Key Points
Question
What is the expected recovery after ambulatory cancer surgery informed by patient-reported symptoms monitoring?
Findings
In this cohort study, 12 433 patients completed at least 1 Recovery Tracker survey (87% response rate; 110 936 surveys assigned). Overall, the symptom burden was modest in this population, with the highest severity within the first 3 postoperative days.
Meaning
Detailed remote symptom monitoring data can inform further implementation, dissemination, and maintenance of such programs, enhance patient education, and help set expectations.
This cohort study describes the patterns of postoperative recovery among patients undergoing ambulatory cancer surgery with remote symptom monitoring using an ePRO platform—the Recovery Tracker.
Abstract
Importance
Complex cancer procedures are now performed in the ambulatory surgery setting. Remote symptom monitoring (RSM) with electronic patient-reported outcomes (ePROs) can identify patients at risk for acute hospital encounters. Defining normal recovery is needed to set patient expectations and optimize clinical team responses to manage evolving problems in real time.
Objective
To describe the patterns of postoperative recovery among patients undergoing ambulatory cancer surgery with RSM using an ePRO platform—the Recovery Tracker.
Design, Setting, and Participants
In this retrospective cohort study, patients who underwent 1 of 5 of the most common procedures (prostatectomy, nephrectomy, mastectomy, hysterectomy, or thyroidectomy) at the Josie Robertson Surgery Center at Memorial Sloan Kettering Cancer Center from September 2016 to June 2022. Patients completed the Recovery Tracker, a brief ePRO platform assessing symptoms for 10 days after surgery. Data were analyzed from September 2022 to May 2023.
Main Outcomes and Measures
Symptom severity and interference were estimated by postoperative day and procedure.
Results
A total of 12 433 patients were assigned 110 936 surveys. Of these patients, 7874 (63%) were female, and the median (IQR) age at surgery was 57 (47-65) years. The survey response rate was 87% (10 814 patients responding to at least 1 of 10 daily surveys). Among patients who submitted at least 1 survey, the median (IQR) number of surveys submitted was 7 (4-8), and each assessment took a median (IQR) of 1.7 (1.2-2.5) minutes to complete. Symptom burden was modest in this population, with the highest severity on postoperative days 1 to 3. Pain was moderate initially and steadily improved. Fatigue was reported by 6120 patients (57%) but was rarely severe. Maximum pain and fatigue responses (very severe) were reported by 324 of 10 814 patients (3%) and 106 of 10 814 patients (1%), respectively. The maximum pain severity (severe or very severe) was highest after nephrectomy (92 of 332 [28%]), followed by mastectomy with reconstruction (817 of 3322 [25%]) and prostatectomy (744 of 3543 [21%]). Nausea (occasionally, frequently, or almost constantly) was common and experienced on multiple days by 1485 of 9300 patients (16%), but vomiting was less common (139 of 10 812 [1%]). Temperature higher than 38 °C was reported by 740 of 10 812 (7%). Severe or very severe shortness of breath was reported by 125 of 10 813 (1%).
Conclusions and Relevance
Defining detailed postoperative symptom burden through this analysis provides valuable data to inform further implementation and maintenance of RSM programs in surgical oncology patients. These data can enhance patient education, set expectations, and support research to allow iterative improvement of clinical care based on the patient-reported experience after discharge.
