Measuring Daily Compliance With Physical Activity Tracking in Ambulatory Surgery Patients: Comparative Analysis of Five Compliance Criteria

Ryan Kelly, Simon Jones, Blaine Price, Dmitri Katz, Ciaran McCormick, Oliver Pearce, Ryan Kelly, Simon Jones, Blaine Price, Dmitri Katz, Ciaran McCormick, Oliver Pearce

Abstract

Background: Physical activity trackers such as the Fitbit can allow clinicians to monitor the recovery of their patients following surgery. An important issue when analyzing activity tracker data is to determine patients' daily compliance with wearing their assigned device, using an appropriate criterion to determine a valid day of wear. However, it is currently unclear as to how different criteria can affect the reported compliance of patients recovering from ambulatory surgery. Investigating this issue can help to inform the use of activity data by revealing factors that may impact compliance calculations.

Objective: This study aimed to understand how using different criteria can affect the reported compliance with activity tracking in ambulatory surgery patients. It also aimed to investigate factors that explain variation between the outcomes of different compliance criteria.

Methods: A total of 62 patients who were scheduled to undergo total knee arthroplasty (TKA, ie, knee replacement) volunteered to wear a commercial Fitbit Zip activity tracker over an 8-week perioperative period. Patients were asked to wear the Fitbit Zip daily, beginning 2 weeks prior to their surgery and ending 6 weeks after surgery. Of the 62 patients who enrolled in the study, 20 provided Fitbit data and underwent successful surgery. The Fitbit data were analyzed using 5 different daily compliance criteria, which consider patients as compliant with daily tracking if they either register >0 steps in a day, register >500 steps in a day, register at least one step in 10 different hours of the day, register >0 steps in 3 distinct time windows, or register >0 steps in 3 out of 4 six-hour time windows. The criteria were compared in terms of compliance outcomes produced for each patient. Data were explored using heatmaps and line graphs. Linear mixed models were used to identify factors that lead to variation between compliance outcomes across the sample.

Results: The 5 compliance criteria produce different outcomes when applied to the patients' data, with an average 24% difference in reported compliance between the most lenient and strictest criteria. However, the extent to which each patient's reported compliance was impacted by different criteria was not uniform. Some individuals were relatively unaffected, whereas others varied by up to 72%. Wearing the activity tracker as a clip-on device, rather than on the wrist, was associated with greater differences between compliance outcomes at the individual level (P=.004, r=.616). This effect was statistically significant (P<.001) in the first 2 weeks after surgery. There was also a small but significant main effect of age on compliance in the first 2 weeks after surgery (P=.040). Gender and BMI were not associated with differences in individual compliance outcomes. Finally, the analysis revealed that surgery has an impact on patients' compliance, with noticeable reductions in activity following surgery. These reductions affect compliance calculations by discarding greater amounts of data under strict criteria.

Conclusions: This study suggests that different compliance criteria cannot be used interchangeably to analyze activity data provided by TKA patients. Surgery leads to a temporary reduction in patients' mobility, which affects their reported compliance when strict thresholds are used. Reductions in mobility suggest that the use of lenient compliance criteria, such as >0 steps or windowed approaches, can avoid unnecessary data exclusion over the perioperative period. Encouraging patients to wear the device at their wrist may improve data quality by increasing the likelihood of patients wearing their tracker and ensuring that activity is registered in the 2 weeks after surgery.

Trial registration: ClinicalTrials.gov NCT03518866; https://ichgcp.net/clinical-trials-registry/NCT03518866.

Keywords: activity tracking; adherence; compliance; surgery; total knee arthroplasty.

Conflict of interest statement

Conflicts of Interest: None declared.

©Ryan Kelly, Simon Jones, Blaine Price, Dmitri Katz, Ciaran McCormick, Oliver Pearce. Originally published in JMIR mHealth and uHealth (http://mhealth.jmir.org), 26.01.2021.

Figures

Figure 1
Figure 1
Differences in compliance calculations for the patients in our study. The scores are plotted against the most lenient criterion, >0 Steps, and show the difference between this criterion and the other measures.
Figure 2
Figure 2
Heatmaps for 10 participants, illustrating the variations in patterns of physical activity throughout the day and across the 8-week perioperative period (from 2 weeks presurgery to 6 weeks postsurgery). The x-axis represents the day, beginning 2 weeks prior to surgery (day -14) and ending 6 weeks after surgery (day 42). The red line indicates the day of surgery (day 0). The y-axis represents the hour of the day. The color of cells corresponds to the number of steps recorded in a given hour, ranging from white (0) to black (500+).
Figure 3
Figure 3
Daily compliance rates over time. The percentage of the sample that were compliant on any given day is illustrated by the y-axis. The dark gray line represents the mean average across all 5 of the compliance criteria. The height of the gray shaded region indicates the standard deviation between measures over time. The red vertical line represents the day of surgery.
Figure 4
Figure 4
Comparison of daily compliance rates for all 5 compliance criteria.
Figure 5
Figure 5
Temporal variations in compliance for the 5 criteria over the perioperative period. (A) The proportion of the clip-worn group that was compliant on each day. (B) The variation between criteria for the clip-worn group. (C) The proportion of the wrist-worn group that was compliant on each day. (D) The variation between criteria for the wrist-worn group.

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