University of Groningen Perioperative telemonitoring of older patients with cancer Jonker, Leonie

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University of Groningen

Perioperative telemonitoring of older patients with cancer

Jonker, Leonie

DOI:

10.33612/diss.165626246

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Publication date:

2021

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Jonker, L. (2021). Perioperative telemonitoring of older patients with cancer. University of Groningen.

https://doi.org/10.33612/diss.165626246

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Summary and discussion | 185

8 SUMMARY OF FINDINGS

This thesis discusses the possibilities of perioperative telemonitoring, specifically in older patients undergoing cancer surgery. Two systematic reviews and several analyses of the Connecare cohort focus on effectiveness, feasibility, study implementation, inclusiveness, and monitored parameters of perioperative telemonitoring.

First, the broad literature search in Chapter 2 resulted in nine controlled trials with a total of 829 patients who received a telemonitoring intervention and 765 patients who received care as usual before and after major non-cardiac surgery. Telemonitoring techniques included wearable biosensors in-hospital, perioperative use of educational/ supportive web portals, and telephone/email and mobile applications after hospital discharge. A systematic review of these studies demonstrated that perioperative telemonitoring was able to improve time to recovery (to full mobilization and to work), 1-4_{self-efficacy,}1,5_{and pain perception}1,4,6_{in the early postoperative phase compared}

to care-as-usual. However, no strong evidence was found for the effectiveness of telemonitoring on other clinical, patient-reported, and financial outcomes. This could be explained by insufficient quality of technology or incomplete implementation in clinical practice.7

Patients’ perceptions of the usability and acceptability of telemonitoring interventions might influence the completeness of implementation of eHealth systems in clinical practice. A second systematic review to assess the feasibility of perioperative eHealth interventions in the older surgical population examined seven eligible telemonitoring studies that included a total of 223 patients (Chapter 3). Our results indicate that older patients undergoing oncological, cardiovascular, or orthopedic surgery considered telemonitoring interventions to be usable, satisfactory, and acceptable, although compliance and study completion rates ranged widely from 53–86% and 54–95%, respectively. A meta-analysis of these results was not possible due to the large degree of heterogeneity in study population, methodologies, telemonitoring interventions, and definitions of feasibility outcomes. This systematic review confirms that the feasibility of perioperative eHealth interventions for older patients is often overlooked and suggests that future studies on feasibility should at least describe patient characteristics such as functional performance, level of education, and socio-economic status.

The feasibility of our Connecare telemonitoring system and the challenges encountered in the implementation process are presented in Chapter 4. From May 2018 until June 2019, a total of 50 out of 89 (56%) eligible older patients participated. Three patients became ineligible because their operations were cancelled. Of the

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186 | Chapter 8

47 remaining patients, 37 completed the study, resulting in a completion rate of 79%. The patients in the “early” cohort used the tablet-based application of Connecare (self-management system, SMS) and an activity tracker (Fitbit) to monitor their perioperative physical activity up to three months after surgery. The “late” cohort used the complete monitoring system of the SMS, including the Fitbit, along with additional devices to monitor temperature, blood pressure, heart rate, weight, and patient-reported symptoms for two weeks after hospital discharge. In both the “early” and “late” cohorts, older patients considered the remote home monitoring system to be usable and acceptable. The thirteen patients who considered it less usable, had a lower level of education (p = 0.02). Compliance rates varied per parameter, from 90% for measuring physical activity to 75–85% for measuring vital signs and 75–79% for reporting symptoms via electronic health questionnaires. Valuable lessons learned during study implementation might contribute to better design of future telemonitoring studies with older patients. For example, to increase study participation, we preferentially approached patients face to face. To increase acceptability, we provided instructions in a familiar (home) environment with instructions on paper and involved family members in the recruitment process and when providing study instructions. With regard to usability, we used tablets instead of smartphones, pre-installed applications on the tablet, and connected it to Wi-Fi or Bluetooth in the home setting. Moreover, we provided easily accessible telephone support and involved all end-users early in the study implementation phase. It is important to keep IT tools usable to increase the compliance of a population at high risk of developing post-discharge complications. In Chapter 5, we looked into the recruitment process of Connecare in further detail to assess the accessibility and inclusiveness of telemonitoring interventions. Technological and patient-related barriers to participation of non-participants were analyzed, and characteristics of the 86 non-participants were compared with 65 participants in a retrospective analysis. Identified technological barriers included lack of internet access at home (n = 16) and perceived insufficiency of digital skills (n = 12), while the main patient-related barrier was a perceived high mental burden (n = 46). Non-participants were older, more often female, unmarried, living alone, with a higher ASA classification, and were more likely to use more than four types of medications. Postoperative complications, hospital readmissions, and mortality did not significantly differ between participants and participants, although more non-participants were discharged to a skilled nursing facility. Thus, our results confirm the underrepresentation of older female patients with little support of a partner in the same house and more comorbidity. This raises awareness to avoid further division of patients with low and high digital health literacy.8_{Future telemonitoring studies}

