Association Between Remote Monitoring and Acute Care Visits in High-Risk Patients Initiating Intravenous Antineoplastic Therapy

PURPOSE

Traditional oncology care models have not effectively identified and managed at-risk patients to prevent acute care. A next step is to harness advances in technology to enable patients to report symptoms any time, enabling digital hovering-intensive symptom monitoring and management. Our objective was to evaluate a digital platform that identifies and remotely monitors high-risk patients initiating antineoplastic therapy with the goal of preventing acute care visits.

METHODS

This was a single-institution matched cohort quality improvement study conducted at a National Cancer Institute-designated cancer center between January 1, 2019, and March 31, 2020. Eligible patients were those initiating intravenous antineoplastic therapy who were identified as high risk for seeking acute care. Enrolled patients' symptoms were monitored using a digital platform. A dedicated team of clinicians managed reported symptoms. The primary outcomes of emergency department visits and hospitalizations within 6 months of treatment initiation were analyzed using cumulative incidence analyses with a competing risk of death.

RESULTS

Eighty-one patients from the intervention arm were matched by stage and disease with contemporaneous high-risk control patients. The matched cohort had similar baseline characteristics. The cumulative incidence of an emergency department visit for the intervention cohort was 0.27 (95% CI, 0.17 to 0.37) at six months compared with 0.47 (95% CI, 0.36 to 0.58) in the control (P = .01) and of an inpatient admission was 0.23 (95% CI, 0.14 to 0.33) in the intervention cohort versus 0.41 (95% CI, 0.30 to 0.51) in the control (P = .02).

CONCLUSION

The narrow employment of technology solutions to complex care delivery challenges in oncology can improve outcomes and innovate care. This program was a first step in using a digital platform and a remote team to improve symptom care for high-risk patients.

Association between remote monitoring and acute care visits in high-risk patients initiating intravenous antineoplastic therapy

1578

Background: Acute care visits (emergency department [ED] visits or inpatient admissions) for patients with cancer are growing disproportionately. Traditional oncology care models have not effectively identified and managed at-risk patients to prevent acute care. A next step is to harness advances in technology and mobile applications to enable patients to report symptoms any time, enabling “digital hovering” - intensive monitoring and management of high-risk patients. Our objective was to evaluate a digital platform that identifies and remotely monitors high-risk patients initiating intravenous antineoplastic therapy with the goal of preventing unnecessary acute care visits. Methods: This was a single-institution matched cohort quality improvement study conducted at an NCI-designated cancer center between January 1, 2019 and March 31, 2020. Eligible patients were those initiating intravenous antineoplastic therapy who were identified as high-risk for seeking acute care. Patients were identified as high-risk for an acute care visit by their oncologist with decision support from a web-based machine learning model. Enrolled patients’ symptoms were monitored using a digital platform. The platform is integrated into the EMR and includes: 1) a secure patient portal enabling communication and daily delivery of electronic patient-reported outcomes symptom assessments; 2) clinical alerts for concerning symptoms; and 3) a symptom trending application. A dedicated team of registered nurses and nurse practitioners managed reported symptoms. These clinicians acted as an extension of the primary oncology team, assisting with patient management exclusively through the platform. The primary outcomes evaluated were incidence of ED visits and inpatient admissions within six months of intravenous antineoplastic initiation. Results: Eighty-one high-risk patients from the intervention arm were matched by stage and disease with contemporaneous high-risk control patients. Matched cohorts had similar baseline characteristics, including age, sex, race, and treatment. ED visits and hospitalizations within six months of treatment initiation were analyzed using cumulative incidence analyses with a competing risk of death. The cumulative incidence of an ED visit for the intervention cohort was 0.27 (95% CI: 0.17, 0.37) at six months compared to 0.47 (95% CI: 0.36, 0.58) in the control group (p = 0.01). The cumulative incidence of an inpatient admission was 0.23 (95% CI: 0.14, 0.33) in the intervention group versus 0.41 (95% CI: 0.30, 0.51) in the control group (p = 0.02). Conclusions: The narrow employment of technology solutions to complex care delivery challenges in oncology can improve outcomes and innovate care. This program was a first step in using a digital platform and a remote team to improve symptom care in the home for high-risk patients.

Oncology Patients' Perspectives on Remote Patient Monitoring for COVID-19

PURPOSE

Oncology patients are vulnerable to adverse outcomes associated with COVID-19, and clinical deterioration must be identified early. Several institutions launched remote patient monitoring programs (RPMPs) to care for patients with COVID-19. We describe patients' perspectives on a COVID-19 RPMP at a National Comprehensive Cancer Center.

METHODS

Patients who tested positive for COVID-19 were eligible. Enrolled patients received a daily electronic COVID-19 symptom assessment, and a subset of high-risk patients also received a pulse oximeter. Monitoring was provided by a centralized team and was discontinued 14 days after a patient's positive test result and following 3 days without worsening symptoms. Patients who completed at least one assessment and exited the program were sent a patient engagement survey to evaluate the patient's experience with digital monitoring for COVID-19.

