270 Background: Patients now have the ability to utilize electronic patient reported outcomes (ePROs) for remote symptom monitoring (RSM). This analysis seeks to better understand trajectory of reported symptoms during treatment for patients with gynecologic cancer participating in RSM. Methods: We approached patients with gynecological cancer initiating treatment at the Mitchell Cancer Institute (MCI) between 7/1/21-4/30/2022. Patients were eligible if they were starting chemotherapy, targeted therapy, or immunotherapy for a new cancer. Patients seeking a second opinion were excluded. Enrolled patients received symptom survey (PRO-CTCAE questions) via text or email once per week. Initially, only severe alerts were forwarded to the clinical care team; moderate alerts were forwarded to clinical teams once they were comfortable with alert management. Patients completed symptom assessments for 24 weeks or until withdrawal. Patient age at enrollment, race, sex, cancer type, cancer stage, and PROs were abstracted from electronic health records and the PRO platform (Carevive). Descriptive statistics were calculated using frequencies and percentages for categorical variables and median and interquartile ranges (IQR) for continuous variables. Results: A total of 60 female patients with gynecological cancer were enrolled; 33% were Black or African American and 67% were White; median age was 61 years (IQR 53-68). Seventy-eight percent (47/60) of patients reported 379 symptoms with at least one moderate or severe alert during this time period; 32% considered moderate and 68% considered severe. Overall, the most frequently reported symptom was pain (29%). At baseline (week 0), 14% and 41% of 56 patients reported moderate symptoms and severe symptoms, respectively. Symptom burden decreased over time with 4% and 7% of 27 patients who completed a survey at 12 weeks reporting moderate and severe symptoms. Specific symptom trajectories followed similar patterns. Conclusions: In our sample, patients reported the majority of symptoms during the first three months of treatment. Symptom trajectory decreased with time, suggesting symptoms are being effectively monitored and addressed by the clinical teams engaging in RSM. Future research is needed to understand if symptom improvement translates to increased quality of life, decreased hospitalizations, and increased survival for patients, as well as lessen the burden of call volume on the clinical team.
377 Background: Previous randomized controlled trials have demonstrated benefits to patients from remote symptom monitoring (RSM) with electronic patient-reported outcomes (ePROs) including healthcare utilization. However, less is known about the impact of RSM in diverse, real-world populations. Methods: This cross-sectional analysis from a hybrid, type 2 implementation-effectiveness trial evaluated the impact of RSM on healthcare utilization amongst patients with cancer receiving chemotherapy, immunotherapy, monoclonal antibody, or targeted therapy at two academiccancer centers in the Southeastern United States. Modified Poisson regression models with robust standard error and 95% confidence interval (CI) was used to calculate the relative risk (RR) of any hospital or ICU utilization between patients receiving RSM and controls for 3 and 6 months after index date. Models were controlled for age at index, race, sex, cancer type, cancer stage, insurance, prior treatment, comorbidities, RUCA, and follow-up during COVID-19 pandemic. Additional logistic regression models were used to estimate odds ratios (OR) for subset analysis stratified by race (Black or African American, Other, or White), rurality using Rural-Urban Commuting Area Codes, and neighborhood disadvantage using Area Deprivation Index (ADI). Results: From 5/2021-2/2024, 1215 patients were enrolled in RSM; 27% were Black, 16% lived in a rural area, and 25% lived in an area with high neighborhood disadvantage. The populations receiving RSM were similar to the control population (n = 4559); 26% were Black, 22% lived in a rural area, and 28% lived in area with high neighborhood disadvantage. The unadjusted relative risk of hospitalization for patients receiving RSM and control patients were 0.70 (95% CI, 0.63-0.70) and 0.77 (95% CI, 0.71-0.85), respectively. In adjusted analyses, hospitalizations were lower amongst patients receiving RSM compared to control patients with a RR of 0.82 (95% CI 0.73-0.92). Similar patterns were observed for ICU admissions (RR 0.59; 95% CI,0.40-0.88). Analysis by patient subgroup was similar to the overall analysis. A lower odd of hospitalizations and ICU admissions at 6 months was observed across all subset analyses: Black vs. White patients (OR 0.80; OR 0.48); rural vs. urban patients (OR 0.78; OR 0.68); and patients living in areas of high vs. lower neighborhood disadvantage (OR 0.59; OR 0.33). Conclusions: The use of RSM amongst patients receiving treatment for cancer is associated with reductions in hospitalizations and ICU admissions in real-world, diverse settings. Further work to expand this intervention nationally is needed. Clinical trial information: NCT04809740 .
