An increasing proportion of cancer surgeries are ambulatory procedures requiring a stay of ≤1 day in the hospital. Providing patients and their caregivers with ongoing, real-time support after discharge aids delivery of high-quality postoperative care in this new health care environment. There is abundant evidence that patient self-reporting of postoperative symptoms improves quality of care, but the most effective way to monitor and manage this information is not known.
We evaluated 2 approaches to the management of patient-reported symptoms and their potential impact on decreasing urgent care center (UCC) visits, patient anxiety, and caregiver burden up to 30 days after ambulatory cancer surgery. The first approach was Team Monitoring (TM), which encompassed symptom monitoring by the clinical team, with nursing outreach if symptoms exceeded normal limits (current standard of care). The second approach was Enhanced Feedback (EF), in which real-time electronic normative feedback was given to patients about expected symptom severity, with patient-activated care as needed.
This 2-armed, randomized controlled trial (RCT) enrolled patients with breast, gynecologic, urologic, or head and neck cancer who were undergoing ambulatory cancer surgery; their caregivers also were enrolled. Each day for up to 30 days postsurgery, all patient participants completed an electronic symptom survey, the Recovery Tracker, which included items from a validated instrument. In the EF group, an additional report containing expected symptom information, based on survey responses from previous patients, was provided to patients immediately after each survey was submitted, to give immediate information and context about the patient's specific reported symptoms in a graphically pleasing way. For our primary study outcome, we assessed unplanned UCC visits and symptom-related events (eg, adverse events, pain management referrals, nursing calls) between the EF arm and the TM arm within 30 days of surgery. For our secondary outcome, we assessed the patient and caregiver experience (ie, patient engagement, patient anxiety, and caregiver burden). The primary analysis tested the association between the primary outcomes and randomization arm using multivariable logistic regression adjusting for randomization strata as a covariate. Patients also completed the Patient Activation Measure to evaluate patient engagement preoperatively and at 2 weeks and 2 months postoperatively. Caregiver burden was evaluated at 2 weeks and 2 months postoperatively via the Caregiver Reaction Assessment. Semistructured qualitative interviews were also conducted with a subset of patients and caregivers.
Data from 2624 patients were analyzed; 1314 and 1310 patients were randomly assigned to the EF arm and the TM arm, respectively. Data from 1031 caregivers also were evaluated. There was no statistically significant difference in the primary outcome (ie, UCC visits within 30 days of surgery, with or without readmissions) between the treatment arms (EF arm – TM arm: 0.99% [95% bootstrap CI, −0.84% to 3.2%], = .4; EF arm – TM arm: 1.0% [95% bootstrap CI, −0.23% to 3.1%], = .12, respectively). Similarly, there was no statistically significant difference in readmissions within 30 days of surgery between treatment groups (EF arm – TM arm: 0.99%; 95% bootstrap CI, −0.89% to 3.0%; = .4). Analysis of the secondary outcome showed that patients randomly assigned to the EF arm had a quicker reduction in anxiety than those in the TM arm and had fewer nursing calls over time, equating to 14% fewer calls over the first 10 days postoperatively (multivariable negative binomial regression adjusting for strata; β = .13; 95% CI, .08-.19; < .001) and 10% fewer calls over the entire 30-day postoperative period (multivariable negative binomial regression adjusting for strata; β = .10; 95% CI, .05-.16; < .001). Qualitative findings supported the quantitative results in that the patients' perception of care and of the Recovery Tracker did not vary greatly between the EF and TM arms, but having the opportunity to report symptoms via the Recovery Tracker and get feedback (automated or by phone call) was appreciated. Caregiver qualitative-interview participants were not significantly burdened by additional responsibilities.
In this large RCT, we found no evidence that an automated mechanism (ie, EF) for providing immediate normative feedback to patients reporting their symptoms after ambulatory cancer surgery was less effective than the standard-of-care nurse monitoring (ie, TM) in terms of UCC visits and readmissions (primary outcome). The EF system reduced nursing workload, and patient anxiety diminished more quickly over the 10-day monitoring period (a secondary outcome). The Recovery Tracker plus EF may provide a patient-centered alternative to the nurse-intensive current management of postoperative patient-reported symptoms.
The patient population at our institution is generally of a higher socioeconomic status, with higher education and greater access to technology, than that of the general population, which may affect generalizability of the results.
