Electronic Patient Symptom Management Program to Support Patients Receiving Cancer Treatment at Home During the COVID-19 Pandemic

Assessing health outcomes: a systematic review of electronic patient-reported outcomes in oncology

PURPOSE

This study investigates the clinical impact of electronic patient-reported outcome (ePRO) monitoring apps/web interfaces, aimed at symptom-management, in cancer patients undergoing outpatient systemic antineoplastic treatment. Additionally, it explores the advantages offered by these applications, including their functionalities and healthcare team-initiated follow-up programmes.

METHODS

A systematic literature review was conducted using a predefined search strategy in MEDLINE. Inclusion criteria encompassed primary studies assessing symptom burden through at-home ePRO surveys in adult cancer patients receiving outpatient systemic antineoplastic treatment, whenever health outcomes were evaluated. Exclusion criteria excluded telemedicine-based interventions other than ePRO questionnaires and non-primary articles or study protocols. To evaluate the potential bias in the included studies, an exhaustive quality assessment was conducted, as an additional inclusion filter.

RESULTS

Among 246 identified articles, 227 were excluded for non-compliance with inclusion/exclusion criteria. Of the remaining 19 articles, only eight met the rigorous validity assessment and were included for detailed examination and data extraction, presented in attached tables.

CONCLUSION

This review provides compelling evidence of ePRO monitoring's positive clinical impact across diverse cancer settings, encompassing various cancer types, including early and metastatic stages. These systems are crucial in enabling timely interventions and reducing communication barriers, among other functionalities. While areas for future ePRO innovation are identified, the primary limitation lies in comparing clinical outcomes of reviewed articles, due to scale variability and study population heterogeneity. To conclude, our results reaffirm the transformative potential of ePRO apps in oncology and their pivotal role in shaping the future of cancer care.

Symptom experience of patients undergoing treatment for multiple myeloma: a longitudinal real-world electronic patient-reported outcomes study

PURPOSE

Patients with multiple myeloma (MM) experience significant symptom burden. We used a symptom monitoring app to longitudinally characterize the MM treatment experience in detail based on line of therapy (LOT).

METHODS

Adults with MM on active treatment completed weekly symptom monitoring surveys. Patients on their 4th LOT or greater were considered heavily pretreated. We characterized moderate to very severe (MOD-VS) symptom prevalence, weekly symptom burden, symptom bother (FACT-GP5), and health-related quality of life (HR-QoL) (EORTC QLQ-C30 Item 30) per LOT.

RESULTS

We considered 109 patients on LOT < 4 and 47 on LOT ≥ 4. The top MOD-VS symptoms were fatigue (71.6% of patients), muscle pain (59.8%), general pain (51.6%), numbness/tingling (48.4%), and insomnia (47.6%). More patients on LOT ≥ 4 experienced numbness/tingling (66.7% vs. 41.3%; OR 2.84, 95% CI 1.27-6.37; p = 0.0098) and fatigue (83.3% vs. 65.6%; OR 2.60, 95% CI 0.96-7.09; p = 0.0557). Some symptoms (fatigue, muscle pain, anxiety) persisted for months among patients on LOT ≥ 4, but patients on LOT < 4 also had unmet longitudinal needs (numbness/tingling, dyspnea). Patients on LOT ≥ 4 had more weeks with ≥ 3 MOD-VS symptoms (27.1% of weeks vs. 15.7%; OR 2.56, 95% CI 1.07-6.08; p = 0.0337) and experienced high symptom bother more often (39.1% of surveys vs. 30.0%; OR 4.23, 95% CI 1.37-13.10; p = 0.0123). HR-QoL was similar between groups.

CONCLUSION

Heavily pretreated patients experienced greater symptom burden and bother, but patients at earlier LOTs also had unmet needs. Interventions are needed to improve symptom management in MM regardless of LOT, but most pressingly for heavily pretreated patients.

Essential Components of an Electronic Patient-Reported Symptom Monitoring and Management System: A Randomized Clinical Trial

Importance

Multicomponent electronic patient-reported outcome cancer symptom management systems reduce symptom burden. Whether all components contribute to symptom reduction is unknown.