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providing Wi-Fi hotspots at home for patients without internet access, a technical ‘buddy’ or support with technological support materials to decrease the fear of new technologies and enroll patients with limited digital literacy.

Subsequently, we focused on telemonitoring data. We explored the use of objectively measured physical activity in Chapter 6, as this might be a valuable outcome measure for postoperative physical recovery. Chapter 6 aimed to objectively quantify physical activity, assess the recovery of physical activity at three months postoperative, and characterize older patients who recovered to their preoperative levels of physical activity. Results showed a large variability between patients, with median step counts of 5,974 (IQR 4,250–7,922) before surgery, 1,619 (IQR 920–2,839) at hospital discharge, and 4,674 (IQR 3,047–7,592) at three months postoperative. For this reason, we compared postoperative physical activity levels in relation to patients’ own preoperative physical activity level. At three months after surgery, 15/37 (41%) of the patients had returned to ³ 90% of their baseline physical activity. Compared with patients who had not recovered to baseline physical activity at three months, the patients who did recover seemed to have higher self-reported preoperative physical activity, lower ASA scores, and fewer in-hospital complications, although differences were statistically non-significant.

Finally, Chapter 7 analyzed physical activity, vital signs, and patient-reported symptoms during the first two weeks post-discharge in relation to post-discharge adverse events. We hypothesized that post-discharge, physical activity would increase and symptoms would decrease over time and that complications or hospital readmissions would be associated with more measurements outside set values for the parameters (threshold violations). In total, 24 (43%) patients experienced a post-discharge complication, particularly in the first two weeks after hospital discharge, and 13 (23%) were readmitted to the hospital. This confirms the extent of the clinical problem we address by improving post-discharge monitoring. Over the first 14 days following discharge, physical activity levels improved, but patient-reported symptoms did not. In total, 392 out of 5,379 (7%) measurements violated parameter thresholds, mainly because of physical inactivity (<1000 steps per day). Patients with readmissions had more physical activity threshold violations and patients with post-discharge complications had a higher median pain score compared with patients who did not experience these adverse events. A lower level of physical activity at hospital discharge and in the period after discharge was associated with hospital readmissions. No differences in threshold violations of other parameters were observed between patients with and without post-discharge complications and readmissions. These results confirm that detecting and predicting post-discharge complications is complex and multifactorial. Objectively measured physical activity might be of predictive value for post-discharge adverse events, and it needs to be part of future perioperative telemonitoring studies.

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188 | Chapter 8

GENERAL DISCUSSION

In conclusion, this thesis describes the first steps in exploring the possibilities and challenges of perioperative telemonitoring of older patients with cancer. Although we cannot yet demonstrate that remote home monitoring detects deviations in post-discharge recovery in a timely manner, this thesis provides valuable insight into the obstacles encountered during implementation of a perioperative telemonitoring study in a vulnerable population. In general, older patients undergoing surgery consider telemonitoring usable and acceptable, yet a substantial proportion of this frail population might not benefit from innovations in telemonitoring because of technological and patient-related barriers. There is no evident relation between vital signs and postoperative symptoms measured in the two weeks after discharge and post-discharge complications and hospital readmissions. However, objective measurement of postoperative physical activity is a valuable method to quantify postoperative physical recovery and might be of predictive value for post-discharge adverse events.

