A Text Message Intervention to Minimize the Time Burden of Cancer Care

Abstract

Patients with cancer spend considerable time commuting to, waiting for, and receiving health care. Patient-reported outcomes have been collected electronically to monitor patients for toxicity related to treatment, but, to the authors' knowledge, they have not been used as a strategy to minimize patients' time spent on cancer care by streamlining care delivery. Researchers at Penn Medicine set an objective to assess the effectiveness and implementation of a text message-based symptom reporting electronic triage (e-triage) versus usual care to minimize the time toxicity associated with ambulatory cancer care. The methods employed included a hybrid type 1 effectiveness-implementation, unblinded, randomized controlled trial and sequential mixed-methods study, which was conducted between December 1, 2021, and December 31, 2022, with a follow-up period of 3 months or three visits (whichever came first, but all within the 2-year window). Adult patients with solid tumors receiving single-agent immune checkpoint inhibitors (ICIs) with access to a text-messaging device were enrolled, with a target sample size of 176. The intervention was a symptom-based e-triage via mobile text messaging combined with routine laboratory testing. Participants in the e-triage group with normal bloodwork and no symptoms of drug toxicity on e-triage were eligible to fast-track to ICI infusion, bypassing the pretreatment office visit. The primary end point was total time per ambulatory encounter; secondary end points included wait time, ED or hospital visits, health-related quality of life, patient satisfaction, and implementation (reach and fidelity). Implementation readiness (acceptability, appropriateness, and feasibility), barriers, and facilitators were evaluated in a mixed-methods analysis among treating oncologists, measured via surveys and focus groups. For the study, 40 patients were randomly assigned, of which 31 were evaluated for the primary end point; the median age among the 40 participants was 67.5 years of age (interquartile range 59.5-71.5 years of age), 80.0% were male, and 84.6% were white. Those randomly assigned to the e-triage group of the pilot randomized controlled trial (n=19, n=16 evaluable) had an average of 66.0 minutes less total time (95% confidence interval [CI], -123.7 to -8.08 minutes; P=0.03) and 30.1 minutes less wait time (95% CI, -60.9 to 1.1 minutes; P=0.08) per encounter, than those in usual care (n=21 randomly assigned, n=15 evaluable). ED or hospital visits, health-related quality of life, and patient satisfaction scores were similar. In the mixed-methods study, oncologists (n=31, 17 completed the survey) found the e-triage acceptable (mean 3.8, standard error [SE] 0.1), appropriate (mean 3.8, SE 0.1), and feasible (mean 3.9, SE 0.1) on a 5-point Likert scale of agreeability. Perceived barriers to uptake included challenges in patient identification, potential for drug toxicity underreporting, and reimbursement concerns. The authors conclude that the results of this pilot randomized controlled trial of a text message-based e-triage supports further investigation into the use of text message-based symptom reporting by patients as a strategy to safely assess readiness for treatment and thus reduce the time toxicity associated with cancer care.

FIGURE 1. Study Schema

This figure depicts the two distinct approaches used for the study. A randomized controlled trial (Panel A) was used to assess the impact on patients under different care delivery models: usual care and the e-triage intervention. A mixed-methods approach (Panel B) was used to assess the views of the treating oncologists with respect to the intervention. FACT-G = Functional Assessment of Cancer Therapy — General, PSQ-18 = Patient Satisfaction Questionnaire 18. Source: The authors NEJM Catalyst (catalyst.nejm.org) © Massachusetts Medical Society

FIGURE 2. Consolidated Standards of Reporting Trials (CONSORT) Diagram

This figure shows the process by which patients were considered for inclusion in the study, and reasons that they would later remain in or exit the study. Ultimately, of the 383 individuals screened and the 152 deemed eligible, 51 individuals consented to participate in the alternative care model. Of that group, 40 participants were randomly assigned, 19 to the intervention group and 21 to the control group. The final analysis is based on 31 patients, 16 in the intervention group and 15 in the control group. Source: The authors NEJM Catalyst (catalyst.nejm.org) © Massachusetts Medical Society

FIGURE 3. Minimal Time Savings to Improve the Patient Experience

Patients were asked to reflect on the minimum amount of time that could be removed from an oncology office visit without impacting the quality of their visit, with response choices ranging in 15-minute increments from 15 minutes to greater than 60 minutes (Panel A, left). Patients were also asked to reflect on and choose which component(s) of care this time would ideally be removed from (Panel B, right). Results were measured as a frequency score. Patients could select multiple components of care that they would ideally shorten. These responses are based on surveys completed by the 51 patients who consented to participate. Source: The authors NEJM Catalyst (catalyst.nejm.org) © Massachusetts Medical Society

FIGURE 4. Physician Impressions of and Openness to Implementing Digital Strategies to Minimize Time Toxicity

Physicians were asked about (1) perspectives of time toxicity and its significance, whether or not strategies to reduce time toxicity are needed, and whether or not they are open to digital strategies to reduce time toxicity; as well as for input on (2) readiness to implement a digital strategy using the acceptability, appropriateness, and feasibility of intervention measures metrics. Each measure consisted of four items on a five-point Likert scale for which the means and standard errors were calculated. Ultimately, physicians strongly agreed that the time burden of routine cancer care is significant and that strategies are needed to reduce it. Physicians agreed that the proposed intervention is acceptable, appropriate, and feasible. The data are based on responses from 17 of 32 faculty surveyed. Source: The authors NEJM Catalyst (catalyst.nejm.org) © Massachusetts Medical Society

FIGURE 5. Physician Perception of the Most Actionable Components of Time Toxicity

Physicians were asked questions regarding the time burdens of cancer care and the components of these time burdens; for each question, they indicated the top three components. Physicians most frequently indicated that commuting to and waiting for infusion were the components of care that patients spent the most time on (Panel A, top left). They reported that minimizing the time spent on labs and scans as well as waiting for infusion were the most feasible to address (Panel B, top right). Physicians also reported that waiting for infusion and waiting for the clinician were the two components they think that patients most want to be more efficient (Panel C, bottom left) and that those two components are also most critical to make more efficient (Panel D, bottom right). The data are based on responses from 17 of 32 faculty surveyed. Source: The authors NEJM Catalyst (catalyst.nejm.org) © Massachusetts Medical Society