Learning From Real-world Implementation of Daily Home-Based Symptom Monitoring in Patients With Cancer

Abstract

Routine use of home-based symptom monitoring and management using electronic patientreported outcomes (ePRO) to improve care delivery is on the horizon. Randomized clinical trials demonstrate that use of patient-reported symptoms can have marked impact on patient outcomes, including minimizing symptom burden, enhancing quality of life, reducing hospitalizations, increasing time receiving cancer treatments, and, in some studies, improving survival. [1][2][3][4] As a result, these powerful tools are now recommended as part of value-based health care initiatives, including the proposed Oncology Care First Model by the Center for Medicare and Medicaid Innovation and the American Society of Clinical Oncology's Oncology Medical Home Model. 5 One might think that with this evidence, as well as the pressure from professional organizations and payers, that health care systems across the country would rapidly adopt this approach to patient care. However, this is not the case, and few health systems have successfully, fully integrated ePRO. 6 While the lack of adoption of this practice is multifactorial, one key component of the implementation gap is the lack of knowledge about how the intervention itself should be delivered as part of routine care.In the study by Daly and colleagues, 7 the authors begin to tackle an important question of frequency of assessment administration in ePRO. This study used daily symptom assessment in contrast to the weekly schedule that has been used in many of the prior studies. With the daily assessments, patients completed a mean (SD) of 3.9 (2.5) assessments per week in the initial 6 months, but this tapered off over time, falling to 2.7 (2.1) assessments being completed per week after 1 year of enrollment. While Daly et al 7 did not report a goal for completion, this falls well below the 80% to 85% completion rates observed in studies of weekly symptom monitoring and raises questions about the distribution of assessment responses. 8 Additionally, frequent assessments have the potential to lead to survey fatigue. Further work is needed to understand optimal frequency over the course of illness. For example, the frequency of assessment may be higher initially and taper as patients transition to the survivorship phase. In a 2019 study by Denis et al 2 of patients in surveillance for lung cancer, weekly symptoms were leveraged to identify new symptoms and recurrence, which was associated with a 19% survival difference at 2 years. While this may be ideal for a disease in which patients recur early after initial treatment, for diseases for which the course is more indolent with later recurrences (eg, metastatic hormone-sensitive breast cancer), a less frequent cadence may be more appropriate, given the length of time expected for completing assessments. Ultimately, robust studies are needed to understand both clinically meaningful timing and to garner patient perspectives on varying schedules.Another key consideration is that patients who do not complete assessments may be systematically differen...

Efficacy of the PRO-CTCAE mobile application for improving patient participation in symptom management during cancer treatment: a randomized controlled trial

“…A key benefit of the implementation of ePRO symptom monitoring is expected to be an improvement in patient participation in symptom management [ 20 ]. Patient-centered e-health services are generally expected to facilitate self-management and empowerment [ 21 ].…”

Effects of a change in recall period on reporting severe symptoms: an analysis of a pragmatic multisite trial

“…Integration of patient-reported outcomes into electronic health records for active symptom management is gaining traction ( 4-6 ). If electronic patient-reported outcomes are to be integrated successfully into routine practice, it is important to consider aspects of electronic patient-reported outcome deployment, including recall period, frequency of symptom reporting, and potential changes to clinic workflows resulting from increased alerts for severe or worsening symptoms ( 7 , 8 ).…”