Assessing Patient-Reported Outcomes in Routine Cancer Clinical Care Using Electronic Administration and Telehealth Technologies: Realist Synthesis of Potential Mechanisms for Improving Health Outcomes

BACKGROUND

The routine measurement of patient-reported outcomes in cancer clinical care using electronic patient-reported outcome measures (ePROMs) is gaining momentum worldwide. However, a deep understanding of the mechanisms underpinning ePROM interventions that could inform their optimal design to improve health outcomes is needed.

OBJECTIVE

This study aims to identify the implicit mechanisms that underpin the effectiveness of ePROM interventions and develop program theories about how and when ePROM interventions improve health outcomes.

METHODS

A realist synthesis of the literature about ePROM interventions in cancer clinical care was performed. A conceptual framework of ePROM interventions was constructed to define the scope of the review and frame the initial program theories. Literature searches of Ovid MEDLINE, Ovid Embase, Scopus, and CINAHL, supplemented by citation tracking, were performed to identify relevant literature to develop, refine, and test program theories. Quality appraisal of relevant studies was performed using the Mixed Methods Appraisal Tool.

RESULTS

Overall, 61 studies were included in the realist synthesis: 15 (25%) mixed methods studies, 9 (15%) qualitative studies, 13 (21%) descriptive studies, 21 (34%) randomized controlled trials, and 3 (5%) quasi-experimental studies. In total, 3 initial program theories were developed regarding the salient components of ePROM interventions-remote self-reporting, real-time feedback to clinicians, and clinician-patient telecommunication. The refined theories posit that remote self-reporting enables patients to recognize and report symptoms accurately and empowers them to communicate these to clinicians, real-time feedback prompts clinicians to manage symptoms proactively, and clinician-patient telephone interactions and e-interactions between clinic encounters improve symptom management by reshaping how clinicians and patients communicate. However, the intervention may not achieve the intended benefit if ePROMs become a reminder to patients of their illness and are not meaningful to them and when real-time feedback to clinicians lacks relevance and increases the workload.

CONCLUSIONS

The key to improving health outcomes through ePROM interventions is enabling better symptom reporting and communication through remote symptom self-reporting, promoting proactive management of symptoms through real-time clinician feedback, and facilitating clinician-patient interactions. Patient engagement with self-reporting and clinician engagement in responding to feedback are vital and may reinforce each other in improving outcomes. Effective ePROM interventions might fundamentally alter how clinicians and patients interact between clinic encounters.

Readiness for implementation of novel digital health interventions for postoperative monitoring: a systematic review and clinical innovation network analysis

An increasing number of digital health interventions (DHIs) for remote postoperative monitoring have been developed and evaluated. This systematic review identifies DHIs for postoperative monitoring and evaluates their readiness for implementation into routine health care. Studies were defined according to idea, development, exploration, assessment, and long-term follow-up (IDEAL) stages of innovation. A novel clinical innovation network analysis used coauthorship and citations to examine collaboration and progression within the field. 126 DHIs were identified, with 101 (80%) being early stage innovations (IDEAL stage 1 and 2a). None of the DHIs identified had large-scale routine implementation. There is little evidence of collaboration, and there are clear omissions in the evaluation of feasibility, accessibility, and the health-care impact. Use of DHIs for postoperative monitoring remains at an early stage of innovation, with promising but generally low-quality supporting evidence. Comprehensive evaluation within high-quality, large-scale trials and real-world data are required to definitively establish readiness for routine implementation.

Mobile devices and wearable technology for measuring patient outcomes after surgery: a systematic review

Complications following surgery are common and frequently occur the following discharge. Mobile and wearable digital health interventions (DHI) provide an opportunity to monitor and support patients during their postoperative recovery. Lack of high-quality evidence is often cited as a barrier to DHI implementation. This review captures and appraises the current use, evidence base and reporting quality of mobile and wearable DHI following surgery. Keyword searches were performed within Embase, Cochrane Library, Web of Science and WHO Global Index Medicus databases, together with clinical trial registries and Google scholar. Studies involving patients undergoing any surgery requiring skin incision where postoperative outcomes were measured using a DHI following hospital discharge were included, with DHI defined as mobile and wireless technologies for health to improve health system efficiency and health outcomes. Methodological reporting quality was determined using the validated mobile health evidence reporting and assessment (mERA) guidelines. Bias was assessed using the Cochrane Collaboration tool for randomised studies or MINORS depending on study type. Overall, 6969 articles were screened, with 44 articles included. The majority (n = 34) described small prospective study designs, with a high risk of bias demonstrated. Reporting standards were suboptimal across all domains, particularly in relation to data security, prior patient engagement and cost analysis. Despite the potential of DHI to improve postoperative patient care, current progress is severely restricted by limitations in methodological reporting. There is an urgent need to improve reporting for DHI following surgery to identify patient benefit, promote reproducibility and encourage sustainability.