250 Background: Electronic patient reported outcomes (ePROs) enable patients to report symptoms from treatment in real time using their mobile device. This analysis sought to better understand the trajectory of reported symptoms via remote symptom monitoring (RSM) during treatment for patients with lung cancer. Methods: We approached patients with lung cancer initiating treatment at the Mitchell Cancer Institute (MCI) between March 2022-October 2023 to participate in an RSM program. Patients were eligible if they were initiating treatment (chemotherapy, targeted therapy, or immunotherapy) for the first time at MCI. Patients seeking a second opinion were excluded. Enrolled patients received a symptom survey (PRO-CTCAE questions) once a week via text or email. Alerts were forwarded to the clinical care team for symptom management. Patients completed symptom assessments for 24 weeks or until withdrawal. At 24 weeks, patients were given the ability to continue symptom assessments if they were continuing treatment. Patient demographics including age at enrollment, race, sex, cancer type, cancer stage, and PRO data were collected from electronic health records and the PRO platform (Carevive). Descriptive statistics were calculated using frequencies and percentages for categorical variables and median and interquartile ranges (IQR) for continuous variables. Results: Of 80 patients approached, a total of 57 (71%) patients with lung cancer were enrolled in RSM; 20% were Black or African American and 80% were White; median age was 66 (IQR 61-73). Over 24 weeks, 732 symptom alerts were reported; 75% considered moderate and 25% considered severe. Overall, the most frequently reported symptom was pain (29%), followed by dyspnea/cough (25%) and constipation (13%). At baseline (week 0), 78 moderate symptoms and 39 severe symptoms alerts were reported. At week 24, 10 moderate symptoms and 4 severe symptoms alerts were reported. Overall, there was a decrease in symptom alerts over time for both moderate and severe alerts. Specific symptom trajectories followed similar patterns. Conclusions: In our sample, most symptoms were reported during the initial three months of treatment with a subsequent decrease in symptom alerts over time, indicating effective monitoring and management by clinical teams engaged in RSM. Future research is needed to understand if symptom improvement correlates with enhanced quality of life, reduced hospitalizations, and prolonged survival, as well as a lessened burden of call volume on the clinical team. Future analyses should also be done to compare similar results of different disease types.
328 Background: Disparities in pain management for Black patients with cancer are well-documented, but less is known about other symptom clusters like gastrointestinal (GI), respiratory, and urinary symptoms. This study assessed racial disparities in electronically reported symptom clusters among Black and White patients with cancer enrolled in a Remote Symptom Monitoring (RSM) program. Methods: Patients with cancer at the University of Alabama at Birmingham (UAB) and the Mitchell Cancer Institute (MCI) reported symptoms weekly using the Patient Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAEs). The GI symptom cluster included decreased appetite, nausea, vomiting, constipation, and diarrhea; the respiratory cluster included cough and shortness of breath; the urinary cluster included frequent urinary problems. We assessed the presence of any moderate/severe symptoms or any severe symptoms (triggering a nurse alert) in the clusters. The study evaluated surveys submitted within the first six months after RSM enrollment. Generalized linear mixed effects modeling with random effects adjusting for cancer type, sex, and age were used to calculate the odds of reporting any moderate/severe pain between Black and White patients. Results: Among 1454 patients (31% Black, 69% White), 17,937 surveys were analyzed. The median age for Black patients was 59 (IQR 47-66) and 63 (IQR 54-71) for White patients. Breast cancer was most common in both groups (36% Black, 23% White), followed by gynecological (20% Black, 17% White) and gastrointestinal cancers (19% Black, 18% White). At baseline, both races reported similar proportions of moderate/severe or severe symptom for all clusters (Table). During the first six months in the RSM program, symptom proportions remained similar (Table). These findings were consistent in adjusted analysis for the GI (OR 0.85; 95% CI 0.68-1.07), respiratory (OR 1.18; 95% CI 0.87-1.61), and urinary clusters (OR 0.92; 95% CI 0.61-1.39). Conclusions: Our findings suggest no significant racial disparities in reporting moderate/severe or severe symptoms among Black and White patients with cancer at baseline or within their initial six months in the RSM program across GI, respiratory, and urinary symptom clusters. Survey characteristics. Total Surveys(N=17,937) Baseline Surveys 6 Months Surveys White (n=999) Black(n=455) White(n=11,344) Black(n=5139) Gastrointestinal Symptoms, No. (%) Severe 1376 (8) 121 (12) 59 (13) 783 (7) 413 (8) Moderate/Severe 4701 (26) 300 (30) 130 (29) 2971 (26) 1300 (25) Respiratory Symptoms, No. (%) Severe 438 (2) 28 (3) 29 (6) 241 (2) 140 (3) Moderate/Severe 1612 (9) 90 (9) 62 (14) 996 (8) 464 (9) Urinary Symptoms, No. (%) Severe 333 (2) 31 (3) 13 (3) 184 (2) 105 (2) Moderate/Severe 620 (3) 44 (4) 21 (5) 372 (3) 183 (4)
138 Background: Black patients with cancer report higher pain intensity for both consistent and breakthrough pain. Remote symptom monitoring (RSM) using electronic patient-reported outcomes (ePROs) allows patients with cancer to communicate symptoms between visits. This study evaluated whether there were racial disparities in pain severity reporting among Black and White patients with cancer utilizing RSM with ePROs. Methods: This retrospective study analyzed data from 1453 patients with cancer undergoing treatment who utilized an RSM platform for the completion of weekly PRO-CTCAEs surveys to report pain intensity. Survey data from patients during the initial 6 months following RSM enrollment at the University of Alabama at Birmingham (UAB) and the Mitchell Cancer Institute (MCI) were included. Descriptive statistics were compared using frequencies, percentages, and Cramer’s V for categorical variables. Regression models were adjusted for age, sex, cancer type, and rurality. Results: Data from 1453 patients and 17,722 surveys were analyzed. 454 (31.2%) patients were Black and 999 (68.8%) patients were White. Among 454 baseline surveys completed by Black patients, no pain was reported in 68%, mild pain in 4%, moderate in 12%, and severe in 16%. In comparison, among 999 baseline surveys completed by White patients, no pain was reported in 71%, mild pain in 3%, moderate in 12% and severe in 14% (V=0.03). Among all post-baseline surveys completed by Black patients, no pain was reported in 69% (n=5081), mild pain in 5%, moderate in 13% and severe in 13%. In comparison, among all post-baseline surveys completed by White patients, no pain was reported in 72% (n=11188), mild pain in 4%, moderate in 14% and severe in 10% (V=0.05). In adjusted analysis, severe pain at follow-up was higher amongst Black patients than White patients (OR 1.17; 95% CI 0.87-1.56). Conclusions: Although modestly increased prevalence (3%) in any pain at baseline and severe pain during their 6 months after enrollment in RSM was observed for Black participants compared to Whites, this finding was not significant in adjusted models. This analysis suggests similar pain levels for Black and White patients within RSM programs. RSM can promote proactive reporting and early intervention for pain, which may help to mitigate previously reported disparities in long-term pain for Black individuals.
