Daily Patient-Reported Symptoms as Predictors of Unplanned Health Care Encounters During Chemotherapy: Longitudinal Observational Study

Abstract

Purpose: Chemotherapy can cause symptoms that impair quality of life and lead to unplanned health care encounters (UHEs) such as emergency department visits and inpatient admissions. Collecting patient-reported symptom data between clinic visits can enable timely identification of symptoms. This observational study aimed to identify how daily individual symptoms are associated with UHE.

Methods: We recruited patients (n = 183) receiving cytotoxic chemotherapy for solid tumors into our 90-day study. Participants completed a modified version of the patient-reported outcome-Common Terminology Criteria for Adverse Events questionnaire assessing common chemotherapy symptoms daily, and UHE information was extracted from medical records. We fit a series of logistic generalized estimating equations to evaluate day-level associations between moderate-to-severe daily symptoms and the occurrence of UHE within 7 days.

Results: On days with moderate-to-severe symptom levels, the odds of having one or more UHE within 7 days were 4.53 times higher for vomiting (95% CI, 1.77 to 11.58; P = .002), 2.84 times higher for decreased appetite (95% CI, 1.94 to 4.17; P < .001), 2.5 times higher for shortness of breath (95% CI, 1.44 to 4.34; P = .001), 1.76 times higher for diarrhea (95% CI, 1.11 to 2.79; P = .02), 1.65 times higher for fatigue (95% CI, 1.20 to 2.26; P = .002), and 1.58 times higher for pain (95% CI, 1.01 to 2.48; P = .04) relative to days with no-to-mild levels of that symptom. After adjusting for days since study enrollment, the odds of UHE were 2.17 times higher on days with moderate-to-severe pain in the abdomen (95% CI, 1.31 to 3.58; P = .003). The odds of UHE within 7 days also increased significantly as the number of moderate-to-severe symptoms increased (P < .001).

Conclusion: Specific daily symptoms were associated with increased risk of subsequent UHE during chemotherapy. Interventional studies are needed to better understand whether daily remote monitoring of these symptoms can reduce UHE.

Figure 1.

Distribution of the Maximum Rating Across All Available Attributes (Severity, Frequency, Interference) for Each Daily Patient-Reported Symptom (n=9,510)

Figure 2.

Example daily symptom profiles among (A) participants who had one or more unplanned healthcare encounters (UHE) during the study and (B) participants who did not. The number of days since study enrollment is plotted along the x-axis and individual symptoms are plotted along the y-axis; symptoms that contributed to the number of “significant” moderate-to-severe symptom outcome are displayed in blue text. The green-red color scale reflects the maximum rating across all available attributes for the symptom, with green corresponding to 0 (or not endorsed) and red to 4. The white-blue color scale reflects the number of “significant” symptoms present at a moderate-to-severe level, with white corresponding to 0 and the darkest blue to 4 or more. Missing values are displayed in grey. For participants who had a UHE, the day of the UHE is indicated by an asterisk and the 7-day window surrounding the UHE is indicated by black vertical lines.