Introduction
Complex procedures are increasingly being performed with reduced lengths of postoperative hospital stay.1,2 Although a short hospital stay has many benefits, it also requires patients and caregivers to manage their recovery at home.3 Common postoperative symptoms, such as pain, fatigue, and nausea, represent a major source of distress for surgical patients and can result in unplanned acute care visits following surgery.4 It can be difficult for patients to distinguish between symptoms that are expected during recovery and potentially serious adverse events, such as infection.5 Additionally, clinicians generally do not know what patients are experiencing while recovering at home unless the symptoms rise to a level such that the patient contacts the office or seeks acute care.6,7,8
Remote symptom monitoring (RSM) using electronic patient-reported outcomes (ePROs) provides a means to bridge the gap between patients at home and their clinical teams, promoting patient-centered care, communication, and shared decision-making.9,10,11 In response, the US Centers for Medicare and Medicaid Services will now require symptom monitoring with ePROs as part of its value-based programs, such as the Enhancing Oncology Model (EOM). Analysis of data from existing RSM platforms is needed to inform widespread implementation across oncology practices that will participate in the EOM and similar programs. One example includes Recovery Tracker, which we developed and implemented in 2016 for patients undergoing cancer surgery at our ambulatory surgery center, the Josie Robertson Surgery Center at Memorial Sloan Kettering Cancer Center (MSK), New York, New York.12 Recovery Tracker is a 10-day postoperative ePRO RSM platform with automated clinical alerts and follow-up for concerning responses. In a study of 7165 patients, we observed that implementation of Recovery Tracker reduced the need for unnecessary urgent care visits.12
Our knowledge of symptom burden during recovery and what defines a normal postoperative course remains insufficient. For instance, it is known that pain, fatigue, and nausea are common and expected symptoms for all surgical patients, but the exact severity and trajectory of such symptoms during recovery has not been rigorously analyzed. There is a need to define recovery after ambulatory oncologic procedures during the acute postoperative care phase to provide information and set expectations for patients and enhance RSM.
We are uniquely positioned to define the normal postoperative recovery in a cohort of 12 433 patients (110 936 surveys) treated at a single free-standing ambulatory center where all patients received the same standardized RSM platform, the Recovery Tracker. The objective of this study was to describe the patterns of postoperative recovery by common symptoms across ambulatory surgical oncology patients. This information can support patients and their caregivers in managing their postdischarge care, provide outcome and experience data to inform RSM implementation, improve care delivery and education, and identify areas for further research.
Methods
Electronic Platform and Survey Delivery
The Recovery Tracker is a short electronic survey assessing symptoms for 10 days after surgery.12 Two patient education touch points introduce the Recovery Tracker to the patient: at the presurgical clinic visit (informational pamphlet), with more extensive information (including an animated video) provided subsequently as part of discharge teaching after surgery. After discharge, patients receive daily email invitations (triggered automatically based on Current Procedural Terminology code, per procedure) directing them to complete the Recovery Tracker on the secure MyMSK Patient Portal. The proprietary survey system within the portal, MSKEngage, is built with a responsive design so patients can complete the surveys via computer, tablet, or mobile phone. Each survey is available for 24 hours. This study was approved by the Memorial Sloan Kettering Institutional Review Board, and informed consent was waived because the study was considered minimal risk and only involved survey procedures. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
Domains and Measures
The Recovery Tracker survey items (eTable 1 in Supplement 1) were adapted from the National Cancer Institute Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events,13 a validated PRO instrument designed for standardized symptom assessment in patients on cancer clinical trials. Some items were modified to be more specifically relevant for postsurgical patients (eg, asking about wound redness rather than intravenous site redness). Twelve questions assess symptoms of pain, fatigue, constipation, nausea, vomiting, fever, chills, shortness of breath, and wound condition, and 2 questions address pain and fatigue interference based on the patient’s initial severity response.
Patient Population and Postoperative Symptom Trajectories
We performed a retrospective analysis of the patient-reported symptoms for 12 433 consecutive patients who underwent the top 5 procedures performed at our ambulatory surgery center from the start of the Recovery Tracker implementation in September 2016 through June 2022. All patients underwent ambulatory extended recovery surgery (1 overnight stay). These procedures include radical prostatectomy (laparoscopic or robotic), nephrectomy (partial or total; robotic, laparoscopic, or open), mastectomy (unilateral and bilateral, with and without immediate reconstruction), hysterectomy (laparoscopic or robotic, open, vaginal, and including other gynecologic pelvic procedures), and thyroidectomy (all open) (Table 1).
