“Compared with usual care (UC), patient-reported outcome (PRO)-based symptom management can decrease symptom burden, improve QOL, cut ED visits, and extend survival time in patients undergoing systemic cancer treatment,” explains Qiuling Shi, MD, PhD. “In 2011, using the Interactive Voice Response system, researchers in the United States proved that patients receiving PRO-based symptom management would have a lower symptom burden than those receiving UC following lung cancer surgery. As a result of increased Internet access, the web-based electronic PRO (ePRO) demonstrates the potential to improve care delivery by allowing clinicians to better monitor patient outcomes in real-time. However, whether this technique will enhance recovery from cancer surgery, both in-hospital and after discharge, and to what extent the ePRO will burden the healthcare system, remain understudied.”

For a paper published in the Journal of Clinical Oncology, Dr. Shi and colleagues sought to assess the efficacy and feasibility of PRO-based symptom management soon after lung cancer surgery. They performed a multicenter, randomized controlled trial (RCT) consisting of 166 participants.

Surgeons Responded to 100% of Symptom Alerts Within 24 Hours

Prior to surgery, patients with clinically diagnosed lung cancer were randomly assigned 1:1 to post-operative PRO-based symptom management or UC. Patients described symptoms using the MD Anderson Symptom Inventory before surgery, daily after surgery, and twice a week following discharge for as long as 4 weeks through an ePRO system. In the intervention group, treating surgeons managed over-threshold electronic alerts caused by any of the five target symptom scores (score ≥4 on a 0-10 scale for pain, fatigue, disturbed sleep, shortness of breath, and coughing). The control group was treated with UC and no alerts were generated. Total symptom threshold events (any target symptom with a score of ≥4) at discharge served as the primary outcome.

“We found that during post-operative hospitalization and 4 weeks after discharge, the intervention group produced 968 symptom threshold events, along with 417 alerts,” Dr. Shi says. “Surgeons reacted to 100% of the symptom alerts within 24 hours. At discharge, the intervention group reported fewer symptom threshold events than the control group. At 4 weeks post-discharge, this difference was maintained between the intervention and control groups. The intervention group also had a lower complication rate than the control group.”

The study team also observed that surgeons took a median of 3 minutes addressing an alert and only 24.7% of alerts took 5 or more minutes to manage. Most patients (96.4%) in the intervention group found the PRO-based symptom management approach helpful. Although the composite symptom score of the five target symptoms was similar between the two groups during hospitalization, it was significantly lower in the intervention group than in the control group throughout the first 4 weeks after discharge (Figure). “The takeaway from this is that rather than providing patients with the ePRO-based system as after-discharge care, implementing this system immediately after surgery may benefit patients with a quicker recovery,” Dr. Shi says.

Integration of Patient-Reported Outcome-Based Symptom Management into Daily Ward Rounds

Dr. Shi and colleagues conclude that ePRO-based symptom management after lung cancer surgery was associated with decreased symptom burden, improved functional status, and fewer complications in the early post-operative period. “Moreover, our study showed that this patient care approach—comprising electronic symptom monitoring and rapid response to the over-threshold alerts—had an acceptable surgeon burden, high surgeon acceptability, and high patient satisfaction. This high acceptance and high response rate may be attributed to the integration of ePRO assessments into daily ward rounds during the in-hospital phase.”

To further lessen the burden on doctors and increase real-world feasibility, the researchers suggest that the ideal model may be one where symptom alerts are intelligently triaged and automatically looped into an applicable pathway for intervention by self-management or a team of nurses and doctors.

In the future, the study team would like to see the ePRO care model used for other major types of surgeries, such as post-open abdominal, brain, or bone surgeries, during the first 30 days for reducing risk for complications and significantly improving recovery. “This study provides evidence of the utility of effective digital therapy with ePRO plus triage platform during post-operative care,” Dr. Shi says.