Association between remote monitoring and acute care visits in high-risk patients initiating intravenous antineoplastic therapy.
Authors: Daly Robert Michael , Nicholas Kevin , Flynn Jessica , Panageas Katherine , Silva Nicholas , Duck Elaine , Zervoudakis Alice , Holland Jessie C. , Salvaggio Rori , Begue Aaron , Wagner Isaac , Sokolowski Stefania , Zablocki Melissa , Chiu Yeneat Ophelia , Kuperman Gilad , Simon Brett A. , Perchick Wendy , Reidy Diane Lauren 
Published: June 2022

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Background: Acute care visits (emergency department [ED] visits or inpatient admissions) for patients with cancer are growing disproportionately. Traditional oncology care models have not effectively identified and managed at-risk patients to prevent acute care. A next step is to harness advances in technology and mobile applications to enable patients to report symptoms any time, enabling “digital hovering” - intensive monitoring and management of high-risk patients. Our objective was to evaluate a digital platform that identifies and remotely monitors high-risk patients initiating intravenous antineoplastic therapy with the goal of preventing unnecessary acute care visits. Methods: This was a single-institution matched cohort quality improvement study conducted at an NCI-designated cancer center between January 1, 2019 and March 31, 2020. Eligible patients were those initiating intravenous antineoplastic therapy who were identified as high-risk for seeking acute care. Patients were identified as high-risk for an acute care visit by their oncologist with decision support from a web-based machine learning model. Enrolled patients’ symptoms were monitored using a digital platform. The platform is integrated into the EMR and includes: 1) a secure patient portal enabling communication and daily delivery of electronic patient-reported outcomes symptom assessments; 2) clinical alerts for concerning symptoms; and 3) a symptom trending application. A dedicated team of registered nurses and nurse practitioners managed reported symptoms. These clinicians acted as an extension of the primary oncology team, assisting with patient management exclusively through the platform. The primary outcomes evaluated were incidence of ED visits and inpatient admissions within six months of intravenous antineoplastic initiation. Results: Eighty-one high-risk patients from the intervention arm were matched by stage and disease with contemporaneous high-risk control patients. Matched cohorts had similar baseline characteristics, including age, sex, race, and treatment. ED visits and hospitalizations within six months of treatment initiation were analyzed using cumulative incidence analyses with a competing risk of death. The cumulative incidence of an ED visit for the intervention cohort was 0.27 (95% CI: 0.17, 0.37) at six months compared to 0.47 (95% CI: 0.36, 0.58) in the control group (p = 0.01). The cumulative incidence of an inpatient admission was 0.23 (95% CI: 0.14, 0.33) in the intervention group versus 0.41 (95% CI: 0.30, 0.51) in the control group (p = 0.02). Conclusions: The narrow employment of technology solutions to complex care delivery challenges in oncology can improve outcomes and innovate care. This program was a first step in using a digital platform and a remote team to improve symptom care in the home for high-risk patients.