Electronic Symptom Monitoring Research Articles

Pilot randomized trial of an electronic symptom monitoring and reporting intervention for hospitalized adults undergoing hematopoietic stem cell transplantation.

Patients undergoing a hematopoietic stem cell transplantation (HCT) have varied symptoms during their hospitalization. This study examined whether daily symptom reporting (with electronic patient-reported outcomes [PROs]) in an inpatient bone marrow transplant clinic reduced symptom burden on post-transplant days +7, +10, and +14. A prospective, single-institution 1:1 pilot randomized, two-arm study recruited HCT patients. HCT inpatients (N = 76) reported daily on 16 common symptoms using the PRO version of the Common Terminology for Adverse Events (PRO-CTCAE). Fisher's exact test was used to examine differences in the proportion of patients reporting individual symptoms. Multivariable linear regression modeling was used to examine group differences in peak symptom burden, while controlling for symptom burden at baseline, age, comorbidity, and transplantation type (autologous or allogeneic). HCT patients receiving the PRO intervention also experienced lower peak symptom burden (average of 16 symptoms) at days +7, +10, and +14 (10.4 vs 14.5, p = 0.03). Daily use of electronic symptom reporting to nurses in an inpatient bone marrow transplant clinic reduced peak symptom burden and improved individual symptoms during the 2weeks post-transplant. A multi-site trial is warranted to demonstrate the generalizability, efficacy, and value of this intervention. ClinicalTrials.gov identifier: NCT02574897.

Electronic symptom monitoring with patient-reported outcomes in patients recovering from ambulatory minimally invasive gynecologic cancer surgery: A prospective pilot study

Electronic symptom monitoring with patient-reported outcomes in patients recovering from ambulatory minimally invasive gynecologic cancer surgery: A prospective pilot study

Use of remote symptom monitoring with breast cancer survivors using patient-reported outcome (PRO) measures in MyChart.

e23125 Background: Electronic patient-reported outcome monitoring has been found to improve quality of life and overall survival when used with metastatic cancer patients during treatment (Basch, et al., 2017). There has been limited data on using PROs to enhance clinical outcomes in cancer survivorship. This pilot study of breast cancer survivors assessed utilization and satisfaction of electronic proactive symptom and adherence monitoring. Methods: Eighty breast cancer survivors who had completed surgery, chemotherapy, and/or radiation and had received their survivorship care plan were randomized to either usual care or to the PRO monitoring group. The PRO group received questions from the NIH PROMIS toolkit through their patient portal (EPIC) monthly for 6 months. The triage nurse received an alert if the survivor reported on the questionnaire that they had moderate to severe symptoms, had not taken their medication, or would like to speak to a nurse. Participants in the control arm were assessed for sadness, anxiety and satisfaction with provider communication at their usual follow-up visits. Results: Response rates for surveys ranged from 47to 75%. Patients in the PRO monitoring group exhibited no difference in satisfaction at 3 months but had significantly higher scores at 6 months for communication (P=0.005) and monitoring (P= 0.002). Anxiety scores were not significantly different among the usual care group versus the frequent remote monitoring group. Conclusions: Electronic PROs monitoring between clinic visits improved satisfaction with communication and follow-up without increasing anxiety in breast cancer survivors. The pilot data indicate continued development of efficient PROs monitoring can be an important tool to transform the survivorship care plan from a document to an active process of proactively monitoring symptoms and adherence. Support: UG1CA189823. Reference: Basch, E., Deal, A. M., Dueck, A.C., et al. (2017). Overall Survival Results of a Trial Assessing Patient-Reported Outcomes for Symptom Monitoring During Routine Cancer Treatment. Jama, 318 (2), 197. Study Number: A23_Pilot2

Developing a real-time electronic symptom monitoring system for patients after discharge following cancer-related surgery