Table 1. Survey and Patient Characteristics.
| Characteristic | Procedure | ||||||
|---|---|---|---|---|---|---|---|
| Prostatectomy | Nephrectomy | Mastectomy without reconstruction | Mastectomy with immediate reconstruction | Hysterectomy | Thyroidectomy | All | |
| Survey initiation | September 2016 | September 2016 | April 2017 | April 2017 | April 2017 | December 2017 | NA |
| Unique patients assigned a survey, No. | 3973 | 395 | 1288 | 3805 | 1913 | 1059 | 12 433 |
| Patients completing at least 1 survey, No. (%) | 3543 (89) | 332 (84) | 1044 (81) | 3322 (87) | 1645 (86) | 928 (88) | 10 814 (87) |
| Total surveys assigned, No. | 35 550 | 3511 | 11 348 | 33 571 | 17 612 | 9344 | 110 936 |
| Surveys completed, % | 63 | 55 | 52 | 56 | 60 | 58 | 59 |
| Age at surgery, median (IQR), ya | 63 (57-68) | 60 (51-68) | 61 (51-70) | 47 (41-55) | 56 (48-65) | 48 (36-58) | 57 (47-65) |
| Sexa | |||||||
| Female | 0 | 142 (36) | 1213 (94) | 3802 (100) | 1913 (100) | 804 (76) | 7874 (63) |
| Male | 3973 (100) | 253 (64) | 75 (5.8) | 3 (<0.1) | 0 | 255 (24) | 4559 (37) |
| BMIa,b | |||||||
| Total, No. | 3968 | 393 | 1288 | 3805 | 1911 | 1058 | 12 423 |
| Median (IQR) | 28.2 (25.7-31.1) | 29.1 (25.9-33.3) | 26.7 (23.0-31.1) | 25.0 (22.0-29.1) | 28.4 (24.0-34.0) | 27.2 (23.9-31.8) | 27.2 (23.8-31.1) |
| ASA classification, No. (%)a | |||||||
| III or IV | 1471 (37) | 212 (54) | 708 (55) | 1418 (37) | 725 (38) | 343 (32) | 4877 (39) |
| Unknown | 1 (<1) | 0 | 0 | 1 (<1) | 2 (<1) | 0 | 4 (<1) |
Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index; NA, not applicable.
Among unique patients assigned surveys.
Calculated as weight in kilograms divided by height in meters squared.
Statistical Analysis
Descriptive statistics (frequency and proportions) are reported to describe the rates of survey completion and symptom burden for the full cohort and stratified by procedure type. We also evaluated whether age at surgery was associated with completion rates, using linear regression and including cubic splines to allow for nonlinearity. Local polynomial smoothing was used to visualize the association between postoperative day (POD) and pain severity and fatigue severity, separately and for each procedure type. To test the association between procedure type and the outcomes of pain and fatigue, separately, we used generalized estimating equations. Significance was set at P < .05, and all P values were 2-tailed. All statistical analyses were conducted using Stata version 15.0.
Results
Patient Characteristics
A total of 12 433 patients were assigned 110 936 surveys. Of these patients, 7874 (63%) were female, and the median (IQR) age at surgery was 57 (47-65) years. Patient characteristics are reported in Table 1. Patients who underwent immediate reconstruction were younger than patients who underwent mastectomy without reconstruction (median [IQR] age, 47 [41-55] years vs 61 [51-70] years).
Recovery Tracker Response Rates
Overall, 10 814 patients (87%) responded to at least 1 of the 10 daily surveys, and a total of 65 274 surveys (59%) were completed (Table 1). Patients submitted a median (IQR) of 7 (4-8) surveys, and each assessment took a median (IQR) of 1.7 (1.2-2.5) minutes to complete. Completion rates were similar across the different procedures (Table 1). Mean completion rate by age was relatively flat, averaging between 57% and 61% from ages 35 to 75 years across all procedures (eTable 2 in Supplement 1). Overall, patients completed the lowest proportion of surveys on POD 1 (485 of 1484 [33%]) and the highest proportion between POD 3 to 7 (mean [SD], 63% [1.1]; eTable 3 in Supplement 1). The reduced number of surveys assigned on POD 1 reflect that most overnight patients do not receive a survey on the day of discharge. Survey response rates increased over the years, reflecting enhanced education for nursing staff and enhanced patient education and the addition of printed information and instructions at the time of discharge. In 2017, 5297 of 12 595 assigned surveys (42%) were completed overall and 786 of 1381 patients (57%) completed 3 or more surveys. These numbers increased to 12 552 of 21 352 surveys (59%) and 1748 of 2392 patients (73%) in 2019 and to 15 497 of 23 596 (65%) and 2095 of 2631 (80%), respectively, in 2021.
