Feasibility of Tablet-Based Patient-Reported Symptom Data Collection Among Hemodialysis Patients

Abstract

Introduction: Individuals receiving in-center hemodialysis have high symptom burdens but often do not report their symptoms to care teams. Evidence from other diseases suggest that use of symptom electronic patient-reported outcome measures (ePROMs) may improve outcomes. We assessed the usability of a symptom ePROM system and then implemented a quality improvement (QI) project with the objective of improving symptom communication at a US hemodialysis clinic. During the project, we assessed the feasibility of ePROM implementation and conducted a substudy exploring the effect of ePROM use on patient-centered care.

Methods: After conducting usability testing, we used mixed methods, guided by the Quality Implementation Framework, to implement a 16-week symptom ePROM QI project. We performed pre-, intra-, and postproject stakeholder interviews to identify implementation barriers and facilitators. We collected ePROM system-generated data on symptoms, e-mail alerts, and response rates, among other factors, to inform our feasibility assessment. We compared pre- and postproject outcomes.

Results: There were 62 patient participants (34% black, 16% Spanish-speaking) and 19 care team participants (4 physicians, 15 clinic personnel) at QI project start, and 32 research participants. In total, the symptom ePROM was administered 496 times (completion rate = 84%). The implementation approach and ePROM system were modified to address stakeholder-identified concerns throughout. ePROM implementation was feasible as demonstrated by the program's acceptability, demand, implementation success, practicality, integration in care, and observed trend toward improved outcomes.

Conclusions: Symptom ePROM administration during hemodialysis is feasible. Trials investigating the effectiveness of symptom ePROMs and optimal administration strategies are needed.

Keywords: hemodialysis; implementation; improvement; mixed methods; patient-reported outcomes; quality; symptoms.

Graphical abstract

Figure 1

Quality implementation framework and related symptom monitoring in renal replacement therapy–hemodialysis (SMaRRT-HD) implementation strategies. The figure displays the 4 phases of the Quality Implementation Framework with associated activities from the SMaRRT-HD system implementation. ^aIn phase 1, clinic personnel received an overview of the project (rationale, objectives, timeline) in a 20-minute presentation at a routine monthly clinic personnel meeting. In phase 2, clinic personnel participated in 1 “lunch-and-learn” session during which they reviewed a draft implementation plan and provided feedback. Nurses (5) and patient care technicians (8) received a 1-time 5-minute individual training on how to administer the SMaRRT-HD electronic patient-reported outcome measure (ePROM) on the tablet by the research assistant. Medical providers (4) were e-mailed instructions for accessing the online system for longitudinal symptom reports. QI, quality improvement.

Figure 2

Quality improvement (QI) project implementation timeline and data collection.The figure depicts the implementation timeline including changes in the symptom monitoring in renal replacement therapy–hemodialysis (SMaRRT-HD) system. Preproject data (interviews, clinical outcomes) were collected in the 4 weeks before and after the 16-week implementation period. Iterative changes were made in response to end-user feedback during the 16-week project (e.g., changes to symptom severity thresholds for e-mail alerts [weeks 5 and 8], recall period in question stem [week 8], and administration frequency [week 8]).

Figure 3

Symptom monitoring in renal replacement therapy–hemodialysis (SMaRRT-HD) completion and assistance rates. The figure displays SMaRRT-HD completion and assistance rates (clinic staff and quality improvement [QI] support team, separately) as documented by the QI support team. There were missing data on staff assistance rates in weeks 2 and 16, as no QI support team member was in the clinic on at least 1 of the 2 days of electronic patient-reported outcome measure (ePROM) administration. The stars depict the 2 weeks when ePROM completion rates fell below 80%. During week 6, there was a clinic water issue on 1 of the 2 ePROM administration days, necessitating treatment stoppage, and during week 16, the tablets were out of charge at the start of ePROM administration on day 1.

Figure 4

Symptom monitoring in renal replacement therapy–hemodialysis (SMaRRT-HD)–reported symptom severity findings (a) and triggered alerts (b). Over the 16-week implementation period, SMaRRT-HD was administered 496 times to 66 unique patients (398 weekly and 98 monthly administrations). (a) The number of times each symptom was reported and associated severity across the 496 electronic patient-reported outcome measures (ePROMs). (b) The number of completed ePROMs at each administration week and number of e-mail alerts that were generated at the 3 tested symptom severity thresholds (Supplementary Table S6).