In contrast with other European Connecare studies, our local Connecare study was solely observational, and telemonitoring was not integrated into care as usual. In Israel, the

Connecare IT system was integrated into care pathways in an orthopedic department

in a newly founded hospital. In Catalonia, Spain, the system was implemented as a new feature on top of home visits for patients with chronic pulmonary diseases. It is to be expected that introducing new technologies together with other organizational changes is easier than adding new technologies in a perioperative care trajectory within a large tertiary hospital like the UMCG that has already been established and is quite well-structured. The association between physical activity and post-discharge adverse events is comparable to findings of previous studies.9-11 _{Nevertheless, we did not find strong}

evidence that telemonitoring can detect post-discharge complications after major non-cardiac surgery, which is in accordance with controlled telemonitoring trials that are included in the systematic review in Chapter 2. Post-discharge telemonitoring does not influence time to onset of symptoms,12_{the occurrence of postoperative complications,}5

or health care consultations.12,13_{To investigate patterns and timing of complications after}

onco-geriatric surgery, detailed information about objectively measured parameters is required. In recent studies, various parameters were continuously measured by one single device in the hospital setting, instead of using multiple different devices such as in our study.14,15 _{In home settings, additional vital parameters such as respiration rate or}

oxygen saturation, validated questionnaires for postoperative symptoms, or monitoring of surgical site by photographs could contribute to a more complete telemonitoring system. At the same time, excessive data collection could create challenges regarding safety, privacy, usability, technology, and integration in clinical practice.

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However, telemonitoring should not be used solely for the purpose of detecting complications. As demonstrated in Chapter 2, perioperative telemonitoring can improve functional or patient-reported outcomes such as time to recovery, 1-4

self-efficacy,1,5_{and pain perception}1,4,6 _{Therefore, telemonitoring should have the aim of}

improving various clinical and patient-reported outcomes and reducing costs. It could be used to personalize preoperative and postoperative care. In preoperative settings, there is potential for real-time monitoring to help with making decisions about, for example, whether to starting prehabilitation or to proceed with the planned surgery. In postoperative care, telemonitoring information could be of assistance for screening, triaging, and personalizing the planned postoperative follow-up. Observed or reported postoperative symptoms could generate automated feedback to the patient, which may consist of reassurance, general nursing advice, or routine or emergency medical consultation and treatment. With the additional information provided by telemonitoring, patients could receive postoperative care tailored to their needs instead of a standard unadjusted follow-up schedule.

Telemonitoring is just one example of recent developments in eHealth. In health care, limited financial and personnel resources have not kept up with the increase in demand due to greater life expectancy. EHealth has the potential to make the health care system more efficient, which will help it cope with the increased need for health care in today’s aging population. Although health care providers and patients were skeptical toward eHealth at first, the implementation of eHealth has gained more support worldwide. The COVID-19 pandemic has accelerated this process. During the pandemic, eHealth has become even more attractive because the delivery of remote health care lowers the risk of contamination and could relieve the burden on hospital and health care resources.16,17 _{EHealth is used not only to improve hospital care, but}

also in primary care, home care, self-care, and in nursing homes or skilled nursing facilities.18-20_{Attention to vulnerable older patients in this process is required to prevent}

further widening of the gap between patients with low and high digital health literacy. Teaching older adults new digital skills will decrease this gap and also increaser well-being, by improving autonomy, and fulfilling the need to connect with and matter in current society.21 _{In this way, increasing digital literacy could lead to empowerment; for}

example, it could enable older adults to live at home independently for a longer time and be less dependent on their family. However, most aspects of healthcare cannot be replaced digitally. Help with activities of daily living, physical examinations, wound care, or surgical interventions require real-life action and support from a healthcare professional. In addition, in-person visits are preferred for consultations where non-verbal communication is required, such as when delivering bad news. The personal aspect of attention and involvement in healthcare is too important to let digital

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190 | Chapter 8

communication replace all face-to-face consultations. Therefore, we must focus on the aspects of healthcare that we can improve with eHealth. It is necessary to invest time and effort in accessible and feasible eHealth solutions to ensure the quality and capacity of future healthcare for our aging population.

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8 REFERENCES

1. Bouwsma EVA, Huirne JAF, Van De Ven PM, et al. Effectiveness of an internet-based perioperative care programme to enhance postoperative recovery in gynecological patients: Cluster controlled trial with randomised stepped-wedge implementation. BMJ Open. 2018;8(1).

2. Bouwsma EVA, Bosmans JE, Van Dongen JM, et al. Cost-effectiveness of an internet-based perioperative care programme to enhance postoperative recovery in gynaecological patients: Economic evaluation alongside a stepped-wedge cluster-randomised trial. BMJ

Open. 2018;8(1).

