Impact of remote symptom monitoring (RSM) with electronic patient-reported outcomes (ePRO) on hospitalization, survival, and cost in community oncology practice: The Texas Two-Step study.
Authors: Patt Debra A. , Patel Amila Meera , Bhardwaj Arun , Hudson Kathryn Elizabeth , Amondikar Ninad , Christman Amanda , Books Holly , Townsend Sydney , Escudier Susan Marie , Basch Ethan 
Published: October 2023

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Background: There is rising interest to integrate electronic patient reported outcomes (ePRO) solutions for symptom monitoring to enhance the quality of care in oncology and to support value-based care (VBC) models. Step 1 of the Texas Two-Step Study demonstrated successful implementation of an ePRO system in >200 sites of service of a large community oncology practice. We now report step 2 of our study which evaluates the impact of ePROs in reducing adverse outcomes and cost of care among cancer patients enrolled in CMS’ Oncology Care Model (OCM) VBC program. Methods: This observational study focused on patients with metastatic cancer enrolled in the OCM program at Texas Oncology between July 2020 to December 2020. Patients who enrolled and completed ≥1 survey via the ePRO tool defined the study arm. Patients were matched and balanced for confounders with propensity score matching (PSM). Data used for this analysis included data collected from OCM claims files and the ePRO vendor database. Adverse events (death (D)/hospitalizations (H)/Emergency Department (ED) visits), average H/ED visits per patient, average length of H, total Medicare cost (i.e. Medicare paid amounts for different services except Part D drugs) were study measures. Mann-Whitney U and Chi-Square tests compared continuous and categorical variables, respectively, and multivariable logistic regression was used to adjust the covariates (age, gender, cancer type, therapy line). Results: Out of 831 metastatic cancer patients, 458 matched patients (229 patients per group) were identified through PSM. In our matched cohort, ~52% of patients were male, with a mean age of 74 years. Mean total adverse events were significantly less (0.98 vs 1.41 p-value: 0.007) in the study group (SG) as compared to control (C). We observed decreased rates of H (20% vs 32.5%; p value: <0.05), ED (38.4% vs 42.3%) and D (11.8% vs 16.6%) in the SC compared to C. After adjusting for covariates, the SG had decreased odds of H (aOR: 0.51; 95% CI 0.33, 0.8; p-value 0.002) compared to C. Similar, but not statistically significant, effects were observed in the case of D and ED visits. Average number of H (0.28 vs 0.52, p-value-0.003) and ED visits (0.51 vs 0.75, p value: 0.01) per patient were also lower in the SG as compared to C. In addition, mean H duration per patient (days) was significantly less in the SG as compared to C (1.9 vs 3.2, p value: 0.03). ePRO engagement also reduced the total cost of care (per member per month) by an average of $1146. Conclusions: RSM with ePROs reduced adverse outcomes and cost of care among patients with metastatic cancer in a large multi-site community oncology practice. Additional studies to include a larger patient population are warranted to strengthen these observations. This work suggests that ePRO use in the community setting does improve patient outcomes and enhance VBC.