In research, a lot of things we show are statistically relevant but not practically relevant. This study is a beautiful example of both.
—William A. Dunson, Jr, MD
The use of an automated computer-based telephone monitoring system to assess symptoms during outpatient chemotherapy—and provide intervention where appropriate by a nurse practitioner—substantially reduced the number of days with symptoms in a study reported at the 18th Annual Conference of the National Comprehensive Cancer Network (NCCN).1
“We asked whether this system would decrease symptom days, and we saw a dramatic effect in some areas,” said William A. Dunson, Jr, MD, of the Huntsman Cancer Institute at the University of Utah, Salt Lake City. “In research, a lot of things we show are statistically relevant but not practically relevant. This study is a beautiful example of both.”
He cited two main concerns in the cancer clinic: controlling patients’ symptoms and freeing up nurses to care for patients—that is, not having their time consumed by telephone calls. “These are big challenges in every clinic,” Dr. Dunson said.
The study evaluated an automated system that all patients called every morning to report on common chemotherapy-related symptoms. Those who reported the presence of symptoms were questioned as to the frequency of vomiting, intake of liquids, and so forth. Symptoms that were moderate-to-severe were referred to the nurse practitioner, in the intervention arm.
The system was prospectively evaluated among 358 patients beginning a course of chemotherapy. The majority of patients were white, the average age was 55, and about one-third were currently employed. Diagnoses included mainly breast (43%), lung (17%), and ovarian (10%) cancers; fewer than 7% each had colorectal, pancreatic, head and neck, endometrial, and other tumor types.
All participants called the automated system daily to report the presence and severity of symptoms on a 10-point scale. Additionally, those in the intervention group received automated self-care messages tailored to symptom severity during the daily call, and received a personal call from the nurse practitioner if the presence of moderate (4–7) or severe (> 7) symptoms triggered an alert. The nurse practitioner then used NCCN Guidelines for Supportive Care in a case management system.
“This was a proactive system. Instead of waiting for patients to be in disaster mode, we had them call in daily with a status report,” he said.
The majority of patients reported moderate or severe symptoms, including fatigue (83%), pain (79%), nausea (60%), depressed mood (52%), and nervousness/anxiety (49%). The participants were in the study an average of 83 days and completed 89% of the expected daily calls.
‘Dramatic’ Reduction in Days with Symptoms
The intervention group had significantly fewer days with moderate/severe symptoms for all symptoms monitored (P < .001 for each), Dr. Dunson reported. “This was pretty dramatic,” he said.
Out of 83 days on the study, the estimated mean number of days (based on a binomial regression model) with moderate/severe fatigue was 25 in the usual-care group but just 11 in the intervention group—a 55% reduction. Days with moderate/severe pain averaged 19 in the usual-care group but 7 in the intervention group. Average days with nausea were 8 vs 3; with depressed mood, 5 vs 2; and with nervousness or anxiety, 4 vs 1, respectively.
“Moderate to severe symptom days were reduced in the telephone-care group as compared to the usual-care group by over one-half for fatigue and by nearly two-thirds for the other symptoms,” he reported.
Dr. Dunson maintained the study was well controlled in that both groups had to call the center. He believes the intervention by the nurse practitioner was likely the factor that proved most effective in reducing symptom days.
While the study had a dedicated nurse practitioner for this activity, the next step is to use an existing staff nurse. “We presume this will show the same benefit, and it might take even less time,” he said. “The obvious next question is whether it saves money or costs money. I think it will save money if we can use nurses instead of nurse practitioners, certainly if it decreases the amount of time the nurse spends on the phone. It also saves in terms of productivity from the patient’s point of view.”
Dr. Dunson said depending on the outcomes in further testing, this system could become available in the marketplace.
The study was funded by the National Cancer Institute. Larger overall investigations of the automated system, which demonstrated significant symptom reduction across 11 symptoms, were previously presented at last year’s ASCO Annual Meeting2 and the Quality Care Symposium.3 The poster presented at the NCCN Annual Conference represented an individual analysis of symptom outcomes for five symptoms, where the NCCN Guidelines were specifically used for the intervention arm. ■
Disclosure: Dr. Dunson reported no potential conflicts of interest.
1. Dunson WA, Mooney KH, Beck SL, et al: NCCN symptom guidelines coupled with nurse practitioner follow-up reduced moderate to severe symptom days by half or greater in cancer patients receiving chemotherapy. National Comprehensive Cancer Network Annual Conference. Abstract AB2013-7. Presented March 15, 2013.
2. Mooney K, Beck SL, Wong B, et al: Outpatient chemotherapy supportive care: Trial of an IT-integrated, NP-delivered system for unrelieved symptoms. ASCO Annual Meeting. Abstract 9137. Presented June 2, 2012.
3. Mooney K, Beck SL, Wong B, et al: An IT-integrated, computer-based telephone system for monitoring patient-reported symptoms: Result of two trials. Quality Care Symposium. Abstract 2. Presented November 30, 2012.