Association between telehealth and adherence with patient-reported outcomes (PRO)-based remote symptom monitoring among adolescent/young adults (AYA), middle age, and older adults with cancer.
Authors: Subbiah Ishwaria Mohan , Daftary Utpala , Peek Angela , Christensen Sarah , Small Fernando , Vincitore Brandon , Ali Sara , Subbiah Vivek , Roszik Jason , Mendoza Tito R. , Gibbons Chris , Chung Caroline , Williams Loretta A. 
Published: June 2022

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Background: PRO-based remote symptom monitoring favorably impacts quality of life, healthcare utilization, and overall survival in patients (pts) with cancer. However remote PRO completion rates outside of a clinical trial remained widely varied. With the wide adoption of telehealth in cancer care during the pandemic, telehealth’s impact on health behaviors such adherence w remote PROs is not fully characterized. To that end, we investigated PRO completion patterns in routine cancer care, pre- and during the pandemic. Methods: We queried a prospectively maintained institutional database of all PROs remotely delivered to pts at our institution from 1/1/18 to 12/31/21. Pts were divided into 2 time cohorts (“pre-pandemic” 1/1/18 to 3/31/20, “during pandemic” 4/1/20 to 12/31/21) and 3 age cohorts (AYA 15-39y, midage 40-64y, older adults 65y+). We calculated descriptive statistics and compared (t-test, ANOVA) between time and age cohorts and independent variables. Results: Overall 93,875 unique patients over 4 years received 1+ remote PROs as a part of their routine cancer care. PRO response rate increased from 35% prepandemic (12011 of 34742 pts responding) to 67% during pandemic (p <0.00001). To understand patient-level response patterns, we selected one representative global health PRO tool used widely across clinics in our institution and analyzed completion in a representative month over 4 years, 2 before (Oct ’18, ‘19) and 2 mid-pandemic (Oct ’20, ‘21). Overall 2738 pts (median age 60y, range 17-94y; 290 AYA 15-39y, 1444 midage 40-64y, 1004 older adults 65y+) were sent 3249 PROs during these 4m, 1378 PROs to 1075 pts in 2 pre-pandemic months & 1871 to 1663 pts in 2 mid-pandemic months. Overall, PRO response rate increased from 52% pre-pandemic to 81% during, non-responders dropping from 48% to 19%, and response rate without any reminder from the team increasing from 13% pre-pandemic to 79% during. Across all 3 age cohorts, overall PRO response rates increased (AYA up 21%, midage up 27%, seniors up 35%, p 0.012), PRO non-response rate decreased (AYA by 21%, midage by 27%, seniors by 35%, p 0.01), and PRO response rate without reminders from clinic team increased significantly (AYA, by 71%, midage by 78%, senior by 61%, p <0.00001). When further analyzing by visit type during pandemic, the improvements in overall PRO response rates are driven almost exclusively by telehealth where in-person PRO completion decreased by 19% (pre-pandemic 52%, during 33%) while pts who had an upcoming virtual visit had 94% PRO response rate (p < 0.00001). Conclusions: Substantially higher adherence with PRO-based remote symptom monitoring was seen during the pandemic with virtual visits accounting substantially for this broad adherence and the highest increases seen in older adults, highlighting the implications of telehealth on cancer care.