Electronic patient-reported outcome-based symptom management, a new era in surgical patient management

We comment on Dr. Dai et al.’s well-designed study in Journal of Clinical Oncology (1). This article reports the results of a randomized clinical trial comparing standard postoperative care with electronic patient-reported outcomes (ePROs), where patients reported their symptoms immediately across five key domains, and these reports were transmitted directly to the surgical team. The focus of the study was on long-term outcomes (1 year), following an earlier publication from the same group detailing data from the first month (2).

In the initial study, ePRO was already shown to improve symptom control, and this new study demonstrated that this improvement was sustained over the long term. The findings showed that the ePRO group had lower composite scores for both physical and affective interference and reported better scores (indicating lower symptom severity) for fatigue, distress, appetite loss, work interference, enjoyment of life, walking ability, general activity, mood, and social relationships.

This work was built on previous studies with similar findings. For example, Cleeland et al. [2011] compared traditional follow-up care for cancer surgery patients with an automated call system that generates alerts for the surgical team based on patient-reported data (3). This study demonstrated that such an approach not only improved patient satisfaction but also led to a significant reduction in overall symptom interference. Since the coronavirus disease 2019 (COVID-19) pandemic, postoperative care for oncology patients has undergone substantial changes, with an exponential increase in non-face-to-face care (4). In this context, patient follow-up using ePRO has been proven to be a valuable tool, as demonstrated in this study. The same approach could be adapted to centralized healthcare systems, where surgical services cater to large populations, making physical access to healthcare more difficult.

When implementing this type of method, it is crucial to consider factors such as the geographical location of each hospital, the types of patients treated, and the distances to emergency care facilities. Additionally, we must be mindful of the volume of alerts generated. In this study, 65 patients triggered 968 symptom threshold events during postoperative hospitalization and the 4 weeks following discharge, resulting in 417 alerts. Healthcare systems need to be prepared to handle this volume of alerts and respond appropriately. This may require allocating specific resources, time, and space for such tasks. Previous studies have identified and categorized various barriers to the implementation of such methodologies. These include patient-related barriers [e.g., time required to complete Patient-Reported Outcomes Measures (PROMs), difficulty using electronic devices, perceived irrelevance of the data, concerns about privacy], barriers related to the medical team [e.g., insufficient time to interpret and act on data, lack of training in integrating patient-reported outcomes (PROs) into clinical practice, perceived uselessness of certain PRO data], and systemic barriers [e.g., inadequate integration into clinical workflows, insufficient information technology (IT) infrastructure] (5).

An important consideration in studies like this is what happens once the surgical team receives the alert. The team’s first publication described how the main actions included patient consultations, education, medication prescriptions, and recommendations for hospital visits, all of which were conducted according to relevant guidelines and clinical consensus. An interesting question is whether these actions can be standardized and optimized so that a portion of them could be handled by primary care physicians or nurses specifically trained for these tasks.

Another key aspect of ePRO tools is accessibility. Do they work for all patients? It is noteworthy that only 40% (166/418) of the patients in this study met the eligibility criteria. One of the inclusion criteria was that patients must be willing and able to complete the electronic questionnaire using smartphones or tablets. However, the study does not specify the proportion of excluded patients due to this limitation. This raises the question: can we conclude that ePRO tools are only useful for a specific subset of our patient population? In this regard, a recent study that explored the technological barriers associated with ePRO and examined the factors influencing their initial adoption and ongoing engagement, using the Capability, Opportunity, and Motivation Model for Behavior Change (COM-B), is particularly relevant (6). It may also be the case that, in the absence of an ideal model for intensive symptom monitoring, a combination of several models may be necessary for maximum effectiveness.

It is also important to note that clinical trials of this nature are prone to certain biases, particularly masking bias. Patients using these tools, which are sometimes perceived as technological advancements, may experience a placebo effect. In this sense, the fact that the beneficial effects of these tools last for up to 1 year is of considerable significance.

In summary, it is clear that patient monitoring, especially during the first month after surgery, leads to both short- and long-term improvements in symptoms. Different methods have been described for this purpose, including ePRO. We emphasize that patient adherence to the monitoring system is critical. Therefore, each department, hospital, or healthcare institution should develop a method tailored to its patient population to offer intensive non-face-to-face care during the first postoperative month, as this significantly improves outcomes.