Objective

To deconstruct intervention components of the Symptom Care at Home (SCH) system, a digital symptom monitoring and management intervention that has demonstrated efficacy, to determine which component or combination of components results in the lowest symptom burden.

Design, Setting, and Participants

This randomized clinical trial included participants who were older than 18 years, had been diagnosed with cancer, had a life expectancy of 3 months or greater, were beginning a chemotherapy course planned for at least 3 cycles, spoke English, and had daily access and ability to use a telephone. Eligible participants were identified from the Huntsman Cancer Institute, University of Utah (Salt Lake City), and from Emory University Winship Cancer Institute, including Grady Memorial Hospital (Atlanta, Georgia), from August 7, 2017, to January 17, 2020. Patients receiving concurrent radiation therapy were excluded. Dates of analysis were from February 1, 2020, to December 22, 2023.

Interventions

Participants reported symptoms daily during a course of chemotherapy and received automated self-management coaching with an activity tracker without (group 1) and with (group 2) visualization, nurse practitioner (NP) follow-up for moderate-to-severe symptoms without (group 3) and with (group 4) decision support, or the complete SCH intervention (group 5).

Main Outcomes and Measures

The primary outcome, symptom burden, was assessed as the summed severity of 11 chemotherapy-related symptoms rated on a scale of 1 to 10 (with higher scores indicating greater severity), if present.

Results

The 757 participants (mean [SD] age, 59.2 [12.9] years) from 2 cancer centers were primarily female (61.2%). The most common cancer diagnoses were breast (132 [17.4%]), lung (107 [14.1%]), and colorectal (99 [13.1%]) cancers; 369 patients (48.7%) had metastatic disease. The complete SCH intervention including automated self-management coaching and NP follow-up with decision support (group 5) was superior in reducing symptom burden to either of the self-management coaching groups, as shown by the mean group differences in area under the curve (group 1, 1.86 [95% CI, 1.30-2.41] and group 2, 2.38 [95% CI, 1.84-2.92]; both P < .001), and to either of the NP follow-up groups (group 3, 0.57 [95% CI, 0.03-1.11]; P =.04; and group 4, 0.66 [95% CI, 0.14-1.19]; P = .014). Additionally, NP follow-up was superior to self-management coaching (group 1 vs group 3, 1.29 [95% CI, 0.72-1.86]; group 1 vs group 4, 1.20 [95% 12 CI, 0.64-1.76]; group 2 vs group 3, 1.81 [95% CI, 1.25-2.37]; and group 2 vs group 4, 1.72 [95% CI, 1.17-2.26]; all P < .001), but there was no difference between the 2 self-management coaching groups (-0.52 [95% CI, -1.09 to 0.05]; P = .07) or between the 2 NP groups (-0.10 [95% CI, -0.65 to 0.46]; P = .74).

Conclusions and Relevance

In this randomized clinical trial of adult participants undergoing chemotherapy treatment for cancer, the complete intervention, rather than any individual component of the SCH system, achieved the greatest symptom burden reduction. These findings suggest that a multicomponent digital approach to cancer symptom management may offer optimal symptom burden reduction.

Trial Registration

ClinicalTrials.gov Identifier: NCT02779725.

Electronic symptom monitoring for home-based palliative care: A systematic review

BACKGROUND

Coordination and communication challenges in home-based palliative care complicate transitions from hospital care. Electronic symptom monitoring enables real-time data collection, enhancing patient-provider communication. However, a systematic evaluation of its effectiveness in home-based palliative care is lacking.

AIM

To analyze the feasibility, effectiveness, and limitations of electronic symptom monitoring in home-based palliative care, assess the evidence quality, identify the evidence gap, and suggest implications for future research and practice.

DESIGN

This study uses systematic review, meta-analysis, and narrative synthesis (CRD42023457977) to analyze relevant studies until September 2023.

DATA SOURCES

Electronic searches in MEDLINE, CENTRAL, and Embase until September 2023, complemented by hand-searching of references and citations.

RESULTS

This study included twenty studies. The majority of patients positively engage in electronic symptom monitoring, which could improve their quality of life, physical and emotional well-being, and symptom scores without a significant increase in costs. However, firm conclusions about the effects of electronic symptom monitoring on outcomes like survival, hospital admissions, length of stay, emergency visits, and adverse events were limited due to significant variability in the reported data or inadequate statistical power.

