Is the digital divide between older adults and other age groups closing? Impact of telemedicine and adherence with remote symptom monitoring in older adults compared to middle age and AYA patients with cancer.
Authors: Subbiah Ishwaria M. , Peek Angela , Daftary Utpala , Christensen Sarah , Small Fernando , Ali Sara , Williams Loretta A. 
Published: June 2023

e13689

Background: The wide adoption of telehealth during the pandemic brought the concern of widening technology disparity especially between AYAs 15-39y, mid-age 40-64y, older adults 65y+. Also, patient-reported outcomes (PRO)-based remote monitoring of patients (pts) with cancer between clinic visits improves quality of life and overall survival but is also often app-based. Since telehealth’s impact on other tech-related health behaviors such as adherence w remote symptom monitoring is not fully understood, we investigated PRO completion patterns in routine cancer care, pre- and mid pandemic. Methods: We queried a prospectively maintained registry of all remotely delivered PROs through the electronic health record (EHR) at our institution across two consecutive time periods: ‘prepandemic’ 9/1/17-3/31/20; ‘midpandemic’ 4/1/20-1/31/23. We captured pt demographics, cancer characteristics, and PRO adherence outcomes; we summarized descriptive statistics and compared (t-test, ANOVA) between time and age cohorts, PRO adherence and independent variables. Results: In total, 182,850 unique patients receiving routine cancer care were sent 1+ remote PROs outside of a clinic visit. Patient adherence w PROs overall increased, from 34% prepandemic (12548 of 37377 pts responding) to 62% mid-pandemic (89,634 of 145,473 patients responding; p <0.00001). We then analyzed completion patterns of one global health PRO used widely across different oncologic settings to understand patient-level response behaviors. Of 4996 pts sent PROs prepandemic (1/1/18-3/31/20), 2517 (50%) responded; of 13543 pts sent PROs midpandemic (4/1/20-12/31/22), 10171 (75%) responded, an increase of 25%, p<0.001). Prepandemic, 77% of pts responded only after a reminder from the clinical team, while midpandemic, only 2% needed these reminders, with 98% responding without a nudge (p<0.001). Prepandemic, only 42% of seniors responded vs 54% mid-age & 64% AYA (p<0.01); midpandemic response rates increased across age cohorts (seniors increasing to 72%; mid-age to 77%; AYA to 77%) to where now, the difference in completion rates across age cohorts was no longer significant (p0.42). Furthermore, virtual visits accounted for the improvements seen in PRO adherence across age cohorts – with response rate among those with virtual visits being 99.9% in seniors, 99.7% in mid-age, and 100% in AYA during year 2022 while PRO response rates midpandemic in pts with in-person visits decreased across all age cohorts to AYA 29%, mid-age 33%, senior 32%. Conclusions: Telehealth was associated with significantly increased adherence with remote symptom monitoring with older adults accounting for the largest increases in this technology’s uptake to where the previously observed divide in EHR-based PRO adherence between older adults and mid-age & AYA patients was closed.