A real-time electronic symptom monitoring system for patients after discharge following surgery: a pilot study in cancer-related surgery

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Abstract

Background

Advances in peri-operative care of surgical oncology patients result in shorter hospital stays. Earlier discharge may bring benefits, but complications can occur while patients are recovering at home. Electronic patient-reported outcome (ePRO) systems may enhance remote, real-time symptom monitoring and detection of complications after hospital discharge, thereby improving patient safety and outcomes. Evidence of the effectiveness of ePRO systems in surgical oncology is lacking. This pilot study evaluated the feasibility of a real-time electronic symptom monitoring system for patients after discharge following cancer-related upper gastrointestinal surgery.

Methods

A pilot study in two UK hospitals included patients who had undergone cancer-related upper gastrointestinal surgery. Participants completed the ePRO symptom-report at discharge, twice in the first week and weekly post-discharge. Symptom-report completeness, system actions, barriers to using the ePRO system and technical performance were examined. The ePRO surgery system is an online symptom-report that allows clinicians to view patient symptom-reports within hospital electronic health records and was developed as part of the eRAPID project. Clinically derived algorithms provide patients with tailored self-management advice, prompts to contact a clinician or automated clinician alerts depending on symptom severity. Interviews with participants and clinicians determined the acceptability of the ePRO system to support patients and their clinical management during recovery.

Results

Ninety-one patients were approached, of which 40 consented to participate (27 male, mean age 64 years). Symptom-report response rates were high (range 63–100%). Of 197 ePRO completions analysed, 76 (39%) triggered self-management advice, 72 (36%) trigged advice to contact a clinician, 9 (5%) triggered a clinician alert and 40 (20%) did not require advice. Participants found the ePRO system reassuring, providing timely information and advice relevant to supporting their recovery. Clinicians regarded the system as a useful adjunct to usual care, by signposting patients to seek appropriate help and enhancing their understanding of patients’ experiences during recovery.

Conclusion

Use of the ePRO system for the real-time, remote monitoring of symptoms in patients recovering from cancer-related upper gastrointestinal surgery is feasible and acceptable. A definitive randomised controlled trial is needed to evaluate the impact of the system on patients’ wellbeing after hospital discharge.

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Most cited references 50

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Determinants of long-term survival after major surgery and the adverse effect of postoperative complications.

Shukri F Khuri, William G Henderson, Ralph DePalma … (2005)

The objective of this study was to identify the determinants of 30-day postoperative mortality and long-term survival after major surgery as exemplified by 8 common operations. The National Surgical Quality Improvement Program (NSQIP) database contains pre-, intra-, and 30-day postoperative data, prospectively collected in a standardized fashion by a dedicated nurse reviewer, on major surgery in the Veterans Administration (VA). The Beneficiary Identification and Records Locator Subsystem (BIRLS) is a VA file that depicts the vital status of U.S. veterans with 87% to 95% accuracy. NSQIP data were merged with BIRLS to determine the vital status of 105,951 patients who underwent 8 types of operations performed between 1991 and 1999, providing an average follow up of 8 years. Logistic and Cox regression analyses were performed to identify the predictors of 30-day mortality and long-term survival, respectively. The most important determinant of decreased postoperative survival was the occurrence, within 30 days postoperatively, of any one of 22 types of complications collected in the NSQIP. Independent of preoperative patient risk, the occurrence of a 30-day complication in the total patient group reduced median patient survival by 69%. The adverse effect of a complication on patient survival was also influenced by the operation type and was sustained even when patients who did not survive for 30 days were excluded from the analyses. The occurrence of a 30-day postoperative complication is more important than preoperative patient risk and intraoperative factors in determining the survival after major surgery in the VA. Quality and process improvement in surgery should be directed toward the prevention of postoperative complications.

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Assessment of complications after pancreatic surgery: A novel grading system applied to 633 patients undergoing pancreaticoduodenectomy.

Michelle L DeOliveira, Jordan Winter, Markus Schäfer … (2006)

To define a simple and reproducible classification of complications following pancreaticoduodenectomy (PD) based on a therapy-oriented severity grading system. While mortality is rare after PD, morbidity rates remain high. The lack of standardization in evaluating morbidity after PD has severely hampered meaningful comparisons over time and among centers. We adapted a novel classification of complication to stratify morbidity by severity after PD, to test whether the incidence of pancreatic fistula has changed over time, and to identify risk factors in a single North American center. The classification was applied to a consecutive series of 633 patients undergoing PD between February 2003 and August 2005. Another series of 141 patients treated between 1987 and 1990 was also analyzed to identify changes in the incidence and severity of fistula. Univariate and multivariate analyses were performed to link respective complications with preoperative and intraoperative parameters, length of hospital stay, and long-term survival. A total of 263 (41.5%) patients did not develop any complication, while 370 (58.5%) had at least one complication; 62 (10.0%) patients had only grade I complications (no need for specific intervention), 192 patients (30.0%) had grade II (need for drug therapy such as antibiotics), 85 patients (13.5%) had grade III (need for invasive therapy), and 19 patients (3.0%) had grade IV complications (organ dysfunction with ICU stay). Grade V (death) occurred in 12 patients (2.0%). A total of 57 patients (9.0%) developed pancreatic fistula, of which 33 (58.0%) were classified as grade II, 17 (30.0%) as grade III, 5 (9.0%) as grade IV, and 2 (3.5%) as grade V. Delayed gastric emptying was documented in 80 patients (12.7%); half of them were scored as grade II and the other half as grade III. A significant decrease in the incidence of fistula was observed between the 2 periods analyzed (14.0% vs. 9.0%, P < 0.001), mostly due to a decrease in grade II fistula. Cardiovascular disease was a risk factor for overall morbidity and complication severity, while texture of the gland and cardiovascular disease were risk factors for pancreatic fistula. This study demonstrates the applicability and utility of a new classification in grading complications following pancreatic surgery. This novel approach may provide a standardized, objective, and reproducible assessment of pancreas surgery enabling meaningful comparison among centers and over time.