The article presented is the result of a randomized clinical trial comparing usual postoperative care versus ePRO, where patients immediately report their symptoms on five targets and these are immediately reported to the surgeon. In this case, the article focuses on long-term outcomes (1 year) as previously the same group published data on the first month (2). In the first study it was already shown that follow-up with ePRO shows better symptom control, in this study it is shown that this improvement is prolonged in the long term. In this study, it was found that the group followed by means of ePRO had a lower composite score for physical interference and affective interference and also reported lower scores (it means, better scores) in fatigue, distress, lack of appetite, work, enjoyment of life, walking, general activity, mood and relations with others.

This work builds on previous work with similar results. For example, in the work of Cleeland et al. compares the usual follow-up of patients undergoing cancer surgery with automated calls that patients receive and that create alerts for the surgical team to act on (3). This paper of 2011 already demonstrates that this practice improves patient satisfaction and significant effect of reduction in overall symptom interference. After the COVID-19 pandemic, the postoperative management of oncology patients underwent a radical change in many respects exponentially increasing non-face-to-face care (4). In this sense, patient follow-up using ePRO can be a very useful tool as demonstrated in this article. The same could be applied to centralized healthcare systems where surgical services serve large population areas and therefore physical access may be more complex.

When applying this type of method, it is essential to analyze the situation and geographic location of each hospital, the type of patients treated, the distances to its emergency department, etc. We must be aware of the high number of reported alerts; in fact, in this study 65 patients generate during the postoperative hospitalization and 4 weeks after discharge, 968 symptom threshold events that brought 417 alerts. We must be prepared to receive this amount of alerts and act on them, so the healthcare system will have to provide space/time for this type of new task. This fact has been studied in different works where the barriers to this type of methodology are specified and classified into those dependent on the patient [time required to complete PROMs (patient reported outcome measures), patient inability to complete PROMs, difficulty using electronic devices to complete PROMs, perceived irrelevance of PROMs and their lack of value, concerns that PROMs may compromise the doctor to patient relationship, concerns around privacy], those dependent on the medical team (insufficient time to interpret, action and discuss PRO data with patients during clinics, lack of knowledge regarding how to interpret and integrate PROs into clinical practice, perceived uselessness of certain PRO data, difficulty using the electronic PRO collection system) and those dependent on the healthcare system itself (lack of integration into clinical workflows, inability to action ePRO data, inadequate IT infrastructure) (5).

In this line, it would be important to highlight in this type of study, what was done once the surgical team received the alert. The first paper published by this team describes that mainly included consultation, patient education, medication prescription, and hospital visit suggestions, which were conducted according to relevant guidelines and consensus. An interesting question would be whether these actions performed can be standardized and optimized so that at least a percentage can be solved by primary care physicians or nurses trained specifically for this task.

An essential aspect when talking about this kind of tool is accessibility. Do they work for all our patients? It is striking that in this same study only 40% (166/418) meet the eligibility criteria. One of the inclusion criteria was defined as patients who were willing and able to fill out the electronic questionnaire (e-questionnaire) on their smartphones or tablets. It is not specified, what proportion of not included patients has been for this reason. In other words, could we conclude that these tools are useful but only for a specific population of our patients? In this line, it is very interesting the recently published study where the technological barriers generated by ePRO are assumed and the factors influencing their initial uptake of and ongoing engagement with ePRO symptom monitoring guided by the COM-B are explored (6). It is also possible that in the absence of an ideal model for this type of intensive monitoring a combination of several models will be necessary for maximum effectiveness.

It should be noted that these clinical trials inherently have a clear masking bias and patients with the use of these tools, sometimes perceived by the general population as technological advances, may have a certain placebo effect. In this sense, the fact that the beneficial effect of these tools lasts up to 1 year is a matter of some relevance.

In summary, we believe it is evident that patient monitoring, especially during the first month, obtains short- and long-term improvements in patient symptoms. In this sense, different methods have been described, among them the ePRO. We would like to emphasize that patient adhesion and adherence to the system used are of great importance. Therefore, each department, hospital or health institution must create the method that best suits its patients to offer intensive non-face-to-face care during the first postoperative month, as this improves the results.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Thoracic Disease. The article has undergone external peer review.

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1427/prf

Funding: None.

Conflicts of interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1427/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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