CONCLUSION

Introducing electronic symptom monitoring in home-based palliative care holds potential for enhancing patient-reported outcomes, potentially decreasing hospital visits and costs. However, inconsistency in current studies arising from diverse monitoring systems obstructs comparability. To advance, future high-quality research should employ standardized follow-up periods and established scales to better grasp the benefits of electronic symptom monitoring in home-based palliative care.

Effects of transitional care interventions on quality of life in people with lung cancer: A systematic review and meta-analysis

AIM

To identify and appraise the quality of evidence of transitional care interventions on quality of life in lung cancer patients.

BACKGROUND

Quality of life is a strong predictor of survival. The transition from hospital to home is a high-risk period for patients' readmission and death, which seriously affect their quality of life.

DESIGN

Systematic review and meta-analysis.

METHODS

The PubMed, Embase, Cochrane Library, Web of Science and CINAHL databases were searched from inception to 22 October 2022. The primary outcome was quality of life. Statistical analysis was conducted using Review Manager 5.4, results were expressed as standard mean difference (SMD) with a 95% confidence interval (CI). The risk of bias of the included studies was assessed using the Cochrane risk of bias assessment tool. This study was complied with PRISMA guidelines and previously registered in PROSPERO (CRD42023429464).

RESULTS

Fourteen randomized controlled trials were included consisting of a total of 1700 participants, and 12 studies were included in the meta-analysis. It was found that transitional care interventions significantly improved quality of life (SMD = 0.21, 95% CI: 0.02 to 0.40, p = .03) and helped reduce symptoms (SMD = -0.65, 95% CI: -1.13 to -0.18, p = .007) in lung cancer patients, but did not significantly reduce anxiety and depression, and the effect on self-efficacy was unclear.

CONCLUSIONS

This study shows that transitional care interventions can improve quality of life and reduce symptoms in patients, and that primarily educational interventions based on symptom management theory appeared to be more effective. But, there was no statistically significant effect on anxiety and depression.

RELEVANCE TO CLINICAL PRACTICE

This study provides references for the application of transitional care interventions in the field of lung cancer care, and encourages nurses and physicians to apply transitional care plans to facilitate patients' safe transition from hospital to home.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Interventions for Concerning Patient-Reported Outcomes in Routine Cancer Care: A Systematic Review

IMPORTANCE

Collecting patient-reported outcomes (PROs) in routine cancer care improves patient-clinician communication, decision making, and overall patient satisfaction. Recommendations exist regarding standardized ways to collect, store, and interpret PRO data. However, evidence on incorporating PROs into cancer process of care, especially the type of HIs that are warranted after observing a concerning PRO and the effectiveness of these HIs are lacking.

OBJECTIVE

This study summarizes HIs triggered after PRO completion and their effectiveness in improving patient outcomes for adults being treated for cancer types that are resource intensive and associated with high symptom burden [i.e., gastrointestinal (GI), lung, and head and neck cancer (HNC)]. Secondary outcomes included factors associated with poor implementation of PROs.

EVIDENCE REVIEW

A literature search of peer-reviewed publications on MEDLINE, CINAHL Plus, APA PsycInfo, Scopus, and Cochrane was conducted following PRISMA guidelines from 1 January 2012, to 31 July 2022. Trial and real-world studies describing HIs after PRO completion for adult patients being treated for GI, lung, and HNC were included. Sixteen studies involving 144,496 patients were included. The Joanna Briggs Institute critical appraisal checklist was used to assess risk of bias.

FINDINGS

Of the 16 included studies, 5 included patients with HNC. Commonly used PRO measurement tools were the PRO-CTCAE and ESAS. Only three studies reported specific HIs delivered in response to concerning PROs and measured their effectiveness on patient outcomes. In all three studies, these HIs significantly improved cancer-related care. The most common HIs undertaken in response to concerning PROs were referrals to other specialists/allied healthcare professionals, medication changes, or self-management advice. Provider-related barriers to PRO measurement and delivery included the overwhelming number of alerts, the time required to address each PRO and the unclear role of healthcare providers in response to these alerts. Patient-related barriers included lower digital literacy and socioeconomic status, older age, rural living, and patients suffering from GI and HNC.