351 Background: One key challenge of practice transformation activities, such as remote symptom monitoring (RSM) using electronic patient reported outcomes (ePROs), is identification of patients starting treatment. In real-world settings, reliance on referrals is likely to miss patients. We describe the difficulties encountered in patient identification and the subsequent changes implemented in protocol to remediate this. Methods: We conducted two PDSA cycles focused on identification and engagement of patients for RSM at the Mitchel Cancer Institute (MCI). Target patient capture was > 75%. Modifications to the patient identification process were documented. Schedules of physicians participating in the RSM program were reviewed from 6/2021 – 5/2022 to identify eligible patients. Patients were considered eligible if they were starting chemotherapy, targeted therapy, or immunotherapy. Patients seeking a second opinion were excluded. Patient demographics, cancer type, cancer stage, and PROs were abstracted from electronic health records and the PRO platform (Carevive). Initial clinic roll-out was conducted in gynecologic oncology, with expansion to breast and thoracic oncology in 10/2021 and 3/2022, respectively. The proportion of eligible patients approached per month was reported.Results: In the first PDSA cycle, the eligibility criteria was defined. Although clinical trials included advanced disease, non-clinical staff screening expressed concern about determining advanced vs. early-stage disease. Thus, inclusion criteria was broadened to include all patients starting treatments. From 6/2021 –8/2021, navigators identified patients by screening patients who presented for chemo-education visits. The navigation team approached 23 patients during this period. However, this process didn’t identify all eligible patients as not all patients beginning treatment received chemo-education visits. In PDSA Cycle 2, the process for new patient contact from initial call for appointment through treatment was reviewed. The implementation team screened all patients in a physician’s schedule a week prior to the office visit as well as on the day of visit. This updated process identified all eligible patients starting either intravenous or oral chemotherapy. The recruitment process was modified to screen the physician schedules rather than chemo educator visits. From 9/2022-5/22, the proportion of eligible patients identified and approached remained high at 100%. This methodological screening process helped the navigation team identify all eligible patients in an efficient manner and they reported comfort in expanding to additional disease teams. Conclusions: Systematic screening of physician schedules can be successfully leveraged for patient identification and reduce time spent manually screening for eligible patients by non-clinical navigators. Clinical trial information: NCT04809740.
345 Background: Use of electronic patient-reported outcome data allows patients to report symptoms in real time. This analysis aims to better understand the trajectory for symptoms reported via Remote Symptom Monitoring (RSM) by patients receiving gastrointestinal (GI) cancer treatment. Methods: This retrospective cohort study included patients initiating GI cancer treatment (chemotherapy, targeted therapy, and immunotherapy) between August 2022 and April 2023 at USA Health Mitchell Cancer Institute (MCI). Patients were eligible if they were starting a new treatment or had started treatment in the past 30 days. Patients received a weekly symptom survey over the course of 24 weeks through text message or e-mail. Patients were monitored for a total of 24 weeks regardless of their enrollment date. Patients reported symptoms as mild, moderate, severe, or very severe. All moderate and severe alerts were sent to the clinical nurse via the electronic medical record (EMR) to be acknowledged. After enrollment, health information including age, race, sex, zip code, ethnicity, cancer type, and cancer stage were extracted from the EMR. Descriptive statistics were calculated to examine frequencies of reported symptoms and their severity over time. Results: Of 75 GI patients approached, 63 patients (84%) were enrolled in RSM; 44% were female; 30% of patients were Black or African American, and median age was 65 (range 30-82). GI cancer types varied; Pancreatic (21%), Rectal (13%), Colorectal (14%), Colon (13%), Gastric (11%), Liver (11%), and other (17%). Over 24 weeks, 424 alerts were reported. Pain (31%), nausea and vomiting (21%), and decreased appetite (17%) were the most reported symptoms. 311 alerts were moderate (73%) and 113 were severe (27%). At week 0 (baseline; n = 63) 37 moderate alerts and 21 severe alerts were reported. At week 24 (final week; n = 63) 7 moderate alerts and 6 severe alerts were reported. Overall, there was a decreasing trajectory from week to week for moderate and severe alerts, with outliers noted at weeks 8 and 20. Conclusions: Findings suggest that RSM allows for an improvement in symptom trajectory for GI cancer patients based on the decrease in moderate and severe alerts reported from baseline to week 24. This decrease suggests that reported symptoms are being appropriately monitored and addressed by the patient's clinical care team due to improvement of symptoms or improvement of symptom management. Future research is needed to determine the benefits of prolonged RSM utilization by patient-reported quality of life as well as survival rate.