Overall Symptom Burden
Symptom severity generally decreased over time for all symptoms reported, with the highest severity reported between POD 1 and 3. Overall, pain and fatigue were the most frequently reported symptoms, with 7383 of 10 809 (68%) and 6120 of 10 810 (57%), respectively, describing moderate or greater severity symptoms on at least 1 day (Table 2). Maximum pain and fatigue responses of very severe were reported in only 324 of 10 814 (3%) and 106 of 10 814 (1%), respectively. Pain and fatigue consistently decreased over time for patients (Figure 1 and Figure 2). Across all procedures, mean pain severity was initially moderate and decreased to mild within 4 to 6 days. Similarly, fatigue started in the mild to moderate range and diminished to mild or less by POD 5. Both pain and fatigue scores over time were significantly higher for patients undergoing mastectomy with reconstruction compared with those undergoing mastectomy alone (Figure 1 and Figure 2). Comparing patients undergoing nephrectomy and prostatectomy, pain and fatigue scores over time were higher after nephrectomy (Figure 1 and Figure 2). The maximum pain severity reported was highest after nephrectomy, followed by mastectomy with reconstruction and prostatectomy, with 92 of 332 (28%), 817 of 3322 (25%), and 744 of 3543 (21%), respectively, reporting severe or very severe maximum pain at least once (eTable 4 in Supplement 1). Nephrectomy patients also reported the highest maximal severity of fatigue, with 49 of 332 (15%) reporting severe or very severe fatigue (eTable 5 in Supplement 1).
Table 2. Reported Symptoms by Procedurea.
| Symptom | Procedure, No. (%) | ||||||
|---|---|---|---|---|---|---|---|
| Prostatectomy (n = 3543) | Nephrectomy (n = 332) | Mastectomy without reconstruction (n = 1044) | Mastectomy with immediate reconstruction (n = 3322) | Hysterectomy (n = 1645) | Thyroidectomy (n = 928) | All (n = 10 814) | |
| Pain | 2491/3540 (70) | 237/332 (71) | 545/1044 (52) | 2533/3320 (76) | 1096/1645 (67) | 481/928 (52) | 7383/10 809 (68) |
| Fatigue | 1891/3541 (53) | 224/332 (67) | 514/1044 (49) | 2008/3321 (60) | 963/1644 (59) | 520/928 (56) | 6120/10 810 (57) |
| Nausea | 286/3137 (9) | 61/289 (21) | 135/883 (15) | 630/2845 (22) | 245/1381 (18) | 128/765 (17) | 1485/9300 (16) |
| Vomiting | 30/3543 (1) | 6/332 (2) | 15/1043 (1) | 59/3322 (2) | 20/1645 (1) | 9/927 (1) | 139/10 812 (1) |
| Shortness of breath | 391/3543 (11) | 57/332 (17) | 89/1043 (9) | 354/3322 (11) | 197/1645 (12) | 103/928 (11) | 1191/10 813 (11) |
| Temperature >38 °C | 282/3542 (8) | 43/332 (13) | 69/1044 (7) | 168/3321 (5) | 135/1645 (8) | 43/928 (5) | 740/10 812 (7) |
| Swelling | 1463/3543 (41) | 89/332 (27) | 264/1043 (25) | 912/3317 (27) | 478/1643 (29) | 290/928 (31) | 3496/10 806 (32) |
| Bruising | 1493/3345 (45) | 130/313 (42) | 292/1043 (28) | 1206/3318 (36) | 545/1643 (33) | 126/927 (14) | 3792/10 589 (36) |
| Discharge | 193/3543 (5) | 10/332 (3) | 231/1043 (22) | 644/3321 (19) | 59/1644 (4) | 28/927 (3) | 1165/10 810 (11) |
| Rednessb | 343/1344 (26) | 32/111 (29) | 57/284 (20) | 198/1094 (18) | 65/409 (16) | 35/184 (19) | 730/3426 (21) |
| Surgical site getting more red or biggerb | 533/2206 (24) | 47/222 (21) | 146/763 (19) | 504/2231 (23) | 218/1242 (18) | 172/744 (23) | 1620/7408 (22) |
| Constipationb | 912/1344 (68) | 60/111 (54) | 121/285 (42) | 571/1098 (52) | 239/409 (58) | 96/185 (52) | 1999/3432 (58) |
| No bowel movement in the past 2 db | 1004/2180 (46) | 104/219 (47) | 191/752 (25) | 815/2194 (37) | 300/1224 (25) | 224/730 (31) | 2638/7299 (36) |
| Contacted clinician | 1161/2517 (46) | 105/228 (46) | 266/660 (40) | 994/2250 (44) | 357/1014 (35) | 202/550 (37) | 3085/7219 (43) |
| Visited the ER | 163/2517 (7) | 15/228 (7) | 15/659 (2) | 66/2251 (3) | 54/1014 (5) | 15/550 (3) | 328/7219 (5) |
Abbreviation: ER, emergency room.