3. Vonk Noordegraaf A, Anema JR, van Mechelen W, et al. A personalised eHealth programme reduces the duration until return to work after gynaecological surgery: Results of a multicentre randomised trial. BJOG. 2014;121(9):1127-35; 4. Skraastad EJ, Borchgrevink PC, Nilsen TIL,

et al. Postoperative quality and safety using efficacy safety score (ESS) and a wireless patient monitoring system at the ward: A randomised controlled study. Acta Anaesthesiol Scand. 2020;64(3):301-308.

5. Wang Q, Wang J, Zhao J, et al. Effects of a home care mobile app on the outcomes of discharged patients with a stoma: A randomised controlled trial. J Clin Nurs. 2018;27(19-20):3592-3602. 6. Gustavell T, Sundberg K, Segersvärd R, et

al. Decreased symptom burden following surgery due to support from an interactive app for symptom management for patients with pancreatic and periampullary cancer. Acta Oncol. 2019;58(9):1307-1314.

7. DeChant HK, Tohme WG, Mun SK, et al. Health systems evaluation of telemedicine: A staged approach. Telemed J. 1996;2(4):303-312. 8. Hoogland AI, Mansfield J, Lafranchise EA, et al.

eHealth literacy in older adults with cancer. J

Geriatr Oncol. 2020. Jan 6.

;S1879-4068(19)30438-12.

9. Low CA, Bovbjerg DH, Ahrendt S, et al. Fitbit step counts during inpatient recovery from cancer surgery as a predictor of readmission. Ann Behav

Med. 2018;52(1):88-92.

10. Sun V, Dumitra S, Ruel N, et al. Wireless monitoring program of patient-centered outcomes and recovery before and after major abdominal cancer surgery. JAMA Surg. 2017;152(9):852-859.

11. Panda N, Solsky I, Huang EJ, et al. Using smartphones to capture novel recovery metrics after cancer surgery. JAMA Surg. 2019;155(2):1-7. 12. Sengpiel J, Fuehner T, Kugler C, et al. Use of

telehealth technology for home spirometry after lung transplantation: A randomized controlled trial. Prog Transplant. 2010;20(4):310-317. 13. Zand A, Nguyen A, Stokes Z, et al. Patient

experiences and outcomes of a telehealth clinical care pathway for postoperative inflammatory bowel disease patients. Telemed J E Health. 2020;26(7):889-897.

14. Downey C, Randell R, Brown J, Jayne DG. Continuous versus intermittent vital signs monitoring using a wearable, wireless patch in patients admitted to surgical wards: Pilot cluster randomized controlled trial. J Med Internet Res. 2018;20(12):e10802-e10802.

15. Cardona-Morrell M, Prgomet M, Turner RM, et al. Effectiveness of continuous or intermittent vital signs monitoring in preventing adverse events on general wards: A systematic review and meta-analysis. Int J Clin Pract. 2016;70(10):806-824. 16. Bashshur R, Doarn CR, Frenk JM, et al.

Telemedicine and the COVID-19 Pandemic, Lessons for the Future. Telemed J E Health. 2020 May;26(5):571–73.

17. Khairat S, Meng C, Xu Y, et al. Interpreting COVID-19 and Virtual Care Trends: Cohort Study. JMIR Public

Health Surveill. 2020 Apr 15;6(2):e18811.

18. Zanaboni P, Fagerlund AJ. Patients’ use and experiences with e-consultation and other digital health services with their general practitioner in Norway: Results from an online survey. BMJ Open. 2020;10(6):e034773-2019-034773.

19. Wong ZS, Siy B, Da Silva Lopes K, et al. Improving patients’ medication adherence and outcomes in nonhospital settings through eHealth: Systematic review of randomized controlled trials. J Med

Internet Res. 2020;22(8):e17015.

20. Ohligs M, Stocklassa S, Rossaint R, et al. Employment of telemedicine in nursing homes: Clinical requirement analysis, system development and first test results. Clin Interv

Aging. 2020;15:1427-1437.

21. Raad Volksgezondheid & Samenleving. De derde levensfase: Het geschenk van de eeuw. januari 2020. Available at: https://Www.raadrvs. nl/documenten/publicaties/2020/01/08/de-derde-levensfase-het-geschenk-van-de-eeuw.