Mobile health technology for remote home monitoring after surgery: a meta-analysis

BACKGROUND

Mobile health (mHealth) technology has been proposed as a method of improving post-discharge surveillance. Little is known about how mHealth has been used to track patients after surgery and whether its use is associated with differences in postoperative recovery.

METHODS

Three databases (PubMed, MEDLINE and the Cochrane Central Registry of Controlled Trials) were searched to identify studies published between January 1999 and February 2021. Mobile health was defined as any smartphone or tablet computer capable of electronically capturing health-related patient information and transmitting these data to the clinical team. Comparable outcomes were pooled via meta-analysis with additional studies compiled via narrative review. The quality of each study was assessed based on Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.

RESULTS

Forty-five articles met inclusion criteria. While the majority of devices were designed to capture general health information, others were specifically adapted to the expected outcomes or potential complications of the index procedure. Exposure to mHealth was associated with fewer emergency department visits (odds ratio 0.42, 95 per cent c.i. 0.23 to 0.79) and readmissions (odds ratio 0.47, 95 per cent c.i. 0.29 to 0.77) as well as accelerated improvements in quality of life after surgery. There were limited data on other postoperative outcomes.

CONCLUSION

Remote home monitoring via mHealth is feasible, adaptable, and may even promote more effective postoperative care. Given the rapid expansion of mHealth, physicians and policymakers need to understand these technologies better so that they can be integrated into high-quality clinical care.

Post-discharge Telemonitoring of Physical Activity, Vital Signs, and Patient-Reported Symptoms in Older Patients Undergoing Cancer Surgery

BACKGROUND

Postoperative home monitoring could potentially detect complications early, but evidence in oncogeriatric surgery is scarce. Therefore, we evaluated whether post-discharge physical activity, vital signs, and patient-reported symptoms are related to post-discharge complications and hospital readmissions in older patients undergoing cancer surgery.

METHODS

In this observational cohort study, we monitored older patients (≥65 years of age) undergoing cancer surgery, for 2 weeks post-discharge using tablet-based applications and connected devices. Outcome measures were post-discharge complications and readmissions; physical activity and patient-reported symptoms over time; and threshold violations for physical activity (step count <1000 steps/day), vital signs (temperature <36°C or >38°C; blood pressure <100/60 mmHg or >150/100 mmHg; heart rate <50 bpm or >100 bpm; weight -5% or +5% of weight at discharge); and patient-reported symptoms (pain score greater than the previous day; presence of dyspnea, vomiting, dizziness, fever).

RESULTS

Of 58 patients (mean age 72 years), 24 developed a post-discharge complication and 13 were readmitted. Measured parameters indicated 392 threshold violations out of 5379 measurements (7.3%) in 40 patients, mostly because of physical inactivity. Patients with readmissions had lower physical activity at discharge and at day 9 after discharge and violated a physical activity threshold more often. Patients with post-discharge complications had a higher median pain score compared with patients without these adverse events. No differences in threshold violations of other parameters were observed between patients with and without post-discharge complications and readmissions.

CONCLUSION

Our results show the potential of telemonitoring older patients after cancer surgery but confirm that detecting post-discharge complications is complex and multifactorial.

Patient generated health data and electronic health record integration in oncologic surgery: A call for artificial intelligence and machine learning

In this review, we aim to assess the current state of science in relation to the integration of patient-generated health data (PGHD) and patient-reported outcomes (PROs) into routine clinical care with a focus on surgical oncology populations. We will also describe the critical role of artificial intelligence and machine-learning methodology in the efficient translation of PGHD, PROs, and traditional outcome measures into meaningful patient care models.

National Study of Immediate and Delayed Readmissions After Colostomy Creation

BACKGROUND

Readmissions after colorectal operations adversely impact patient recovery and are associated with about $300 million in additional health care expenditure in the United States alone. The present study aimed to characterize nonelective, short-term readmissions of colorectal surgery patients who underwent colostomy.

METHODS

The Nationwide Readmissions Database was used to identify patients who received a colostomy from 2010 to 2015. Patients were stratified by discharge-to-readmission interval: immediate (within 7 d) and delayed (7-30 d). Nonparametric trend analysis and multivariable regression were performed to identify predictors of immediate and delayed readmission.

RESULTS

Of an estimated 376,693 operations requiring colostomies during the study, in-hospital survival was 92.3%, with higher rates after elective compared with nonelective operations (96.5 versus 90.8%, P < 0.001). Overall, 15.3% patients undergoing elective and nonelective colostomy creation returned to the hospital within 30 d, with 41.6% of these readmissions occurring by the first week of discharge (immediate). Readmission rates and proportion of immediate and delayed groups did not significantly change over the 6-year study period. Nonhome discharge increased the odds of immediate (AOR 1.25, 95% CI 1.17-1.34) and delayed readmission (AOR 1.44, 95% CI 1.35-1.54). Annually, immediate and delayed rehospitalizations after colostomy creation were responsible for $64 and 82 million in excess costs, respectively.