Patients who experienced moderate or greater severity, occasional or higher frequency of the corresponding symptom, or answered yes to the corresponding symptom on at least 1 day.
Questions related to the symptoms of constipation and redness were updated to ask questions about bowel movement in the past 2 days and the surgical site getting more red or bigger, respectively.
Figure 1. Pain Severity by Postoperative Day for the Top 5 Surgical Procedures.
A total of 10 809 patients completed at least 1 Recovery Tracker survey; of these, 324 (3%), 1796 (14%), and 403 (3%) reported a maximum pain severity of very severe, severe, or none, respectively. Dashed lines indicate 95% CIs.
Figure 2. Fatigue Severity by Postoperative Day for the Top 5 Surgical Procedures.
A total of 10 810 patients completed at least 1 Recovery Tracker survey; of these, 106 (1%), 1108 (9%), and 883 (7%) reported a maximum fatigue severity of very severe, severe, or none, respectively. Dashed lines indicate 95% CIs.
Other symptoms are also presented in Table 2 but are not displayed graphically, as they were not experienced every day by most patients. As sensitivity analyses, we summarized these symptoms across varying combinations of number of days and symptom intensity reported (data not shown), but the overall patterns were similar. Constipation was a common complaint across all procedures. Swelling and bruising at the surgical site(s) were the next most commonly reported symptoms, experienced by one-third of patients at moderate or greater severity. At least some nausea was experienced on multiple days by 2156 of 8435 patients (26%), and occasional or more frequent nausea was reported on at least 1 day by 1485 of 9300 (16%) (Table 2), but vomiting was rare (139 of 10 812 [1%]). Temperature greater than 38 °C was reported by 740 of 10 812 patients (7%). Shortness of breath at moderate or greater severity was reported by 1191 of 10 813 (11%) and experienced on 2 or more days and 3 or more days by 373 of 9846 (4%) and 151 of 9086 (2%), respectively; shortness of breath was severe or very severe for only 125 of 10 813 (1%).
Based on feedback from office practice nurses at our ambulatory surgery center, the language of 2 PRO items was modified to reduce perceived ambiguity. The initial constipation question asked about the severity of constipation, where severe or higher responses beginning on POD 3 corresponded to 733 of 3418 patients (21%). The item was changed to more specifically ask whether the patient had a bowel movement in the past 2 days, beginning on POD 3. This change corresponded to 2204 of 6211 patients overall (35%) and 852 of 1872 prostatectomy patients (46%) who responded no. Modifying the item about the severity of wound redness to asking if the surgical site redness was getting more red or bigger did not change the rate at which patients reported moderate or greater severity (728 of 3412 [21%] and 1398 of 6302 [22%], respectively).
Discussion
In this study, we describe the patterns of postoperative recovery in patients undergoing ambulatory cancer surgery with RSM using the Recovery Tracker platform. Rigorously defining these symptoms is critical for several reasons: to align the patient’s expectations, refine the clinical team’s response, inform quality metrics based on patient-reported data, enhance implementation strategies for ePRO-based RSM, and identify areas for further research. Collectively, this will lead to improved health care delivery in settings where RSM is required and increasingly used.