BackgroundPatients undergoing major cancer surgery frequently require post-acute care for complications and adverse effects. Enhanced recovery after surgery programmes mean that patients are increasingly discharged home earlier. Symptom/complication detection post-discharge is sub-optimal. Systematic patient monitoring post-discharge following surgery may be optimally achieved through routine electronic patient-reported outcome (ePRO) data capture. ePRO systems that employ clinical algorithms to guide management of patients and automatically alert clinicians of clinically-concerning symptoms can improve patient outcomes and decrease hospital admissions. ePRO systems that provide individually-tailored self-management advice and integrate live ePRO data into electronic health records (EHR) may also advance personalised health and patient-centred care. This study aims to develop a hospital EHR-integrated ePRO system to improve detection and management of complications post-discharge following cancer-related surgery.MethodsThe ePRO system was developed in two phases: (1) Development of a web-based ePRO symptom-report from validated European Organisation for Research and Treatment of Cancer (EORTC) questionnaires, clinical opinion and patient interviews, followed by hospital EHR integration; (2) Development of clinical algorithms triggering symptom severity-dependent patient advice and clinician alerts from: (i) prospectively-collected patient-completed ePRO symptom-report data; (ii) stakeholder meetings; (iii) patient interviews. Patient advice was developed from: (i) clinician-patient telephone consultations and patient interviews; (ii) review of hospital patient information leaflets (PIL) and patient support websites.ResultsPhase 1, including interviews with 18 patients, identified 35 symptom-report items. In phase 2, 130/300 (43%) screened patients were eligible. 61 (47%) consented to participate and 59 (97%) provided 444 complete self-reports. Stakeholder meetings (9 clinicians, 1 patient/public representative) and patient interviews (n = 66) refined advice/alert accuracy. 15 telephone consultations, 7 patient interviews and review of 28 PILs and 3 patient support websites identified 4 themes to inform self-management advice. Comparisons between ePRO symptom-report data, telephone consultations and clinical events/outcomes (n = 27 patients) further refined clinical algorithms.ConclusionsA hospital EHR-integrated ePRO system that alerts clinicians and provides patient self-management advice has been developed to improve the detection and management of problems and complications after discharge following surgery. An ongoing pilot study will inform a multicentre randomised trial to evaluate the effectiveness of the ePRO system compared to usual care.

A Decade in Review: Cancer Care Ontario's Approach to Symptom Assessment and Management.

In 2007 Cancer Care Ontario (CCO) implemented standardized systematic symptom evaluation in all cancer patients in Ontario using the Edmonton Symptom Assessment System. The initial implementation did not include symptom management guidance and this limited the success of the implementation. Within a short time, the need for guidance on how to respond to symptoms became apparent. To describe how CCO has approached electronic symptom monitoring and related clinical response to symptom scores. CCO's approach to symptom management includes acknowledgment, assessment, and intervention steps. In partnership with the Program in Evidence Based Care, CCO developed guidance documents for management of each of the symptoms assessed with Edmonton Symptom Assessment System. These materials included an in-depth document similar to the full guidelines created by Program in Evidence Based Care for cancer treatment topics, a shorter pocket guide, and a 1-page algorithm. The guidance was aligned with symptom score severity. The 1-page algorithm was the most popular format of these materials. When time for revisions came, only this document was revised. When additional PRO measures were implemented, the plan ensured that the launch included a bundle of clinician-facing and patient-facing guidance materials together with the measure. All resources are accessible from a mobile-friendly website. Providing clear guidance for symptom management is an important part of successful PRO measure implementation. Involving a wide range of stakeholders early in the creation of such resources facilitates implementation and team building.

Pilot randomized trial of an electronic symptom monitoring intervention for hospitalized patients with cancer.

Hospitalized patients with cancer experience a high symptom burden, which is associated with poor health outcomes and increased health care utilization. However, studies investigating symptom monitoring interventions in this population are lacking. We conducted a pilot randomized trial to assess the feasibility and preliminary efficacy of a symptom monitoring intervention to improve symptom management in hospitalized patients with advanced cancer. We randomly assigned patients with advanced cancer who were admitted to the inpatient oncology service to a symptom monitoring intervention or usual care. Patients in both arms self-reported their symptoms daily (Edmonton Symptom Assessment System and Patient Health Questionnaire-4). Patients assigned to the intervention had their symptom reports presented graphically with alerts for moderate/severe symptoms during daily team rounds. The primary end point of the study was feasibility. We defined the intervention as feasible if >75% of participants hospitalized >2 days completed >2 symptom reports. We observed daily rounds to determine whether clinicians discussed and developed a plan to address patients' symptoms. We used regression models to assess intervention effects on patients' symptoms throughout their hospitalization, readmission risk, and hospital length of stay (LOS). Among 150 enrolled patients (81.1% enrollment), 94.2% completed >2 symptom reports. Clinicians discussed 60.4% of the symptom reports and developed a plan to address the symptoms highlighted by the symptom reports 20.8% of the time. Compared with usual care, intervention patients had a greater proportion of days with lower psychological distress (B = 0.12, P = 0.008), but no significant difference in the proportion of days with improved Edmonton Symptom Assessment System-physical symptoms (B = 0.07, P = 0.138). Intervention patients had lower readmission risk (hazard ratio = 0.68, P = 0.224), although this difference was not significant. We found no significant intervention effects on hospital LOS (B = 0.16, P = 0.862). This symptom monitoring intervention is feasible and demonstrates encouraging preliminary efficacy for improving patients' symptoms and readmission risk.ClinicalTrials.gov identifier NCT02891993.