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Electronic patient-reported outcome systems in oncology clinical practice.

Antonia Bennett, Roxanne E Jensen, Ethan Basch (2015)

Patient-reported outcome (PRO) questionnaires assess topics a patient can report about his or her own health. This includes symptoms (eg, nausea, fatigue, diarrhea, pain, or frequent urination), physical functioning (eg, difficulty climbing stairs or difficulty fastening buttons), and mental health (eg, anxiety, fear, or worry). Electronic PRO (ePRO) systems are used in oncology clinical care because of 1) their ability to enhance clinical care by flagging important symptoms and saving clinicians time; 2) the availability of standardized methods for creating and implementing PROs in clinics; and 3) the existence of user-friendly platforms for patient self-reporting like tablet computers and automated telephone surveys. Many ePRO systems can provide actionable links to clinical care such as summary reports in a patient's electronic medical record and real-time e-mail alerts to providers when patients report acute needs. This review presents 5 examples of ePRO systems currently in use in oncology practice. These systems support multiple clinical activities, including assessment of symptoms and toxicities related to chemotherapy and radiation, postoperative surveillance, and symptom management during palliative care and hospice. Patient self-reporting is possible both at clinical visits and between visits over the Internet or by telephone. The implementation of an ePRO system requires significant resources and expertise, as well as user training. ePRO systems enable regular monitoring of patient symptoms, function, and needs, and can enhance the efficiency and quality of care as well as communication with patients. Copyright © 2012 American Cancer Society, Inc.

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Author and article information

Contributors

H. S. Richards:

ORCID: http://orcid.org/0000-0001-9181-7005

hollie.richards@bristol.ac.uk

J. M. Blazeby: j.m.blazeby@bristol.ac.uk

A. Portal: amanda.portal@bristol.ac.uk

R. Harding: ruth.harding@uhbristol.nhs.uk

T. Reed: Trudy.Reed@uhbristol.nhs.uk

T. Lander: Tom.Lander@uhbristol.nhs.uk

K. A. Chalmers: katy.chalmers@bristol.ac.uk

R. Carter: r.n.carter@leeds.ac.uk

R. Singhal: rishi.singhal@heartofengland.nhs.uk

K. Absolom: K.L.Absolom@leeds.ac.uk

G. Velikova: g.velikova@leeds.ac.uk

K. N. L. Avery: kerry.avery@bristol.ac.uk

Journal

Journal ID (nlm-ta): BMC Cancer

Journal ID (iso-abbrev): BMC Cancer

Title: BMC Cancer

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2407

Publication date (Electronic): 10 June 2020

Publication date PMC-release: 10 June 2020

Publication date Collection: 2020

Volume: 20

Electronic Location Identifier: 543

Affiliations

[1 ]GRID grid.5337.2, ISNI 0000 0004 1936 7603, Medical Research Council ConDuCT-II Hub for Trials Methodology Research, National Institute for Health Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School, Population Health Sciences, , University of Bristol, ; 39 Whatley Road, Bristol, BS8 2PS UK

[2 ]GRID grid.410421.2, ISNI 0000 0004 0380 7336, Division of Surgery, , University Hospitals Bristol NHS Foundation Trust, ; Bristol, BS2 8HW UK

[3 ]GRID grid.5337.2, ISNI 0000 0004 1936 7603, Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Bristol Medical School, Population Health Sciences, , University of Bristol, ; 39 Whatley Road, Bristol, BS8 2PS UK

[4 ]Section of Patient-Centred Outcomes Research, Leeds Institute of Medical Research at St James’s, University of Leeds, St James’s Hospital, Leeds, LS9 7TF UK

[5 ]GRID grid.415490.d, ISNI 0000 0001 2177 007X, Queen Elizabeth Hospital Birmingham, ; Mindelson Way, Edgbaston, Birmingham, B15 2WB UK

Author information

H. S. Richards http://orcid.org/0000-0001-9181-7005

Article

Publisher ID: 7027

DOI: 10.1186/s12885-020-07027-5

PMC ID: 7285449

PubMed ID: 32522163

SO-VID: a13b0e0b-2973-4309-acf0-50afd00bb605

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 20 August 2019

Date accepted : 1 June 2020

Funding

Funded by: National Institute for Health Research

Award ID: RP-PG-0611-20008

Custom metadata

ScienceOpen disciplines: Oncology & Radiotherapy

Keywords: adverse events,pilot studies,patient-reported outcomes,electronic health record,internet,cancer, gastrointestinal,gastrointestinal surgical procedures,self-management

Data availability:

ScienceOpen disciplines: Oncology & Radiotherapy

Keywords: adverse events, pilot studies, patient-reported outcomes, electronic health record, internet, cancer, gastrointestinal, gastrointestinal surgical procedures, self-management

A real-time electronic symptom monitoring system for patients after discharge following surgery: a pilot study in cancer-related surgery

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Abstract

Background

Methods

Results

Conclusion

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Karger: Oncology

Most cited references 50

Determinants of long-term survival after major surgery and the adverse effect of postoperative complications.

Assessment of complications after pancreatic surgery: A novel grading system applied to 633 patients undergoing pancreaticoduodenectomy.

Electronic patient-reported outcome systems in oncology clinical practice.

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