Association Between Electronic Patient Symptom Reporting With Alerts and Potentially Avoidable Urgent Care Visits After Ambulatory Cancer Surgery

Abstract

IMPORTANCE Increasingly complex surgical procedures are being performed in the outpatient setting, increasing the burden on patients and caregivers to manage their postoperative symptoms. Electronic patient-reported symptom tracking may reduce this burden and help patients distinguish between expected symptoms and those requiring intervention.OBJECTIVE To determine whether electronic symptom reporting with clinical alerts for 10 days after ambulatory cancer surgery is associated with a reduction in potentially avoidable urgent care visits, defined as a visit not leading to admission. DESIGN, SETTING, AND PARTICIPANTSThis retrospective cohort study was conducted at the Josie Robertson Surgery Center (JRSC), Memorial Sloan Kettering Cancer Center's ambulatory surgery center with overnight stay capacity from September 20, 2016, to December 31, 2018. Patients undergoing prostatectomy, nephrectomy, mastectomy with or without immediate reconstruction, hysterectomy, or thyroidectomy at the surgery center before (n = 4195) and after (n = 2970) implementation of the Recovery Tracker (RT) electronic postoperative symptom survey were included. Data analyses were conducted from February 1 to November 24, 2020.EXPOSURES A short electronic survey assessing symptoms daily for 10 days after surgery, administered via the patient portal, with alerts to the clinical team and follow-up for concerning responses. MAIN OUTCOMES AND MEASURESThe main outcome was Memorial Sloan Kettering urgent care center visits with and without readmission and any readmission within 30 days after surgery. Nursing workload was measured by patient phone calls, emails, and secure messages as documented in the electronic medical record.RESULTS A total of 7165 patients were analyzed, including 4195 (median age, 53 [interquartile range (IQR), 44-63] years; 3490 women [83%]) from the pre-RT implementation period and 2970 (median age, 56 [IQR,[46][47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62][63][64][65] years; 2221 women [75%]) from after full implementation. On multivariable, intent-to-treat analysis by study period, having surgery in the post-RT period was associated with a 22% decrease in the odds of an urgent care center visit without readmission (OR, 0.78; 95% CI, 0.60-1.00; P = .047). Having responded to at least 1 survey was associated with a 42% reduction in the odds of an urgent care center visit without readmission (OR, 0.58; 95% CI, 0.39-0.87; P = .007). There was no change in the risk of admission. Nursing calls increased by a mean of 0.86 (95% CI, 0.75-0.98) calls per patient after RT implementation (P < .001), a 34% increase. CONCLUSIONS AND RELEVANCEIn this cohort study, electronic symptom reporting with nursing follow-up for clinical alerts was associated with a reduction in potentially avoidable urgent care visits. The low risk and high benefit of this intervention suggest that these systems should be more broadly implemented.

Lessons for Oncology From the COVID-19 Pandemic

“…Technologies such as connected devices (wearables and nonwearables) can passively or actively collect information from patients to transmit to providers 14 . Online platforms and mobile applications can help collect patient-reported outcome measures (PROMs) and guide patients through disease surveillance and symptom monitoring 15–17 . Tools such as artificial intelligence (AI)–powered chat bots can increase opportunities for conversational, bidirectional information exchange to provide information to patients and assist with triaging patients to the correct resources and clinical staff 18 …”

“…Data show that oncology patients can use virtual visits while receiving radiation and beginning systemic therapy without delays in treatment or increases in adverse events 40,42 . Multiple trials have shown that interventions incorporating PROMs and remote symptom monitoring into oncology care reduced avoidable acute care visits, improved quality of life, improved symptom control, and increased survival 15,17,83,84 . Data collected from wearable and nonwearable connected devices have been shown to correlate with clinically meaningful outcomes such as treatment toxicity and self-rated quality of life 14 .…”

“… 40 , 42 Multiple trials have shown that interventions incorporating PROMs and remote symptom monitoring into oncology care reduced avoidable acute care visits, improved quality of life, improved symptom control, and increased survival. 15 , 17 , 83 , 84 Data collected from wearable and nonwearable connected devices have been shown to correlate with clinically meaningful outcomes such as treatment toxicity and self-rated quality of life. 14 A recent prospective trial also showed that an intensive home hospital program for cancer patients reduced unplanned admissions and emergency room visits and substantially lowered the costs of care.…”

Quality and Safety in the Literature: May 2022

“…Computer and smartphone applications have been created for patients to track and report symptoms following discharge with the goal of mitigating complications and minimising the likelihood of readmission 44. A retrospective cohort study published in 2021 that examined the surgical oncology population found that implementation of such an intervention was associated with a 42% reduction in the odds of an urgent care centre visit within 30 days after discharge 45. While the results of cohort studies such as these are encouraging, randomised controlled trials to better assess the impact of remote monitoring programmes on postsurgery readmission rates are lacking.…”

A Randomized Controlled Trial Evaluating Electronic Outpatient Symptom Monitoring After Ambulatory Cancer Surgery

“…The Recovery Tracker is considered standard of care at the study institution and was developed with multi-stakeholder input to monitor patients remotely during the immediate postoperative period. 11,12 In brief, it includes 19 questions adapted from the validated PRO version of the Common Terminology Criteria for Adverse Events 14 delivered to patients daily via the MyMSK Patient Portal for 10 days after surgery (Fig. 1A).…”