We aimed to report symptom burden after discharge from ambulatory surgery in a large National Comprehensive Cancer Network–designated cancer center to define normal recovery with the goal of improving RSM implementation. This homogenous patient experience allows for a rigorous analysis focused on patient-reported symptoms during recovery after hospital discharge. Increasingly, the promotion of patient-centered care in surgical oncology has leveraged the use of ePROs and patient-generated health data, enabled by digital transformation and innovation.11,14,15 Providing patients with ongoing, real-time personalized support after discharge is central to delivering high-quality postoperative care.
The Centers for Medicare and Medicaid Services now require symptom monitoring with ePROs as part of its value-based programs for patients with cancer, including the EOM.16 This further underscores the importance of research studies such as this that help start to benchmark expected recovery, which can be used as a quality metric in the future. Capturing symptom frequency and severity and defining expected recovery is required to enhance and implement these tools. The Recovery Tracker is an example of the successful design and implementation of an ePRO RSM system for surgical oncology patients.12
Our data provide a first granular look at the patient symptom experience in the immediate period after ambulatory extended recovery surgery. In our study population, there were a higher proportion of women due to the high number of breast and gynecologic procedures. Age and American Society of Anesthesiologists classification were as expected for a healthy ambulatory cancer surgery population. Overall, symptom burden was modest in this population. Pain was moderate initially and steadily improved. Fatigue was reported by more than 90% of patients but was rarely severe. Similarly, nausea was common, but vomiting was rare. A somewhat surprising finding was that a substantial proportion of patients (20% to 40%) reported moderate or higher symptoms related to their wound condition (Table 2). Despite a high rate of concern in patient responses, these responses rarely reflected clinical problems requiring intervention but rather represent an expected response to major surgery.
Patient outcomes can be strongly influenced by patient expectations.17 This finding highlights an opportunity for improved education in an effort to align expectations. One such opportunity includes nursing teams using these data to refine preoperative teaching and help set patient expectations. This example illustrates the fluidity of expectations and how they can be modified with focused teaching modules.18,19 We have previously shown that enhanced feedback reports that display symptom severity during recovery from ambulatory cancer surgery can reduce patient anxiety and nursing workload without affecting acute care visits.20 The current unique PRO data are now available to support further improvement of these initiatives and clinical research.21,22 Future work will evaluate whether aligning patient and clinical team expectations influence patient responses and improve satisfaction with care.
Measurement of health care quality using PRO performance measures assesses how well these aspects of care are being delivered and compare the performance of health care systems and different clinician groups.23 Measuring and interpreting symptom reporting are complicated by their multidimensional nature, requiring simultaneous consideration of different symptom categories, severity or frequency, and time. Our data demonstrate that different categorization of responses using severity and incidence generally varies in a predictable manner, with a similar pattern across different symptoms and stepwise decreases in prevalence with severity and number of days reported (Table 3). Furthermore, while patients are used to responding on a continuous scale for common symptoms (eg, pain or fatigue), what constitutes mild or moderate vs severe for less familiar symptoms (eg, wound redness or swelling) may not be clear or consistently reported by different patients. When using PROs and an intervention, more research is needed to determine which symptoms and what PRO dose (intensity and time) are important to patients and clinicians to optimize and set response thresholds and to drive appropriate interventions, such as reassurance, enhanced surveillance, treatment such as oral antibiotics, in-person examination, or referral to acute care. Collectively, this will help define appropriate patient-centered relevant PRO performance measures.
Table 3. Reported Number of Days With Moderate or Higher Symptoms and Severity of Symptoms on at Least 1 Day.
| Symptom | Patients, %a | |||||
|---|---|---|---|---|---|---|
| Days with moderate or higher symptoms | Severity of symptoms on ≥1 d | |||||
| ≥1 | ≥2 | ≥3 | Moderate or higher | Severe or higher | Very severe | |
| Pain | 68 | 43 | 29 | 68 | 20 | 3 |
| Fatigue | 57 | 35 | 23 | 57 | 11 | 1 |
| Constipation | 44 | 24 | 12 | 44 | 20 | 7 |
| Bruising | 35 | 20 | 13 | 35 | 5 | 1 |
| Swelling | 32 | 16 | 9 | 32 | 3 | <1 |
| Redness | 16 | 7 | 3 | 16 | 2 | <1 |
| Nausea | 14 | 6 | 3 | 14 | 3 | 1 |
| Shortness of breath | 11 | 3 | 1 | 11 | 1 | <1 |
| Discharge | 11 | 4 | 2 | 11 | 1 | <1 |
| Vomiting | 1 | <1 | 0 | 1 | <1 | <1 |
A total of 10 814 patients responded to at least 1 survey. For constipation and redness (n = 4496), responses are limited only to patients who answered at least 1 survey prior to the questions being revised to have binary response options.