325 Background: Remote symptom monitoring (RSM) utilizes electronic patient-reported outcomes (ePROs) to facilitate the monitoring and management of treatment-related symptoms outside of traditional healthcare appointment settings. Research suggests benefits surrounding the implementation of RSM; however, there is a literature gap regarding patient and provider perceptions of its implemented use. Methods: This qualitative study included patients and providers from the University of Alabama at Birmingham (UAB) and the Mitchell Cancer Institute (MCI) in Mobile, Alabama, who participated in semi-structured interviews aimed at gaining insight into the experiences of and perceptions surrounding RSM utilization. Interviews occurred over the phone, via digital videoconference, or in person, and were transcribed and inductively coded using NVivo software alongside a constant comparative method to establish a grounded coding schema. Results: Forty patients (20 UAB; 20 MCI) and 30 oncology providers (16 UAB; 14 MCI) identified 25 benefits across 3 overarching themes. Patients and providers found RSM Facilitated Proactive Management enabling early symptom identification and intervention, which helped to reduce symptom burden. Both groups also noticed RSM Improved Therapeutic Alliance, by fostering the relationship between the patient and their care team and enhancing the patient’s sense of safety and security through continued and sincere communication. Patients and providers also discussed how RSM Promoted Self-Efficacy and Management among Patients by allowing patients to feel involved and in control of their care, while giving them an inclination to be active members in their care. Providers felt that more active patient involvement in care contributed to a more accurate and thorough reporting of symptoms. Patients and providers also noted drawbacks regarding RSM, including lack of need in cases of no or mild symptoms. Conclusions: Patients and providers recognized the impact RSM had on patient care during cancer treatment. However, given some of the perceived limitations, patient and provider evaluations should continue to ensure successful implementation in future clinical trials. Clinical trial information: NCT04809740 .
340 Background: Remote symptom monitoring (RSM) by electronic patient-reported outcomes (ePRO) data can elicit actionable symptoms from patients with cancer. However, patients with different cancer diagnoses are likely to have differing symptom profiles and variability in symptom alerts. To understand potential workflow needs, this analysis was conducted to determine which types of symptoms and severity of alerts can be expected based on cancer type. Methods: Cancer patients initiating chemotherapy, immunotherapy, or targeted therapy at 2 academic cancer centers in Alabama, UAB O’Neal Comprehensive Cancer Center and USA Health Mitchell Cancer Institute (MCI), were enrolled in ePRO-based RSM. Site rollouts were differential: UAB enrolled by disease group starting May 2021, MCI by provider starting July 2021. Patients received weekly symptom surveys of selected PRO-CTCAE questions through the Carevive ePRO mobile platform (PROmpt), triggering alerts to clinical teams if reported symptoms were determined to be moderate or severe. Demographics, cancer diagnosis, and ePRO data were extracted from electronic health records and Carevive. Descriptive statistics of categorical variables were calculated by frequencies and percentages; Cramer’s V and Cohen’s d were used for associations and effect size. Results: UAB enrolled 598 patients and MCI enrolled 274 patients by April 2023, consistent with the patient volume difference of the centers. 68% of enrollees were White; MCI saw a moderately higher % of Black patients (V: 0.21). 67% of enrolled patients were female. Median age was 61 years (Interquartile range: 51-69); UAB patients were slightly younger (d: 0.15). Among 872 enrolled patients, 9765 symptom alerts were generated. There was a small effect of cancer type on the overall type of symptoms and symptom severity reported (V: 0.11 and 0.09 respectively). Of the total number of symptom alerts, 28.0% of the alerts generated were for pain, followed by nausea/vomiting (14.9%), and constipation (11.7%). When broken down by cancer type, pain was the symptom most frequently reported for each type. The next most frequently reported symptoms differed but were as expected by cancer type: coughing/dyspnea by lung cancer patients (20.6%); urinary complaints in genitourinary cancers (14.1%); and nausea/vomiting in gastrointestinal cancers (18.0%). The frequency of moderate alerts was 62.1%, varying from 34.0% in sarcoma to 66.6% in gastrointestinal cancers. 31.1% of the alerts were severe; sarcoma had the most severe alerts (56.0%) and hematologic had the least (27.1%). Conclusions: Across patients with differing cancer types, pain and gastrointestinal issues were over half the reported symptoms. However, variability by cancer diagnosis in both symptom type and severity was observed, suggesting the remote symptom management workload for providers may vary by cancer type.
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