Low risk, high benefit an argument for broader implementation

After ambulatory cancer surgery, remote electronic patient-reported symptom monitoring with nursing follow-up for clinical alerts helped cut down on avoidable urgent care visits for patients, according to an analysis from Memorial Sloan Kettering Cancer Center (MSKCC).

While postoperative symptoms are common, it can be difficult for patients to determine which symptoms are expected and which signify potentially serious events, such as infection, Brett A. Simon, MD, PhD, of the Josie Robertson Surgery Center at MSKCC, New York, and colleagues wrote in JAMA Surgery. The solution, they argued, may lie in remote, electronic symptom monitoring using patient-reported outcomes, which could potentially bridge the gap between patients and clinicians post-surgery and allow for improvements in patient-centered care, communication, and shared decision-making.

Enter the Recovery Tracker (RT) system, a symptom reporting tool developed and implemented at the Josie Robertson Surgery Center. The RT sends brief daily surveys to users via the MyMSK Patient Portal for 10 days to assess common postoperative symptoms; when patient reports exceed certain preset thresholds, the surgeon’s care team is automatically alerted for follow-up with the patient.

To assess whether the RT system helped patients better distinguish between post-surgery symptoms that could be managed at home and those that required hospital admission, Simon and colleagues examined unplanned MSK urgent care center (UCC) visits within 30 days after surgery before and after RT implementation to monitor changes in visits that did not lead to an admission.

“In this retrospective cohort study, electronic patient symptom reporting with clinical alerts after ambulatory cancer surgery was associated with a significant decrease in urgent care visits that did not result in readmission within 30 days post-operatively,” they found. “Importantly, we did not find an association with readmissions, suggesting that the reduction in avoidable visits was related to the intervention and not secular trends, such as improved perioperative technique. Moreover, this association provides evidence that the RT does not create a false sense of security and delay treatment of important problems.”

Simon and colleagues argued that the clinical relevance of their findings are clear: “for 111 patients offered the RT, 1 UCC visit without admission can be avoided. The change in clinic nurse workload associated with this benefit was an increase of less than 1 additional call per patient.”

In an invited commentary accompanying the study, Andrea L. Pusic, MD, MHS, of Brigham and Women’s Hospital in Boston, Pete Stetson, MD, MA, of MSKCC, and Larissa Temple, MD, of the University of Rochester in Rochester, New York, wrote that this study’s success “reveals an important and otherwise unmet need in ambulatory surgical care; namely, that outpatient surgery places considerable additional burdens on patients and caregivers, and they clearly benefit from timely, responsive systems to support them.”

However, they noted that an approach like the RT system “may be difficult to implement in hospitals that are not as centralized and well resourced as MSKCC.” And, they added, while this approach could potentially be applied for noncancer surgeries and other complex procedures with high readmission rates, “new, procedure-specific symptom data and alert setting would be required.”

Despite these observations, Pusic, Stetson, and Temple concluded that the study by Simon et al “clearly demonstrates the positive outcome of a well-planned and executed mobile health platform on clinical care. Such approaches have great potential to increase connectivity with patients and optimize surgical care, quality, and value.”

The retrospective cohort study was conducted from Sept. 20, 2016 (pre-RT implementation) through Dec. 31, 2018 (post-RT implementation). The cohort consisted of patients undergoing prostatectomy, nephrectomy, mastectomy with or without immediate reconstruction, hysterectomy, or thyroidectomy at the Josie Robertson Surgery Center before (n=4,195; median age 53 years; 3,490 women [83%]) and after (n=2,970; median age 56 years; 2,221 women [75%]) RT implementation.

The main study outcome was MSK UCC visits with and without readmission to the hospital within 30 days after surgery. Simon and colleagues also assessed added nursing workload by measuring patient phone calls, emails, and secure messages as documented in the electronic medical record.

“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=0.047),” they found. “Having responded to at least one survey was associated with a 42% reduction in the odds of a [UCC] visit without readmission (OR, 0.58; 95% CI, 0.39-0.87; P=0.007). 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<0.001), a 34% increase.”

While Simon and colleagues acknowledged that their observational study could not definitively determine causality, they argued that the fact that there was an association between RT and the hypothesized outcome, but not other outcomes (e.g., readmission), and that patients who responded to at least one survey saw an improved result, support a causal role for RT in reducing potentially avoidable UCC visits.

They also noted that implementing a postoperative symptom monitoring system has both benefits and drawbacks—while such a system can increase patient confidence, education, and connection to their clinical team, and although marginal costs are relatively low after the higher costs of initial implementation, “the workload of additional nursing calls is nontrivial; efforts to refine alert thresholds, for example, may reduce this incremental workload while maintaining the observed benefits.

“However, given the stress and inconvenience of an unnecessary UCC visit for patients and caregivers, we believe that, even in its present state of development, the RT adds value both for the patient and care team,” they continued. “Future enhancements should focus on improving this value proposition, improving the patient experience and outcomes, and reducing the workload for the clinical team.”

Study limitations included its retrospective design; potential underestimation of total acute care visits due to only capturing MSK UCC visits; patients in this study were generally healthier and had fewer complications than those undergoing inpatient surgeries; and high portal participation rates may reflect higher-than-average socioeconomic status, education, and engagement in care among the study population, potentially limiting applicability to other settings.

  1. Electronic patient symptom reporting with clinical alerts after ambulatory cancer surgery was associated with a significant decrease in urgent care visits that did not result in hospital readmission within 30 days post-operatively, researchers found.
  2. Patients who responded to at least one Recovery Tracker (RT) system survey saw a larger reduction in the odds of an urgent care center visit without readmission.

John McKenna, Associate Editor, BreakingMED™

The study authors had no relevant relationships to disclose.

Pusic reported receiving grants from the Patient-Centered Outcomes Research Institute outside the submitted work and being a co-developer of the BREAST-Q and receiving royalties when it is used in for-profit clinical trials. Temple reported grants from the Patient-Centered Outcomes Research Institute during the conduct of the study.


Cat ID: 159

Topic ID: 97,159,730,935,192,925,159