SUO 2021: Digital Innovations to Improve Perioperative Bladder Cancer Care

(UroToday.com) The Society of Urologic Oncology (SUO) annual winter meeting included a health services research session and a presentation by Dr. Jill Hamilton-Reeves discussing digital innovations to improve perioperative bladder cancer care. Dr. Hamilton-Reeves notes that the promise of digital innovation is that it (i) reduces inefficiencies, (ii) extends support and accountability, (iii) strengthens communication with patients and improves the quality of care, and (iv) makes medicine more personalized for patients.

Dr. Hamilton-Reeves highlighted that Dr. Angie Smith has been a big advocate of improving perioperative bladder cancer care. In work presented at the 2018 AUA annual meeting and subsequently published in Cancer1, Dr. Smith’s group sought to determine which patient-reported outcomes are a high priority in the postoperative cystectomy period in order to identify methods to improve 30-day post-radical cystectomy readmission rates. They conducted in-depth semi-structured interviews with 45 readmitted post-cystectomy patients, caregivers, and providers (n=15/group). They found that the most common patient-reported outcomes described by study participants included dehydration, fever, incisional issues (erythema, drainage, opening), abdominal and flank pain. Additional symptoms included constipation, diarrhea, fatigue, loss of appetite, poor sleep, weakness, and ostomy bag leakage. With regard to cystectomy postoperative processes, 3 general themes emerged:

  1. Incremental learning for cystectomy education
  2. Distinguishing normal from abnormal symptoms
  3. Value of symptom tracking

Subsequently, Dr. Smith’s group is using mobile health to facilitate perioperative cystectomy patient education and improve cystectomy care. They conducted a feasibility and acceptability study of 30 patients, with those enrolled completing questions 90 days following discharge via the Twistle app. This app was developed to (i) automate surveillance, (ii) automate guidance to help patients who report symptoms, (iii) automate alerts to staff and inform them regarding patient symptoms, and (iv) provide media links and attachments. A workflow for this study is as follows:

 

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Preliminary results suggest that patient satisfaction is high and that there were high levels of patient engagement in the first 30 days.

In work from Dr. Hamilton-Reeves’ group, they sought to demonstrate the feasibility of implementing a health care application to provide more patient education and more thorough monitoring during the perioperative period for patients undergoing radical cystectomy2. Participants with home Wi-Fi access who were undergoing radical cystectomy were recruited for this pilot trial and provided with the m.Care health care application, an accelerometer, and vital sign equipment. There were 20 patients enrolled in the study and 15 patients completed the trial. The average step count preoperatively was 5,679 reflecting a sedentary population. Step counts decreased during the inpatient stay (1,351 steps) and trended toward baseline during the postoperative period (3,156 steps). Vital signs were recorded on 85% of assigned days and generated 33 triggers for intervention. While most triggers led to repeat assessment, education, and encouragement, four participants underwent outpatient treatment, including cultures, intravenous fluids, antibiotics, or dronabinol prescription, without the need for hospital readmission.

Dr. Hamilton-Reeves notes that there were several important lessons learned from this pilot trial:

  • Difficulty with technology is part of the process: 40% of the subjects did not sync their accelerometer and thus automating processes reduces patient burden
  • Patients who agreed to participate were younger or they had help at home
  • This trial demonstrated the potential of technology to improve care by early identification of problems to reduce the severity of complications and prevent hospital readmissions
  • On-demand education is more accessible, repeatable, and personalized

Dr. Hamilton-Reeve’s group is also looking at the implementation of nutrition education videos for patients undergoing radical cystectomy. The flow diagram for their BCAN supported study is as follows:

 

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 Other clinician advocates are also recently utilizing wearable fitness trackers for their radical cystectomy patients. Dr. Sia Daneshmand’s group assessed the use of wearable fitness trackers for the measurement of activity level and sleep among 21 radical cystectomy patients. Patients wore either a FitBit or Alta HR fitness tracker for up to 3 weeks preoperatively, throughout their admission, and up to 3 weeks postoperatively. These devices measured daily steps, calories burned, minutes sedentary, minutes active, time slept each day and more. In this pilot study, they found that perioperative activity level may predict length of stay after surgery and discharge disposition. Additionally, elderly patients were more willing to participate, while younger patients had more privacy concerns. Dr. Timothy Daskovitch and colleagues assessed 100 patients undergoing 8 major operations (n=12, radical cystectomy) with a Fitbit used after surgery. They found that a higher step counts on post-operative day 1 was associated with a shorter length of stay, with data suggesting an optimal step goal of 1000-steps after surgery.

Dr. Hamilton-Reeves notes that there are several barriers to mobile health adoption in Urology, as highlighted in the following figure:

 

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Dr. Hamilton-Reeves concluded her presentation by emphasizing that although there are barriers and regulations to overcome to improve perioperative radical cystectomy care, it is important to confront problems as they arise and work through them.

 

Presented by: Jill Hamilton-Reeves, PhD, RD, CSO, Associate Professor, Dietitian, and Certified Oncology Nutritionist at Kansas University Medical Center, Kansas City, MO

Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, @zklaassen_md on Twitter during the 2021 Society of Urologic Oncology (SUO) Winter Annual Meeting, Orlando, FL, Wed, Dec 1 – Fri, Dec 3, 2021. 

References:

  1. Smith AB, Mueller D, Garren B, et al. Using qualitative research to reduce admissions and optimize perioperative cystectomy care. Cancer 2019 Oct 15;125(20):3545-3553.
  2. Metcalf M, Glazyrine V, Glavin K, et al. The feasibility of a health care application in the treatment of patients undergoing radical cystectomy. J Urol. 2019 May;201(5):902-908.

 

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