Use of statistical process control charts to identify impactful implementation strategies for an ePRO-based symptom management program across the SIMPRO Consortium.
Authors: Doolin Jim W , Dias Samira , Cronin Christine , Dizon Don S. , Hazard-Jenkins Hannah W. , Bian Jessica J , Wong Sandra L. , Schrag Deborah , Paudel Roshan , Osarogiagbon Raymond U. , Hassett Michael J. 
Published: June 2023

6579 Background: Collecting electronic patient reported outcomes (ePROs) reduces the burden of cancer and prevents acute care hospitalizations. However, broad implementation in the routine care setting remains challenging, partly because the optimal implementation strategies – actions that are most likely to encourage adoption and use – are not known. Since 2019, the SIMPRO Consortium has deployed an ePRO-based symptom management program (eSyM) across 6 community-based cancer centers. Methods: We used statistical process control (SPC) charts to identify variation due to special versus common causes (random variation) for one key performance indicator (KPI) – the weekly ePROs response rate. All 6 SIMPRO sites contributed data for this analysis: 3 for chemotherapy patients and 3 for surgery patients. Sites had to have at least 18 months of KPI data; information from the first 4 months after eSyM rollout were excluded to account for program ramp-up. The KPI was calculated as the number of patients who submitted an ePRO questionnaire divided by the number eligible to submit a questionnaire each week. The upper and lower confidence limits were set at +/- 2 sigma to allow for 95% of observations to fall within the limits. Three rules were applied to identify special cause variation: 1) astronomical points (outside sigma limits), 2) shifts (8 or more points above or below a center line), and 3) trends (6 or more points consecutively ascending or descending). Implementation strategies that mapped to special cause variations were selected as those most likely to impact the KPI. Results: Across the 6 sites that deployed eSyM, the mean KPI performance ranged from 19.7%-35.7%. SPC charts detected multiple special cause variations in the KPI at all 6 sites, though the patterns varied by site. All sites demonstrated positive and negative astronomical variations as well as positive and negative shifts. Three sites demonstrated negative trends; no sites demonstrated positive trends. Direct patient outreach was the implementation strategy most frequently associated with special cause variation, followed by changes in promoting the ePRO program to clinical staff. Positive changes were associated with strategy initiation; negative changes were associated with strategy discontinuation. Conclusions: Applying SPC charts to a KPI from the eSyM deployment highlighted the effect of personal communication with patients and providers, suggesting that these implementation strategies could offer value to other sites deploying eSyM. The absence of positive trends early in eSyM program deployment underscores the need to identify better implementation strategies and allocate more resources to foster program adoption and sustainability. Applying SPCs to other KPIs, such as symptom severity and healthcare utilization, could improve eSyM deployment and impact.