Daily and weekly mood ratings using a remote capture method in high-risk offspring of bipolar parents: Compliance and symptom monitoring.

To determine the compliance and clinical utility of weekly and daily electronic mood symptom monitoring in adolescents and young adults at risk for mood disorder. Fifty emerging adult offspring of bipolar parents were recruited from the Flourish Canadian high-risk offspring cohort study along with 108 university student controls. Participants were assessed by KSADS/SADS-L semi-structured interviews and used a remote capture method to complete weekly and daily mood symptom ratings using validated scales for 90 consecutive days. Hazard models and generalized estimating equations were used to determine differences in summary scores and regularity of ratings. Seventy-eight and 77% of high-risk offspring and 97% and 93% of controls completed the first 30days of weekly and daily ratings, respectively. There were no differences in drop-out rates between groups over 90days (weekly P=0.2149; daily P=0.9792). There were no differences in mean summary scores or regularity of weekly anxiety, depressive or hypomanic symptom ratings between high-risk offspring and control groups. However, high-risk offspring compared to controls had daily ratings indicating lower positive affect, higher negative affect and lower self-esteem (P=0.0317). High-risk offspring with remitted mood disorder compared to those without had more irregularity in weekly anxiety and depressive symptom ratings and daily ratings of lower positive affect, higher negative affect, and higher shame and self-doubt (P=0.0365). Findings support that high-resolution electronic mood tracking may be a feasible and clinically useful approach in monitoring emerging psychopathology in young people at high-risk offspring of mood disorder onset or recurrence.

Pediatric Patient-Reported Symptom Tracking in Oncology (Pedi-PReSTO): A Feasibility Study

