By Chad Lairamore, PhD, PT, GCS, NCS and Sarah Walker, DPT
University of Central Arkansas
Patient compliance has been a consistent challenge to ensuring appropriate treatment within all fields of healthcare.1-3 Not only is compliance crucial to decreasing healthcare costs by minimizing wasted healthcare dollars on repeated services where benefits are not fully realized; compliance by patients may become a factor in provider viability, with reimbursement impacted by the outcomes that clients achieve.1,4,5 As healthcare continues to move toward value and outcome-based models of reimbursement, this old problem takes on a new perspective as reimbursements may soon be incentivized by, or even directly linked with, patient outcomes.6-8 Additionally, for patients to receive appropriate medical treatment they must have a partnership with the care provider and be engaged in managing their own health care. The choices they make every day have the greatest impact on their wellbeing.1,5 In fact the World Health Organization states that “Increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.”5 Non-compliance is of particular importance in the older adult population, as data indicate that those over the age of 65 are less likely to perform their prescribed home exercise program.9,10
Emerging evidence suggests that providing patients with a more engaging form of home exercise program beyond either the standard written or verbal instructions can result in an increase in patient compliance. In this time of rapidly advancing personal technology, one solution to improving compliance may lie in the palm of our hand through the appropriate utilization of smart devices. Smartphone and tablet applications are a readily available, familiar, and ubiquitous tool at the fingertips of most clinicians and patients.
This technology is currently grossly underutilized and unstudied, but could potentially serve to revolutionize patient outcomes by dramatically increasing rates of patient compliance. However, Individuals over the age of 65 represent the lowest demographic for smart phone usage with only 27% reporting having a smartphone.11
To bridge this gap, we partnered students from the University of Central Arkansas Physical Therapy Department with older adults participating in a pro bono clinic associated with the course Adult Neurological Rehabilitation. Clients were loaned an iPad mini if they did not already own a smart device, and students instructed the clients on use of the smart device. The goals of this learning experience were to 1) facilitate improved engagement and home exercise program compliance, and 2) educate students on the potential use of technology for increasing patient engagement and compliance compared to standard printed home exercise programs.
In order to gauge patient compliance, we used the application Wellpepper during the pro bono clinic and for 1 month following the clinic. Wellpepper is an application that is used to create custom care plans, share and update exercises remotely, and track results.12 The application was administered by student physical therapists using an iPad. With supervision from a licensed physical therapist, students created customized home exercise programs that were then available to clients via the application on their own personal device or the device that was lent to them. Within the app, therapists and students were able to change and update their client’s home exercises, and check in to see if they were being performed. This innovative system attempts to capitalize on the assumption that greater patient engagement and support, coupled with a more dynamic interface, can increase patient compliance.
Anecdotally, we found that clients fell into one of three categories. Those who already had a “relationship” with their smartphone or tablet were likely to engage with the application Wellpepper and perform their home exercise program on a regular basis. The clients who did not own a smartphone or tablet, but who demonstrated an interest in using the application, were also likely to engage with the home exercise program and have good compliance. In fact, several clients who fell in this category bought tablets to be able to continue their exercise routine. Finally, the clients who did not show an early interest in the technology were generally non-compliant with their home exercise program. These results are not surprising as previous research investigating elderly participants use of a home program found that compliance was influenced by the individual’s preference for the program structure and how that program was delivered.13
In conclusion, we found the use of smart devices may increase patient engagement and improve compliance for some older adults. However, smart device usage is not for everyone. Clinicians need to match instructional techniques with their client’s preference. Additionally, as instructors, we need to not only teach our students to use technology for increasing patient engagement, but also to use traditional instructional strategies as well as other alternative strategies to better match home programs to the patient’s preference.
- Martin LR, Williams SL, Haskard KB, DiMatteo MR. The challenge of patient adherence. Therapeutics and Clinical Risk Management. 2005;1(3):189-199.
- Vermeire E, Hearnshaw H, Van Royen P, Denekens J. Patient adherence to treatment: three decades of research. A comprehensive review. Journal of C`linical Pharmacy and Therapeutics. 2001;26(5):331-342.
- Campbell R, Evans M, Tucker M, Quilty B, Dieppe P, Donovan J. Why don’t patients do their exercises? Understanding non-compliance with physiotherapy in patients with osteoarthritis of the knee. Journal of Epidemiology and Community Health. 2001;55(2):132-138.
- Jack K, McLean SM, Moffett JK, Gardiner E. Barriers to treatment adherence in physiotherapy outpatient clinics: A systematic review. Manual Therapy.15(3):220-228.
- Adherence to Long Term Therapies – Evidence for Action. Wolrd Health Organization 2003: http://www.who.int/chp/knowledge/publications/adherence_report/en/.
- VanLare JM, Conway PH. Value-based purchasing—national programs to move from volume to value. New England Journal of Medicine. 2012;367(4):292-295.
- Miller HD. From volume to value: better ways to pay for health care. Health Affairs. 2009;28(5):1418-1428.
- Roadmap for Implementing Value Driven Healthcare in the Traditional Medicare Fee-for-Service Program In: Services TUSDoHaHSaTCfMM, ed. CMS website 2009:31. ????
- Henry KD, Rosemond C, Eckert LB. Effect of number of home exercises on compliance and performance in adults over 65 years of age. Physical Therapy. 1999;79(3):270-277.
- Riel H, Matthews M, Vicenzino B, Bandholm T, Thorborg K, Rathleff MS. Efficacy of live feedback to improve objectively monitored compliance to prescribed, home-based, exercise therapy-dosage in 15 to 19 year old adolescents with patellofemoral pain- a study protocol of a randomized controlled superiority trial (The XRCISE-AS-INSTRUcted-1 trial). BMC Musculoskeletal Disorders. 2016;17:1-12.
- Smith A. U.S. Smartphone Use in 2015. 2015; http://www.pewinternet.org/2015/04/01/us-smartphone-use-in-2015/.
- Weiler A. mHealth and big data will bring meaning and value to patient-reported outcomes. mHealth. 2016;2(1).
- Simek EM, McPhate L, Hill KD, Finch CF, Day L, Haines TP. What are the characteristics of home exercise programs that older adults prefer?: A cross-sectional study. American Journal of Physical Medicine & Rehabilitation. 2015;94(7):508-521.