Characteristics of Veterans Who Drop Out of Home Telehealth Programs and Those Who Adhere to the Use of Home Telehealth Technologies
Use of remote patient monitoring for chronic disease management has been on the rise. Even prior to COVID-19, use of VA’s remote patient monitoring program increased, and resulted in reduced VA hospital admissions and length of stay while maintaining high patient satisfaction. With the rapid expansion of tele and virtual health with COVID-19, it is even more critical to understand the high rates of drop-out and poor adherence to the use of remote patient monitoring over time. 1, 2
A recent retrospective study of Veterans with heart failure helps unravel factors that drive Veteran drop-out from Home Telehealth (HT), and also illuminates the level of adherence to daily HT technology use that many remote patient monitoring programs require.1, 2 Using VA administrative data linked to HT program data on participants from January through June 2014, we followed patients’ use of asynchronous technologies that monitor vital signs and disease symptoms for one year. We calculated weekly compliance levels, time to drop-out, and average adherence at 1, 3, 6, and 12 months. We used a mixed effects Cox regression model to determine the risk of drop-out from the HT Program over a one-year period and general estimating equation with facility as a covariate to model average adherence at 1, 3, 6, and 12 months after first using HT.1, 2
Among the 3,449 Veteran participants, average age was 71 years (standard deviation or SDof 10.4 years).1, 2 The majority were white (75 percent) and male (98 percent). Four percent had one or more hospital readmissions within three days of discharge in the prior year.1 Fifty-eight percent had a CAN score (Care Assessment Need; probability of hospitalization or death in 90 days) of greater than or equal to 95 percent. Forty-seven percent were enrolled in the VA online patient portal MyHealtheVet, and 30 percent had a depression diagnosis. Thirteen percent died in the first year after HT enrollment.1 Percent average adherence increased the longer the patient stayed in the HT program, from 53 percent at one month to 69 percent at one year after first using the HT technologies.2
Veterans at lower risk of drop-out from HT programs were generally younger, Black, healthier (low CAN score and less functional impairment), and enrolled in MyHealtheVet.1 In addition, these Veterans had higher average adherence to the use of HT technologies and no prior hospital readmissions. This is problematic as Veterans who are older, sicker, and frail are often the target population for recruitment into the HT Program for chronic disease management and improvement in health service use, and yet they are the ones who are most at risk for drop-out of HT programs.1 Individualized interventions should be included in the HT plan of care for Veterans enrolled in the HT program to promote continued engagement over time and to address potential barriers to adherence, especially during transitions of care and post discharge.1 This may include looking at potential functional needs and resources that will allow for continued safe community dwelling and self-management in the home setting. In addition, enrollment in an online patient portal may reflect a measure of familiarity with technology that translates to use of HT technologies.
Average adherence increased the longer the patient remained in the HT program. 2 Poor daily adherence to the use of HT has been posited as a potential reason for lack of benefit found in some randomized controlled trials on the use of remote patient monitoring for heart failure.1 We examined predictors of average adherence to the use of HT technologies at different time points (1, 3, 6, and 12 months) in Veterans with heart failure.
Veterans who had lower average adherence at all time points studied were younger, Black, and had depression.2 We found that Black Veterans were less likely to drop out initially, but when in the program, they had lower adherence. This points to the need to educate patients continually on the importance of using their HT technologies on a daily basis and not just episodically. In addition, the association between depression and adherence is particularly concerning due to the high prevalence of depression in patients with heart failure. Depression needs to be addressed in patients with heart failure enrolled in HT to promote continued adherence over time.
In summary, individualized plans of care should be developed for subgroups of Veterans who are a) at high risk of drop-out from HT programs, and b) found to have low adherence to the use of HT technologies. Further study is needed to determine organizational factors that may help prevent HT drop-out and improve adherence (e.g., HT enrollment done face to face instead of by phone) and strategies that target subgroups of patients (e.g., those with depression) who may benefit from additional efforts to improve adherence to HT technologies. Additional research is also needed to fully understand the relationship between racial differences and discontinuation from HT programs and poor adherence. 1, 2