Postoperative symptoms sometimes rise to a point that requires a patient to seek acute care after surgery. However, studies have suggested that a substantial number of cancer-related acute hospital encounters may be preventable with earlier intervention.24,25 By addressing symptoms before they necessitate more costly interventions, such as an acute hospital encounter, oncology clinicians can contribute substantially to reducing total cancer care expenditures. We have previously shown that implementation of the Recovery Tracker reduced overall acute care visits that require readmission by 22% in our ambulatory surgical oncology setting.12 Proactive approaches using RSM and understanding of normal patient-reported symptom trajectory have potential clinical benefits through improved communication and early intervention to reduce acute hospital encounters.
Limitations
Several considerations may limit the generalizability of our study findings. Patients need to have a portal account and a mobile phone or computer access to participate. The portal adoption rate among MSK’s ambulatory surgery patients is approximately 90%, which is significantly higher than national portal utilization averages26 and potentially reflects the age of the patient population and having access to and being proficient with technology. However, advanced age alone should not be seen as a limitation. Further, patients eligible for complex cancer surgery in the ambulatory setting are generally healthy patients with new cancer diagnoses who recover with low rates of complications27; participation rates and symptom profiles for patients with more medical comorbidities undergoing more extensive procedures for cancer from nonambulatory settings (longer hospitalization time) remain to be determined. It is encouraging that there have been successes reported with similar initiatives in patients undergoing thoracic28 and colorectal29 surgery, and the potential benefit of ePRO systems such as the Recovery Tracker may be greater in those populations because of their higher risk of complications.
Conclusions
We have described the postdischarge symptom experience of patients after ambulatory cancer surgery, which for this population is generally moderate and tolerable, and identified areas for improved patient education and expectation setting. The routine collection of self-reported symptom data through the Recovery Tracker in ambulatory oncologic surgery has aided in defining normal recovery while catalyzing exploration of new research questions and clinical care initiatives related to surgical symptom surveillance and management.21,30 This work will augment ongoing enhancements of the Recovery Tracker, including tailored visualization tools and educational resources to aid in surgical decision-making and perioperative education. Through rigorous symptom analysis, we have also identified a need to move from a one-size-fits-all approach to disease site–specific content (ie, tailoring PRO items to be better individualized—for example, patients should be monitored for symptoms of low calcium after undergoing thyroidectomy, whereas symptoms that measure return of bowel function are more clinically actionable following prostatectomy). Expanding to more complex surgical procedures may need different or procedure-specific questions, alerts, and timing. As ePRO data collection for symptom management becomes more prevalent, it is important to consider how the data are used and interpreted by clinicians and patients and how this will inform PRO performance measures, as there is significant variability in PRO questionnaires and data presentation.24,31 RSM programs hold significant promise in improving oncology care. Defining symptoms for ambulatory surgery patients provided in this work will support continued improvement, implementation, and dissemination of these novel clinical care tools.
eTable 1. Recovery Tracker Survey Questions
eTable 2. Survey Response Rates by Patient Age and Procedure
eTable 3. Number and Proportion of Assigned Surveys Completed by Survey Day
eTable 4. Maximum Pain Severity Response
eTable 5. Maximum Fatigue Severity Response
Data Sharing Statement
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eTable 1. Recovery Tracker Survey Questions
eTable 2. Survey Response Rates by Patient Age and Procedure
eTable 3. Number and Proportion of Assigned Surveys Completed by Survey Day
eTable 4. Maximum Pain Severity Response
eTable 5. Maximum Fatigue Severity Response
Data Sharing Statement
