Abstract
BackgroundChemotherapy is associated with a significant risk of toxicity, which often peaks between ambulatory visits to the cancer centre. Remote symptom management support is a tool to optimize self-management and healthcare utilization, including emergency department visits and hospitalizations (ED+H) during chemotherapy. We performed a single-arm pilot study to evaluate the feasibility, acceptability, and potential impact of a telephone symptom management intervention on healthcare utilization during chemotherapy for early stage breast cancer (EBC).MethodsWomen starting adjuvant or neoadjuvant chemotherapy for EBC at two cancer centres in Ontario, Canada, received standardized, nurse-led calls to assess common toxicities at two time points following each chemotherapy administration. Feasibility outcomes included patient enrollment, retention, RN adherence to delivering calls per the study schedule, and resource use associated with calls; acceptability was evaluated based on patient and provider feedback. Impact on acute care utilization was evaluated post hoc by linking individual patient records to provincial data holdings to examine ED+H patterns among participating patients compared to contemporaneous controls.ResultsBetween September 2013 and December 2014, 77 women were enrolled (mean age 55 years). Most commonly used regimens were AC-paclitaxel (58%) and FEC-docetaxel (16%); 78% of patients received primary granulocyte colony-stimulating factor prophylaxis. 83.8% of calls were delivered per schedule; mean call duration was 9 min. The intervention was well received by both patients and clinicians. Comparison of ED+H rates among study participants versus controls showed that there were fewer ED visits in intervention patients [incidence rate ratio (IRR) (95% CI) = 0.54 (0.36, 0.81)] but no difference in the rate of hospitalizations [IRR (95% CI) = 1.02 (0.59, 1.77)]. Main implementation challenges included identifying eligible patients, fitting the calls into existing clinical responsibilities, and effective communication to the patient’s clinical team.ConclusionsTelephone-based pro-active toxicity management during chemotherapy is feasible, perceived as valuable by clinicians and patients, and may be associated with lower rates of acute care use. However, attention must be paid to workflow issues for scalability. Larger scale evaluation of this approach is in progress.
Highlights
Chemotherapy is associated with a significant risk of toxicity, which often peaks between ambulatory visits to the cancer centre
Suboptimal management of toxicities can lead to emergency department visits and hospitalizations (ED+H) during treatment
A contemporaneous control cohort was identified after the study completion from the Activity Level Report (ALR) database, which was linked to other administrative databases to capture information on patient demographic and clinical characteristics, and outcomes
Summary
Chemotherapy is associated with a significant risk of toxicity, which often peaks between ambulatory visits to the cancer centre. A recently published, single-centre randomized controlled trial of remote web-based patient-reported symptom assessments coupled with automatic provider alerts [12, 13] demonstrated that patients receiving remote monitoring had fewer emergency department visits (34% vs 41%) or hospitalizations (45% vs 49%), remained on chemotherapy longer (8.2 vs 6.3 months), and had better survival relative to patients receiving usual follow-up care. All of these studies, have evaluated the impact of these types of interventions in the research setting and have not addressed the additional barriers associated with the implementation and sustainability in routine ambulatory cancer care. Further evaluation is needed to inform effective integration of pro-active toxicity management into existing models of care
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