RESULTS

The survey was distributed to 491 patients, and 257 responded (52% completion rate). The net promoter score was 85%. Most patients agreed that the RPMP was worthwhile, enabled better management of their COVID-19 symptoms, made them feel more connected to their healthcare team, and helped prevent emergency room visits. Identified themes regarding patient-perceived value of a RPMP included (1) security: a clinical safety net; (2) connection: a link to their clinical team during a period of isolation; and (3) empowerment: an education on the virus and symptom management.

CONCLUSION

RPMPs are perceived to be of value to oncology patients with COVID-19. Policymakers should consider how these programs can be reimbursed to keep vulnerable patients at home and out of the acute care setting.

InSight Care Pilot Program: Redefining Seeing a Patient

PURPOSE

Early detection and management of symptoms in patients with cancer improves outcomes. However, the optimal approach to symptom monitoring and management is unknown. InSight Care is a mobile health intervention that captures symptom data and facilitates patient-provider communication to mitigate symptom escalation.

PATIENTS AND METHODS

Patients initiating antineoplastic treatment at a Memorial Sloan Kettering regional location were eligible. Technology supporting the program included the following: a predictive model that identified patient risk for a potentially preventable acute care visit; a secure patient portal enabling communication, televisits, and daily delivery of patient symptom assessments; alerts for concerning symptoms; and a symptom-trending application. The main outcomes of the pilot were feasibility and acceptability evaluated through enrollment and response rates and symptom alerts, and perceived value evaluated on the basis of qualitative patient and provider interviews.

RESULTS

The pilot program enrolled 100 high-risk patients with solid tumors and lymphoma (29% of new treatment starts v goal of 25%). Over 6 months of follow-up, the daily symptom assessment response rate was 56% (the goal was 50%), and 93% of patients generated a severe symptom alert. Patients and providers perceived value in the program, and archetypes were developed for program improvement. Enrolled patients were less likely to use acute care than were other high-risk patients.

CONCLUSION

InSight Care was feasible and holds the potential to improve patient care and decrease facility-based care. Future work should focus on optimizing the cadence of patient assessments, the workforce supporting remote symptom management, and the return of symptom data to patients and clinical teams.

Pilot program of remote monitoring for high-risk patients on antineoplastic treatment

2027

Background: Early detection and management of symptoms in patients with cancer improves outcomes, however, the optimal approach to symptom monitoring and management is unknown. This pilot program uses a mobile health intervention to capture and make accessible symptom data for high-risk patients to mitigate symptom escalation. Methods: Patients initiating antineoplastic treatment at a Memorial Sloan Kettering regional location were eligible. A dedicated staff of RNs and nurse practitioners managed the patients remotely. The technology supporting the program included: 1) a predictive model that identified patients at high risk for a potentially preventable acute care visit; 2) a patient portal enabling daily ecological momentary assessments (EMA); 3) alerts for concerning symptoms; 4) an application that allowed staff to review and trend symptom data; and 5) a secure messaging platform to support communications and televisits between staff and patients. Feasibility and acceptability were evaluated through enrollment (goal ≥25% of new treatment starts) and response rates (completion of > 50% of daily symptom assessments); symptom alerts; perceived value based on qualitative interviews with patients and providers; and acute care usage. Results: Between October 15, 2018 and July 10, 2019, the pilot enrolled 100 high-risk patients with solid tumors and lymphoma initiating antineoplastic treatment (median age: 66 years, 45% female). This represented 29% of patients starting antineoplastics. Over six months of follow-up, the response rate to the daily assessments was 56% and 93% of patients generated a severe symptom alert (Table). Both patients and providers perceived value in the program and 5,010 symptom-related secure messages were shared between staff and enrolled patients during the follow-up period. There was a preliminary signal in acute care usage with a 17% decrease in ED visits compared to a cohort of high-risk unenrolled patients. Conclusions: This pilot program of intensive monitoring of high-risk patients is feasible and holds significant potential to improve patient care and decrease hospital resources. Future work should focus on the optimal cadence of EMAs, the workforce to support remote symptom management, and how best to return symptom data to patients and clinical teams. [Table: see text]

From Theory to Practice: Implementation of Strategies to Reduce Acute Care Visits in Patients With Cancer

Patients with cancer frequently seek acute care as a result of complications of their disease and adverse effects of treatment. This acute care comes at high cost to the health care system and often results in suboptimal outcomes for patients and their caregivers. The Department of Health and Human Services has identified this as a gap in our care of patients with cancer and has called for quality-improvement efforts to reduce this acute care. We highlight the efforts of three centers-a community practice, an academic practice, and a cancer center-to reduce acute care for their patients. We describe the foundational principles, the practice innovation and implementation strategy, the initial results, and the lessons learned from these interventions. Each of the described interventions sought to integrate evidence-based best practices for reducing unplanned acute care. The first, a telephone triage system, led to 82% of calls being managed at home and only 2% being directed to an emergency department (ED) or hospital. The second, a 24-hour continuity clinic, led to a 26% reduction in ED utilization for patients with cancer. The third, a digital symptom monitoring and management program for high-risk patients on active treatment, led to a 17% reduction in ED presentations. There is a need for innovative care delivery models to improve the management of symptoms for patients with cancer. Future research is needed to determine the elements of these models with the greatest impact and how successful models can be scaled to other institutions.