In the 1980s the emergence of a previously unknown, lethal disease—acquired immune deficiency syndrome or AIDS, as it rapidly became known—rocked the world of infectious disease medicine, but the eventual discovery of the viral culprit, HIV, paved the way for science to develop treatments initially to treat the disease and eventually to prevent HIV infection from progressing to AIDS.
That experience provided valuable lessons for oncology—and now, as the U.S. sees a decline in Covid-19 infections, there are signs that this pandemic will likewise provide lessons and possibly new clinical management strategies for oncologists and their patients.
The increase in the use of and payment for telemedicine is one oft-cited consequence of the pandemic, but it is not the only emerging management tool, as Bobby Daly, MD, MBA of Memorial Sloan Kettering Cancer Center in New York and colleagues reported in a study of patient perspectives of remote electronic monitoring published in JCO Oncology Practice.
The researchers enrolled oncology patients who had Covid-19 in the remote monitoring program. All enrolled patients were sent daily electronic Covid-19 symptom assessments, and high risk patients also were given pulse oximeters. “Monitoring was provided by a centralized team and was discontinued 14 days after a patient’s positive test result and following 3 days without worsening symptoms. Patients who completed at least one assessment and exited the program were sent a patient engagement survey to evaluate the patient’s experience with digital monitoring for Covid-19,” they wrote.
The patient engagement survey was sent to 491 patients and 257 provided responses. Almost half of the patients were women (47%), 63% were White, and the median age was 59. “The most prevalent malignancy was hematologic (22%), followed by breast (18%) and GI (16%),” they wrote.
The patients were asked a variety of questions as part of the daily monitoring, including questions about fatigue, fever, coughing, breathing, or gastrointestinal issues. Most of the patients were enrolled as outpatients following positive Covid-19 testing, but hospitalized patients were also enrolled. The hospitalized patients were also given pulse oximeters on discharge.
The patient engagement survey consisted of 22 questions focusing on these areas:
- Patient experience with onboarding.
- Patient experience with monitoring.
- Patient experience with program exit.
- Patient perceived program value.
In his oral presentation at the 2021 ASCO virtual meeting, Daly said patients’ text responses to the survey highlighted three themes regarding perceived program value: security, connection, and empowerment.
“Qualitative analysis of free text responses identified three primary themes regarding patient perceived value of a remote patient monitoring program for Covid-19. The first was security. Patients appreciated that the remote patient monitoring program provided a clinical safety net. As one patient stated, ’It made me feel safe.’ Second, connection. Patients appreciate the link to their clinical teams during a period of isolation. ’It’s a very lonely and scary trip,’ one patient stated, ’and it’s great to have someone helping me navigate through.’ And finally, empowerment. Patients appreciate that the remote patient monitoring program provided education on the virus and symptom management. As one patient stated, ’Knowledge brings comfort,’” he reported.
Daly acknowledged that the generalizability of the findings is limited because the study was confined to a single institution and as such onboarding and monitoring was easily centralized. That said, he also pointed out that this remote monitoring is likely to have benefit among a wide range of cancer patients and thus could be a pandemic lesson worth using post-pandemic.
“This remote patient monitoring program had a high Net Promoter Score, and patients endorsed the agreement by participating in the program they felt better able to manage their symptoms, better understand which symptoms were concerning, better able to cope,” he said. “The three pillars of security, connection, empowerment, that underlie the value proposition for remote patient monitoring likely apply in other clinical contexts outside of Covid-19 symptom monitoring and could serve as the foundation for building remote patient monitoring programs for other clinical indications.”
A second paper, this one from Debra Patt, MD, PhD, MBA, of Texas Oncology and colleagues, looks at implementing electronic patient reported outcomes for symptom monitor in a multisite community oncology practice. This paper, which was published in JCO Clinical Cancer Informatics, takes a step back from Covid-19 and instead focuses on electronic patient-reported outcomes (ePROS) for chemotherapy patients. The findings were also presented in a poster at ASCO 2021.
Patt and colleagues recruited patients receiving care at 210 Texas Oncology practice sites from July 202o through December 2020—again during the pandemic, when many patients were isolated.
“Seventy-three percent (1,841 of 2,522) of enrolled patients completed at least one ePRO assessment. Among these individuals, 64% (16,299 of 25,061) of available weekly ePRO assessments were completed. Over a 10-week period, compliance declined from 72% to 52%,” Patt and colleagues wrote.
Barriers to ePRO identified by the researchers included “lack of a second reminder text or e-mail prompt, inconsistent discussion of reported ePROs by clinicians at visits, and Covid-related changes in workflow.”
Interestingly, although Daly and colleagues found remote monitoring was welcomed by patients during the pandemic, Patt’s team was frustrated by the challenges posed by Covid-19.
“The Covid-19 pandemic certainly affected the ability to optimally implement the symptom management tool and might have affected implementation in several ways,” they wrote. “Process workflows were altered substantially during the Covid-19 pandemic to maintain compliance with CDC guidelines. Staff were tasked with implementing screening protocols, enforcing social distancing, prioritizing and rescheduling patient visits, and treatment. Patients usually attended in-person appointments alone without caregivers to achieve lower volumes in clinic and maintain social distancing. This lack of caregiver presence introduced stress to patients and posed challenges in patient education.”
During the pandemic “likely attention to symptom tracker follow-up was deprioritized in the wake of competing priorities because of the global pandemic simply because the work burden increased substantially. We also robustly implemented telemedicine further altering process workflow and increasing staff work burden in the clinic during the study period,” they concluded.
Yet, the Texas investigators added a final, wistful observation: “It is also possible that patients might have preferred using the tool over the normal process of interacting with the clinic during the Covid-19 pandemic because of disruptions in normal processes in the clinic or fears of presenting to the clinic in person.”
- Electronic remote symptom monitoring technology may provide security and empowerment to cancer patients.
- Note that implementing electronic remote symptom monitoring is likely to require additional resources.
Peggy Peck, Editor-in-Chief, BreakingMED™
Remote Patient Monitory by Daly et al was supported a National Institutes of Health grant to Memorial Sloan Kettering Cancer Center.
Daly disclsored stock and other ownership interests in Quadrant Holdings (leadership role), CVS Health, Walgreens Boots Alliance, Lilly, IBM, Pfizer, Cigna, Baxter, and Zoetis. He also disclosed “other relationship” with AstraZeneca.
Patt is employed by Texas Oncology, McKesson, Mednax. She disclosed consulting or advisory agreements with Pfizer, Rocher, and AstraZeneca and research funding from Merck, Eisia, Seattle Genetics and Lilly.
Cat ID: 122
Topic ID: 78,122,730,933,122,935,192,927,925,934,172
