Digital Symptom Monitoring With PROs in Community Practices Improves Patient QoL

Digitally monitoring patient-reported outcomes (PROs) helps to improve symptom control, physical function, and health-related quality of life, according to a presentation given during the American Society of Clinical Oncology Plenary Series: November 2021 Session.

According to presenter Ethan Basch, MSc, MD, FASCO, there are many barriers and challenges to the usual approach to symptom monitoring in the community setting. On the clinical side, there is limited time to discuss symptoms and symptom management. Additionally, during that session there are often competing priorities. On the patient side, there is often a reluctance to contact their care providers until symptoms grow worse, and problems connecting with the center. Research has found that clinician’s miss up to 50% of symptoms, potentially leading to a downstream of consequences including hospitalization, treatment holds, and preventable suffering.

“These communication hurdles inhibit the ability of clinicians to detect and react early to symptoms before they worsen. An alternative approach is to use digital symptom monitoring with patient reported outcomes,” Said Basch, the Richard M. Goldberg Distinguished Professor in Medical Oncology, professor of Public Health, Health Policy and Management in the Gilling School of Global Public Health, the director of Cancer Outcomes research Program, and chief of Oncology at the University of North Carolina Chapel Hill.

An alternative to traditional symptom monitoring is digital symptom monitoring using electronic PROs. With this method, an electronic symptom sends an e-reminder to patients, who then report symptoms. This is then generated into either an email alert or a report for care providers.

A prior single-center study, STAR (NCT00578006), found that patients who self-reported symptoms had a higher rate of overall survival than those who reported symptoms the traditional way (P =.03). The PRO-TECT study (NCT03249090) was designed as a multicenter evaluation of the PROs method of ensuring good quality-of-life. The trial was made up of 52 community oncology practices across 25 states, each enrolling up to 50 patients with metastatic cancer receiving systemic therapy who were not on a clinical trial.

During the study, patients were randomized 1:1 into either the intervention arm or a control arm. During the intervention arm, patients completed a weekly survey on 12 common symptoms. An email alert was then sent to clinical nurses for severe or worsening symptoms so that they may be addressed. Additionally, reports showing longitudinal symptoms were sent to clinical teams at visits. During the control arm, patients received standard of care symptom management. End points of the study include survival, physical function, symptom control, health-related quality of life, implementation, and satisfaction.

In the experimental arm (n = 593), the median age of patients was 64 (range, 29-89) and 60.5% were female. Races of patients included White (80.4%), Black/African (16.8%), and American (2.1%). Cancer types observed included thoracic (19.9%), breast (16.4%), gastrointestinal (29.2%), genitourinary (11.6%), gynecologic (10.8%), hematologic (5.2%), and other (6.9%). Thirty-seven percent of patients had a high school education or less, 26% lived in rural areas, and 19.2% had never used email or a computer before.

In the control arm, the median age was 62 (range, 28-93) and 56.1% were female. Races of patients included White (78.5%), Black/African (16.3%), and American (5.1%). Cancer types include thoracic (18.4%), breast (13.4%), gastrointestinal (36.6%), genitourinary (7.4%), gynecologic (8.9%), hematologic (5.2%), and other (10.2%). Forty-two percent of patients had a high school education or less, 27.3% lived in a rural area, and 26.5% had never used an email or computer.

At 3 months, 13.8% more patients in the experimental arm reported physical function benefits compared with the control arm (P =.009). Additionally, 16.1% more patients in the experimental arm compared with the control arm reported symptom control benefits (P =.003), and 13.4% more patients in the experimental arm reported health-related quality of life benefits (P =.006).

Among the 20,565 completed surveys, 33.9% triggered email alerts, most common for pain, diarrhea, dyspnea, and nausea. Nurses acted on 59.1% of these email alerts, most commonly with telephone counseling, supportive medications, referrals, and new appointments. Eighty-three percent of patients strongly agreed that questions were easy to understand, 84% strongly agreed with the statement that the system was easy to use, and 70% would recommend the symptom to others. Seventy-two percent said that the symptom improved discussions with doctors or nurses, 70% reported felt doctors or nurses used the information reported, and 78% reported that it made them feel more in control of their own care.

Seventy-eight percent of nurses felt the information was helpful for documentation. Additionally, 84% reported the information improved discussion with patients, and 84% reported the information improved efficiency. However, only 59% said they would recommend the system to future patients and only 64% said they would recommend to other clinics.

“The reason for this reluctance was found in qualitative interviews, to be related to the burden of email alert notifications added on top of other work. Nurses felt that a small amount of protected time was needed to address the email alerts and future implementations should account for this need for protected nursing time to assure successful uptake,” said Basch.

_REFERENCE:

_{Basch E. Digital symptom monitoring with patient-reported outcomes in community oncology practices: A U.S. national cluster randomized trial. Presented at ASCO Plenary Series: November 2021 Session. November 16, 2021; virtual.}