Remote patient monitoring reduces acute care use among patients with cancer, COVID-19
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A remote patient monitoring program significantly reduced the rate of hospitalization among patients with cancer diagnosed with COVID-19, according to results of a cross-sectional analysis presented during the virtual ASCO Annual Meeting.
Such a care model can reduce transmission of COVID-19 while limiting utilization of resources that have been in short supply during the pandemic, according to the researchers.
“Our findings and experiences with the COVID-19 remote patient monitoring [RPM] program have given us optimism about the future of care delivery innovations for [patients with cancer],” Joshua C. Pritchett, MD, fellow in hematology and medical oncology at Mayo Clinic in Rochester, Minnesota, told Healio. “Looking across the scientific program for [ASCO Annual Meeting], and in our field in general, one cannot help but be excited about the advancements in innovative diagnostics and therapeutic options that are increasingly available for [patients with cancer]. As care evolves and becomes more complex, our experience suggests that the conscientious design and implementation of similarly innovative, patient-centered approaches to cancer care delivery may further improve clinical outcomes for our patients.”
Pritchett, Tufia C. Haddad, MD, chair of practice innovation and platform for Mayo Clinic Cancer Center and medical director of the Center for Digital Health RPM program, and colleagues conducted a multisite prospective observational study at Mayo Clinic Cancer Center that included 224 adults with active cancer who were diagnosed with SARS-CoV-2 infection with a polymerase chain reaction assay.
Researchers used Mayo Clinic’s existing RPM program to co-develop a specific COVID-19 RPM program, with partnership and guidance from infectious disease, general internal medicine and pulmonary/critical care experts. The patients were monitored using in-home technology that alerted a team of centralized nurses in the Midwest about any signs of adverse health trends. Three regional COVID-19 physician teams oversaw the program, responded to care escalation from the nurses and facilitated care transitions to and from the hospital, according to Haddad.
In total, 109 adults enrolled in the RPM program. Researchers noted these patients had more underlying comorbidities than patients who did not enroll in RPM, including pulmonary disease (asthma, 9% vs. 4%; obstructive sleep apnea, 19% vs. 15%), hypertension (50% vs. 38%), diabetes (20% vs. 10%) and chronic kidney disease (17% vs. 8%). Also, a smaller proportion of adults in the RPM group were in remission (47% vs. 62%) and had mild or asymptomatic COVID-19 at onset (68% vs. 87%).
Thirty-seven (17%) patients were hospitalized within 48 hours of COVID-19 diagnosis.
Of the remaining 187 patients managed in the outpatient setting, the 116 patients who did not receive RPM appeared more likely to be hospitalized within 30 days after COVID-19 diagnosis than the 71 patients enrolled in RPM. After balancing patient characteristics by inverse propensity weighting, the estimated risk for hospital admission was 2.8% for those who received RPM and 13% for those who did not. Thus, use of the RPM program was associated with a 10% absolute risk reduction, and a 78% (95% CI, 54-102) RR reduction in hospital admission rate.
Patients who received RPM also had shorter hospital length of stay (median days, 3 vs. 6) and lower rates ICU admission (n = 0 vs. 6) and mortality (n = 0 vs. 6), although these differences did not reach statistical significance.
Although prospective data are needed to validate these findings, the study suggests RPM may be associated with reduced use of acute care and improved outcomes, Haddad told Healio.
“We believe that the technology-enabled, nurse-led symptom and vital sign monitoring of our [patients with cancer] during their acute COVID-19 illness enabled us to earlier identify adverse health trends such as a drop in oxygen saturations or blood pressure before symptoms occurred,” she said. “This in turn facilitated earlier care interventions that were able to promptly reverse the disease trajectory. When patients did experience decompensation, many patients were stabilized in ED with simple interventions, such as initiation of supplemental oxygen or administration of IV fluids and antiemetics, and then discharged rather than being admitted to the hospital. The ED physicians had confidence that patients would continue to receive close monitoring and observation by the RPM program and virtual COVID-19 care team.”
If further research can ensure the safety and cost-effectiveness of wider use of RPM, this care model has the potential to be used beyond the pandemic, according to Haddad.
“We aim to procure the best-in-class technology to support our patients and to enable broad scalability through a robust data and analytics platform,” she said. “We also aim to provide more in-home care interventions to avoid need for care escalation at a medical facility.
“Additionally, we must ensure equitable access to these innovative care models and invest in studies that evaluate the impact of RPM on health care disparities so we do not exacerbate the digital divide,” she added.
Perspective
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Pritchett and colleagues reported findings from a very interesting real-world study assessing the impact of a RPM program for patients with cancer and confirmed COVID-19. The program consisted of COVID-19 home monitoring of 71 patients with cancer two to four times daily, reporting physiologic data on blood pressure, O2 saturation, fever and weight combined with patient-reported COVID-19-specific symptom assessments. The remotely entered data triggered alerts at preset thresholds to a centralized virtual care team of nurses who responded using decision trees and protocols to manage care and escalate, as needed, to advanced practice providers or physicians.
The results showed a 78% RR reduction in hospitalizations for the RPM group compared with a group of 116 patients with cancer and COVID-19 who did not undergo RPM, with a trend toward fewer ED visits, as well; however, this did not reach statistical significance. The RPM group was likely at higher risk for severe COVID-19, so the result may not have captured the full benefit of the RPM program given the lower-risk comparison group.
Over the past 5 years, there has been a growing body of research demonstrating the value of automated home monitoring of patient-reported symptoms among those with cancer paired with alerts to providers of symptoms requiring follow-up. The COVID-19 pandemic has further triggered natural experiments that center on cancer care in the home utilizing both in-person and remote interventions.
Pritchett and colleagues add two important elements to this literature. First, the focus was on COVID-19 monitoring among patients with cancer, rather than monitoring of cancer-related symptoms. Second, they added remote monitoring of physiologic data in addition to patient-reported symptoms. This provides further evidence of our ability to improve care of patients with cancer, reducing their exposures during the pandemic and keeping hospital beds and EDs open for those who can’t be safely treated at home.
Home as a place of cancer care is rapidly evolving and demonstrating clear breakthroughs in providing new delivery models that reduce symptom burden, improve quality of life, provide more time at home and reduce costly unplanned hospitalizations and ED use. This includes models such as hospital at home. Payment models that support and incentivize the home as a setting for acute cancer care are needed to sustain these models beyond demonstration projects. Further study and validation of best practices to accelerate adoption into mainstream cancer care should be the next focus.
References:
Basch E, et al. J Clin Oncol. 2016;doi:10.1200/JCO.2015.63.0830.
Laughlin AI, et al. N Engl J Med Catalyst. 2020;doi:10.1056/CAT.20.0258.
Mooney K, et al. Abstract 12000. Presented at: ASCO Annual Meeting; June 4-8, 2021.
Mooney K, et al. Cancer Med. 2017;doi:10.1002/cam4.1002.
Mooney K, et al. J Clin Oncol. 2021;doi:10.1200/JCO.20.03609.
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Pritchett J, et al. Abstract 1503. Presented at: ASCO Annual Meeting (virtual meeting); June 4-8, 2021.
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