a recalcitrant abdominal wound stemming from a diagnosis of calciphylaxis. The patient received multiple weekly sodium thiosulfate infusions to treat her calciphylaxis. In this case, a complex treatment plan and a lack of accessibility to clinical support within the residential setting represented potential barriers to adherence. During the approximately 40-minute welcome call, the VTS listened to issues regarding health care accessibility; assisted the spouse with inspecting the unit, troubleshooting blockage alarms, and tubing obstruction; and provided patient education. 

Patient 1 was treated with RTM-equipped NPWT for a duration of 88 days (6 nonadherent vs. 82 adherent days [Figure 2]), had minimal issues, and was adherent to therapy 93.2% of the time (Figure 3). Figure 4 depicts the therapy graph for this patient generated by RTM-equipped NPWT, which captured trends in therapy adherence over a nearly 90-day period. Patient 1 had a total of 11 interactions with the VTS, which consisted of 1 welcome call, 5 adherence calls, 2 alarms calls, 2 customer care calls, and 1 exit survey call (Table 2). For this patient, the mean RTM-equipped NPWT usage increased 250.3% from 6.60 hours on the trigger day to 23.12 hours following the adherence call. The initial and final wound measurements for patient 1 were 4.9 cm x 17.3 cm x 0.1 cm and 3 cm x 15.5 cm x 0.1 cm, respectively, reflecting a 45.2% change in wound volume. The RTM-equipped NPWT was discontinued due to the patient reaching her therapeutic goal.

Patient 2
A 57-year-old woman developed a surgical site infection after a ventral hernia repair and was discharged home with a RTM-equipped NPWT unit. In contrast with patient 1, this patient was able to retain clinical support within the home. After the welcome call, she proactively initiated calls to the VTS in which concerns and technical issues were addressed. One call placed by the patient facilitated communication between the home health nurse and the VTS, who became a trusted and active resource. Afterwards, the nurse initiated 3 calls to the VTS requesting assistance with dressing application techniques and troubleshooting.

Patient 2 was treated with RTM-equipped NPWT for a duration of 57 days (8 nonadherent vs. 49 adherent days [Figure 2]) and was adherent to therapy 86.0% of the time (Figure 5). The therapy graph generated by RTM-equipped NPWT for patient 2 depicts the level of consistency over a nearly 60-day period, and the usage was below the recommended levels that would prompt an adherence call (Figure 6).

Patient 2 had 20 patient-VTS interactions: 1 welcome call, 3 adherence calls, 1 alarm call, 14 customer care calls, and 1 exit survey call (Table 2). For this patient, the mean RTM-equipped NPWT usage on the trigger day was 6.83 hours, which then increased 221.4% to 21.95 hours following the first adherence call. The initial and final wound measurements for patient 2 were 18 cm x 9 cm x 8 cm and 10 cm x 8 cm x 0.5 cm, respectively. This reflected a 96.9% change in wound volume. This case demonstrated a patient and home health aide nurse possessing the motivation to engage the RTM network team proactively to ensure therapy adherence.

Patient 3
A 53-year-old woman was discharged home with a RTM-equipped NPWT unit to manage a dehisced surgical wound after a hysterectomy. A potential barrier to therapy adherence was anxiety related to her demanding career. However, her determination to resume working as well as unit portability were incentives to remain adherent to RTM-equipped NPWT. The patient resumed work shortly after starting RTM-equipped NPWT, and the VTS advised her on how to manage NPWT in the workplace discreetly, which helped prevent nonadherence.

Patient 3 was treated with RTM-equipped NPWT for a duration of 16 days (2 nonadherent vs. 14 adherent days [Figure 2]) and was adherent to therapy 87.5% of the time (Figure 7). The RTM-equipped NPWT therapy graph for patient 3 mapped steady adherence during the 16-day treatment period, despite being bookended by 2 days of usage below the recommended levels (Figure 8). Patient 3 had a total of 5 VTS interactions: 1 welcome call, 3 customer care calls, and 1 exit survey call (Table 2). The initial wound measurement for this patient was 6.5 cm x 2.7 cm x 6 cm, but the final wound measurement was not recorded after the therapy.

Poor or inconsistent therapy adherence is correlated with adverse or unfavorable outcomes regardless of the effectiveness of a modality.³ Iuga and McGuire⁴ estimated that between $100 billion to $300 billion of avoidable health care costs may be ascribed to therapy nonadherence in the United States per annum, which represents 3% to 5% of total health care costs. 

Patient education, including patient reminders and counseling from health care personnel, are potential strategies that may be implemented to promote therapeutic adherence.⁴ For example, reminders such as telemonitoring and automated alerts afford real-time intervention to address nonadherence.⁴ These reminders and other types of communication between the patient and health care provider are integral to the effectiveness of the provider-patient relationship, helping the patient to engage in shared decision-making pertaining to therapeutic needs and expectations of modality efficacy.⁴ 

Some outpatient analyses have assessed the effect of RTM-equipped NPWT on therapy adherence and health economics relative to NPWT without RTM.^2,5,6 In a study that included 510 patients in an 11-month period and examined the relationship between RTM-equipped NPWT and patient adherence, Griffin and Leyva Casillas suggested RTM-equipped NPWT may be enlisted to influence adherence behavior.^2,5 It was reported that RTM-equipped NPWT use increased 73.5% (mean increase, 7.9 hours) following an adherence call prompted by usage < 16 hours in a 24-hour period.⁴ They noted among patients with < 60% RTM-equipped NPWT use compared with patients with 90% to 100% RTM-equipped NPWT use that there was an increase in the daily reduction rate in wound volume (1.42%–2.23%) and wound surface area (0.86%–1.45%).⁵ In a study by Griffin and Sifuentes,⁶ a statistically significant decrease in the median duration of therapy (27 days vs. 32 days; P = .0394) was noted in 199 patients issued RTM-equipped NPWT relative to 232 patients issued NPWT alone. They⁶ also reported a decrease in 90-day wound-related costs (RTM: $10 515 vs. non-RTM: $12 158) among outpatients in the RTM-equipped NPWT group, but the results did not demonstrate statistical significance.

Although this study is limited to a small patient set, data from the 3 cases presented suggest a RTM-equipped NPWT unit used as a just-in-time adaptive intervention is a feasible option to promote patient adherence to therapy, which could effectively reduce health care costs. These data also suggest that more well-defined, comparative studies are necessary. 

In these 3 cases with complex wounds, the RTM network team was able to interact with the patients in response to usage data collected by the RTM program. The interactions were both proactive and responsive and allowed the VTS to establish a rapport with the patient and to identify any barriers to wound healing. This study shows addressing the barriers to wound healing promoted adherence to NPWT. 

Authors: April Lumpkins, BSN, RN, CWOCN, CFCN; and Tamara Stanton, BSN, RN

Affiliation: KCI, an Acelity Company, San Antonio, TX

Correspondence: April Lumpkins, BSN, RN, CWOCN, CFCN, 12930 West Interstate 10, San Antonio, TX 78249; April.Lumpkins@Acelity.com

Disclosure: The authors are employees of KCI, an Acelity Company (San Antonio, TX). Financial support for this research was provided by KCI, an Acelity Company. Willie M. Heard III, PhD (KCI, an Acelity Company), provided medical writing support. These data were presented at the Symposium on Advanced Wound Care Fall 2018 in Las Vegas, NV.