CONCLUSIONS

Colostomy creation is associated with a steady and high rate of rehospitalization. Nonhome discharge, in addition to several patient comorbidities, is associated with higher odds of readmission. Programs aimed at reduction of immediate readmission are warranted.

Use of Mobile Devices to Help Cancer Patients Meet Their Information Needs in Non-Inpatient Settings: Systematic Review

BACKGROUND

The shift from inpatient to outpatient cancer care means that patients are now required to manage their condition at home, away from regular supervision by clinicians. Subsequently, research has consistently reported that many patients with cancer have unmet information needs during their illness. Mobile devices, such as mobile phones and tablet computers, provide an opportunity to deliver information to patients remotely. To date, no systematic reviews have evaluated how mobile devices have been used specifically to help patients meet to their information needs.

OBJECTIVE

A systematic review was conducted to identify studies that describe the use of mobile interventions to enable patients with cancer meet their cancer-related information needs in non-inpatient settings, and to describe the effects and feasibility of these interventions.

METHODS

MEDLINE, Embase, and PsycINFO databases were searched up until January 2017. Search terms related to "mobile devices," "information needs," and "cancer" were used. There were no restrictions on study type in order to be as inclusive as possible. Study participants were patients with cancer undergoing treatment. Interventions had to be delivered by a mobile or handheld device, attempt to meet patients' cancer-related information needs, and be for use in non-inpatient settings. Critical Appraisal Skills Programme checklists were used to assess the methodological quality of included studies. A narrative synthesis was performed and findings were organized by common themes found across studies.

RESULTS

The initial search yielded 1020 results. We included 23 articles describing 20 studies. Interventions aimed to improve the monitoring and management of treatment-related symptoms (17/20, 85%), directly increase patients' knowledge related to their condition (2/20, 10%), and improve communication of symptoms to clinicians in consultations (1/20, 5%). Studies focused on adult (17/20; age range 24-87 years) and adolescent (3/20; age range 8-18 years) patients. Sample sizes ranged from 4-125, with 13 studies having 25 participants or fewer. Most studies were conducted in the United Kingdom (12/20, 52%) or United States (7/20, 30%). Of the 23 articles included, 12 were of medium quality, 9 of poor quality, and 2 of good quality. Overall, interventions were reported to be acceptable and perceived as useful and easy to use. Few technical problems were encountered. Adherence was generally consistent and high (periods ranged from 5 days to 6 months). However, there was considerable variation in use of intervention components within and between studies. Reported benefits of the interventions included improved symptom management, patient empowerment, and improved clinician-patient communication, although mixed findings were reported for patients' health-related quality of life and anxiety.

CONCLUSIONS

The current review highlighted that mobile interventions for patients with cancer are only meeting treatment or symptom-related information needs. There were no interventions designed to meet patients' full range of cancer-related information needs, from information on psychological support to how to manage finances during cancer, and the long-term effects of treatment. More comprehensive interventions are required for patients to meet their information needs when managing their condition in non-inpatient settings. Controlled evaluations are needed to further determine the effectiveness of these types of intervention.

Patient-reported outcome use in oncology: a systematic review of the impact on patient-clinician communication

PURPOSE

Patient-reported outcomes (PROs) are an increasingly popular tool to optimize care and bridge the gap between patient experience and clinician understanding. The aim of this review was to identify mechanisms through which PROs facilitate patient-clinician communication in the adult oncology population.

METHODS

We conducted a systematic review of the published literature using the following data sources: MEDLINE, EMBASE, CINAHL, PsycINFO, Cab Direct, and CDSR. Studies included in this review reported on the outcomes of PRO use, used PROs as an intervention and not as a study outcome measurement tool, included cancer patients or survivors as study participants, and analyzed patient-clinician communication.

RESULTS

We identified 610 unique records, of which 43 publications met the inclusion and exclusion criteria. Synthesis of the reviewed studies provided evidence of the usefulness of PROs in facilitating patient-clinician communication on a variety of topics. We identified mechanisms though which PROs influenced patient-clinician communication to include increasing symptom awareness, prompting discussion, streamlining consultations, and facilitating inter-professional communication. Barriers to PRO use in communication improvement include technical problems impeding its administration and completion, compliance issues due to lack of incentive or forgetfulness, and use of PROs that do not appropriately assess issues relevant to the patient. Facilitators include increased education on PRO use, using PRO tools that patients find more acceptable, and providing patient data summaries in an easily accessible format for clinicians.

CONCLUSIONS

Our review suggests that PROs facilitate patient-clinician communication through various mechanisms that could perhaps contribute to improvements in symptom management and survival. The impact of PROs on clinical outcomes, however, remains poorly studied.