Background: Online patient and caregiver self-reporting for symptom and toxicity monitoring during chemotherapy can inform proactive clinical management and ameliorate serious adverse events. In adults, patient-reported symptom monitoring during chemotherapy improves quality of life, decreases hospitalizations, and lengthens survival. The feasibility of this approach in pediatrics has not been established. This study assesses the implementation of daily electronic patient-reported symptom monitoring for pediatric oncology patients hospitalized for chemotherapy.Methods: The Common Terminology Criteria for Adverse Events (CTCAE) is used to grade adverse events in cancer trials. The Pediatric PRO-CTCAE is a questionnaire for children to self-report symptoms while undergoing cancer treatment. The study population was patients 7-18 years of age, English-literate, with a planned admission for chemotherapy expected to last 48 hours at a single tertiary care pediatric institution.Patients and caregivers were asked to respond daily, following text or email prompts, to Pediatric PRO-CTCAE questions addressing ten symptoms via REDCap (web-based data capture). Each morning, completed symptom reports were emailed to the frontline clinicians. No instructions were given regarding the use of patient-reported information. Utilization of symptom reports was determined by electronic survey administered to the same clinician several hours following receipt of the report. Provider acceptability was assessed monthly. Patient and caregiver satisfaction was evaluated after discharge.Results: Fifty-five patients and their caregivers were invited to participate and 45 patient/caregiver dyads enrolled (82%). Chemotherapy regimens included those for leukemia/lymphoma (40%), bone marrow transplant (BMT, 11%), solid tumor (36%) and neuro-oncology (13%). Mean patient age was 12.8 years (range 7-18). Mean length of hospitalization was 8.5 days (median 4, range 2-42). Approximately half the evaluable dyads (48.8%) generated at least one symptom report (patient or caregiver) daily; three-quarters (75.6%) submitted symptom reports at least half of all hospitalized days. When stratified to include only leukemia/lymphoma and BMT patients, mean length of stay was 13.8 days (median 6, range 2-42), and proportions of daily symptom report submissions were comparable to the overall cohort. However, all dyads with leukemia/lymphoma or BMT completed at least one symptom report following enrollment, compared to four dyads among the group with neuro-oncology or solid tumor diagnoses that submitted no symptom reports following enrollment.In response to the individual symptom reports (217 from 37 dyads) clinicians reported that clinical actions were taken 25% of the time, including counseling the use of medications already prescribed (43), prescribing a new medication or altering dosage of a currently prescribed medication (22), performing laboratory tests (1) or imaging (3), and obtaining a consult from another service or team (4).All participating healthcare providers (n=42) understood the symptom reports, and all, except one, found the reports useful and expressed interest in continuing to receive them. A quarter of providers reported that reviewing the symptom reports enhanced communication with the patient or family. Patients and caregivers found the questions easy to understand and the system easy to use. Half of the patients (51.7%) reported that submitting symptom reports helped them “a lot” or “completely” to have conversations with their doctors, and most (82.8%) expressed interest in continuing to provide symptom reports after study participation ended. Fewer caregivers (34.4%) endorsed that submitting symptom reports helped them to have conversations with the patient's doctor, but 50% noted that they helped “a lot” or “completely” to keep track of their child's health and to feel more connected to the healthcare team.Conclusion: Patient and caregiver symptom self-reporting is a feasible and acceptable strategy for symptom monitoring in pediatric patients hospitalized for chemotherapy. Patients and their caregivers find this method of symptom reporting beneficial. Further, healthcare providers find the information useful and influential in medical decision-making. Larger scale studies are needed to further assess implementation and impact of symptom monitoring. DisclosuresNo relevant conflicts of interest to declare.

Overall Survival Results of a Trial Assessing Patient-Reported Outcomes for Symptom Monitoring During Routine Cancer Treatment

This study assesses overall survival associated with electronic patient-reported symptom monitoring vs usual care during routine cancer treatment.

Feasibility and acceptance of electronic monitoring of symptoms and syndromes using a handheld computer in patients with advanced cancer in daily oncology practice

We investigated the feasibility and acceptance of electronic monitoring of symptoms and syndromes in oncological outpatient clinics using a PALM (handheld computer). The assessment of a combination of symptoms and clinical benefit parameters grouped in four pairs was tested in a pilot phase in advanced cancer patients. Based on these experiences, the software E-MOSAIC was developed, consisting of patient-reported symptoms and nutritional intake and objective assessments (weight, weight loss, performance status and medication for pain, fatigue, and cachexia). E-MOSAIC was then tested in four Swiss oncology centers. In order to compare the methods, patients completed the E-MOSAIC as a paper and a PALM version. Preferences of version and completion times were collected. Assessments were compared using Wilcoxon signed-rank tests , and the test-retest reliability was evaluated. The pilot phase was completed by 22 patients. Most patients and physicians perceived the assessment as useful. Sixty-two patients participated in the feasibility study. Twelve patients reported problems (understanding, optical, tactile), and five patients could not complete the assessment. The median time to complete the PALM-based assessment was 3min. Forty-nine percent of patients preferred the PALM, 23% preferred a paper version, and 28% of patients had no preference. Paper vs. PALM revealed no significant differences in symptoms, but in nutritional intake (p = 0.013). Test-retest (1h, n = 20) reliability was satisfactory (r = 073-98). Electronic symptom and clinical benefit monitoring is feasible in oncology outpatient clinics and perceived as useful by patients, oncology nurses, and oncologists. E-MOSAIC is tested in a prospective randomized trial.

The impact of technology on medication adherence

Medication nonadherence is a large contributor to inadequate therapeutic outcomes, especially among patients with mental illness and carries a high cost. Intervention strategies to increase adherence have incorporated technological advances, including electronic symptom monitoring and communication systems for patients and providers. This article presents a review of several studies demonstrating how technology may affect medication adherence.

Supporting Clinical Practice Decisions With Real-Time Patient-Reported Outcomes

Supporting Clinical Practice Decisions With Real-Time Patient-Reported Outcomes