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Post-operative morbidity can compromise patient outcome and require acute care services. Cancer patients who utilize the PRO-CTCAE - a standardized, validated method of capturing patient-reported outcomes (PROs) - to report their symptoms have been shown to reduce symptom burden, decrease the need for acute care, and preserve quality of life. Building off this work, a fully EHR-integrated PRO system capturing side effects from surgery could significantly improve health care delivery, particularly in rural populations which has been further challenged by the COVID-pandemic.
Through the NCI's Moonshot-funded IMPACT consortium, Dartmouth-Hitchcock Medical Center (DHMC) in collaboration with 5 other health systems and Epic designed eSyM, an EHR-integrated electronic symptom management program based on the PRO-CTCAE questionnaire. eSyM was deployed at DHMC, a large rural academic medical cancer center, systems beginning in spring 2020, for gynecologic oncology patients having surgery. Prompts to complete questionnaires were disseminated via the standard DHMC Epic-based patient portal (MyChart) on a tapered schedule averaging approximately twice/week for 90 days after surgery. Each survey included at least 6 PRO-CTCAE symptom items including pain, nausea/vomiting, fatigue, anxiety, wound redness and discharge as well items assessing overall wellbeing and functional status. Composite scores were generated for each symptom: 0 for no symptoms, 1-2 for mild/moderate symptoms, and 3 for severe symptoms. Reported severe symptoms automatically prompted an alert message sent directly to nursing staff.
Over the past 90 days, 134 women were eligible to participate in eSyM. 101 women were sent automated eSyM questionnaires after surgery through their patient portal. 69 (68%) activated their portal account and 48 (70%) completed at least 1 questionnaire electronically to report symptoms. Women who used eSyM were younger than those who did not activate their account, 54 vs. 61 years (p=0.05). Women completed a mean of 5 questionnaires over a mean of 19 days after surgery. 20% of patients reported severe symptoms, of which pain was the most common. Women who used eSyM were less likely to require hospitalization in the 90 days after surgery than women who did not participate (p<0.005). Urgent care and ED visits following surgery were comparable between eSyM users and those never activated their account
Women with activated portal accounts had high rates of eSyM utilization to report symptoms after surgery. eSyM users tended to be younger than women who did not activate their accounts. Amidst the COVID-19 pandemic, an electronic platform to report and monitor symptoms following surgery alleviates some of the some of the burdens placed upon the patient and health care systems with in-person care, especially in rural settings. Future areas of research will include more robust patient cohorts from other institutions utilizing eSyM, and an evaluation of health care outcomes, including symptom burden, acceptability and acute care needs associated with eSyM.
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