CONCLUSIONS AND RELEVANCE

This review highlights that PRO-triggered HIs are heterogenous and can improve patient quality of life. Further studies are necessary to determine the types of interventions with the greatest impact on patient care and outcomes.

Implementing cancer symptom management interventions utilizing patient-reported outcomes: a pre-implementation evaluation of barriers and facilitators

PURPOSE

Symptoms can negatively impact quality of life for patients with a history of cancer. Digital, electronic health record (EHR)-integrated approaches to routine symptom monitoring accompanied by evidence-based interventions for symptom management have been explored as a scalable way to improve symptom management, particularly between clinic visits. However, little research has evaluated barriers and facilitators to implementing these approaches in real-world settings, particularly during the pre-implementation phase. Pre-implementation assessment is critical for informing the selection and sequencing of implementation strategies and intervention adaptation. Thus, this study sought to understand pre-implementation perceptions of a remote cancer symptom monitoring and management intervention that uses electronic patient-reported outcome measures for symptom assessment.

METHODS

We interviewed 20 clinical and administrative stakeholders from 4 geographic regions within an academic medical center and its affiliated health system during the months prior to initiation of a stepped-wedge, cluster randomized pragmatic trial. Transcripts were coded using the Consolidated Framework for Implementation Research [CFIR] 2.0. Two study team members reviewed coded transcripts to understand how determinants were relevant in the pre-implementation phase of the trial and prepared analytic memos to identify themes.

RESULTS

Findings are summarized in four themes: (1) ability of the intervention to meet patient needs [recipient characteristics], (2) designing with care team needs in mind [innovation design and adaptability], (3) fit of the intervention with existing practice workflows [compatibility], and (4) engaging care teams early [engaging deliverers].

CONCLUSION

Attention to these aspects when planning intervention protocols can promote intervention compatibility with patients, providers, and practices thereby increasing implementation success.

Palliative care for cancer patients during the COVID-19 pandemic: A narrative synthesis from 36 studies of 16 countries

BACKGROUND

During the COVID-19 epidemic, palliative care has become even more indispensable for cancer patients.

AIM

To identify the changes in palliative care for cancer patients and improvements in palliative care quality during the COVID-19 pandemic.

DESIGN

A systematic review and narrative synthesis was conducted in PubMed, Embase and Web of Science. An evaluation tool using mixed methods was used to assess the quality of the study. The main relevant themes identified were used to group qualitative and quantitative findings.

RESULTS

A total of 36 studies were identified, primarily from different countries, with a total of 14,427 patients, 238 caregivers and 354 health care providers. Cancer palliative care has been experiencing several difficulties following the COVID-19 pandemic, including increased mortality and infection rates as well as delays in patient treatment that have resulted in poorer prognoses. Treatment providers are seeking solutions such as electronic management of patients and integration of resources to care for the mental health of patients and staff. Telemedicine plays an important role in many ways but cannot completely replace traditional treatment. Clinicians strive to meet patients' palliative care needs during special times and improve their quality of life.

CONCLUSIONS

Palliative care faces unique challenges during the COVID-19 epidemic. With adequate support to alleviate care-related challenges, patients in the home versus hospital setting will be able to receive better palliative care. In addition, this review highlights the importance of multiparty collaboration to achieve personal and societal benefits of palliative care.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Phone contacts and treatment discontinuation predict survival cancer patients in a subsidized drug access program

Aim: Survival of patients with Hodgkin's lymphoma is lower in in low- and middle-income countries, but factors leading to these outcomes are poorly understood. The objective of this study was to identify predictive factors associated with overall survival among cancer patients undergoing therapy in seven low- and middle-income countries. Materials & methods: A multicenter cohort was conducted in Egypt, Malaysia, Mexico, Peru, Philippines, Thailand and Ukraine. Results. A total of 460 patients were included. Phone-based support during patient follow-up and number of patients seen by the physician provided a positive impact, while the number of adverse events remains a predictor of death and physician decision to stop treatment. Conclusion: Furthers research on the potential benefit of phone-based programs to support patients with chronic diseases treatments should be explored in less developed countries.