Remote monitoring: how to better care for patients at home

A per­son suf­fer­ing from can­cer must often begin a dif­fi­cult and lengthy course of treat­ment. This peri­od, which can only be stress­ful for the indi­vid­ual, is nec­es­sary for the care of the patient, but leads to many incon­ve­niences. In addi­tion to the risks of unjus­ti­fied hos­pi­tal­i­sa­tion, the effects of tox­i­c­i­ties linked to treat­ments and the way the dis­ease devel­ops are major issues for qual­i­ty of care. 

In oncol­o­gy, the dos­es pre­scribed are some­times high and the patient does not always cope with the side effects. Mon­i­tor­ing of patients dur­ing treat­ment, far from the hos­pi­tal at home, is there­fore nec­es­sary. Today, a new field is emerg­ing that can coun­ter­act these draw­backs: remote mon­i­tor­ing. It can be applied to many dis­eases, offer­ing the pos­si­bil­i­ty of remote med­ical mon­i­tor­ing via dig­i­tal communication. 

Remote mon­i­tor­ing is a promis­ing field that is attract­ing a lot of invest­ment from start-ups, but very few stud­ies are avail­able on the ben­e­fits of this type of mon­i­tor­ing. With my team, we there­fore car­ried out a ran­domised con­trolled tri­al ¹, on a sam­ple of 559 can­cer patients – of all can­cer types – to test the effec­tive­ness of remote mon­i­tor­ing for a chron­ic dis­ease, along with a lon­gi­tu­di­nal study.

Treat­ing can­cer requires reg­u­lar vis­its to the hos­pi­tal. The patient is there­fore often in an envi­ron­ment that is spe­cialised to their needs. Oral treat­ment lim­its these vis­its, but once back home, there is a kind of dis­con­nec­tion that takes place due to a lack of infor­ma­tion. This can lead to a feel­ing of aban­don­ment for the patient so, in order to pro­vide the most appro­pri­ate response, we con­duct­ed a pre­lim­i­nary sur­vey to find out what ele­ments were miss­ing in this long-dis­tance relationship. 

CAPRI, a remote patient mon­i­tor­ing app, was devel­oped from this sur­vey. It is sim­ple to use and allows patients to get in touch direct­ly with the med­ical staff to answer their ques­tions and man­age treat­ment. In our study, where the com­mu­ni­ca­tion sys­tem was mixed, CAPRI allows bilat­er­al or sym­met­ri­cal com­mu­ni­ca­tion – two coor­di­na­tion nurs­es are in charge of the dig­i­tal inter­ac­tions, fur­ther com­plet­ed with tele­phone calls where necessary. 

To eval­u­ate and respond to requests in an effi­cient man­ner, the nurse is accom­pa­nied by 80 deci­sion trees. Dig­i­tal tech­nol­o­gy is there­fore only the tip of the ice­berg; the way the infor­ma­tion is processed by the nurs­es is essen­tial for good fol­low-up care. This is in con­trast to many exist­ing appli­ca­tions, which eval­u­ate but do not guide the patient in his or her jour­ney. Dur­ing the study, 77% of patient requests were direct­ly processed by the nurs­es with­out going through the refer­ring oncol­o­gist. This is, of course, due to a large num­ber of ques­tions that do not require in-depth knowl­edge of the dis­ease. For exam­ple, “can I go swim­ming with the treat­ment?”. But has the direct effect of reliev­ing the already over­ly heavy work­load of the refer­ring oncol­o­gist and val­i­dates the rel­e­vance of the deci­sion tree avail­able to nurses. 

To ensure the effec­tive­ness of this type of fol­low-up, we estab­lished a ran­domised con­trolled sam­ple of 559 patients analysed includ­ing the patient in the CAPRI group or the con­trol group (usu­al care). 

Sev­er­al ben­e­fits of this type of remote mon­i­tor­ing device are appar­ent. Con­stant mon­i­tor­ing of the patient lim­its the dif­fer­ence between the dose nec­es­sary to treat the patient and the dose ini­tial­ly pre­scribed (this is called the rel­a­tive dose inten­si­ty). More­over, this type of mon­i­tor­ing sys­tem helps to pre­vent the tox­i­c­i­ty effects asso­ci­at­ed with the treat­ments. This is a fun­da­men­tal ben­e­fit, because tox­i­c­i­ty, when it becomes severe, is often irre­versible for the patient. Sec­ond­ly, there is a reduc­tion in hos­pi­tal vis­its. With remote mon­i­tor­ing, patients are, on aver­age, hos­pi­tal­ized 1.5 days less than in the con­trol arm. In addi­tion, they vis­it the emer­gency room less often. Last­ly, patients expressed more pos­i­tive experiences.

These ben­e­fits obvi­ous­ly come from the fol­low-up care, but behind it, there is the sig­nif­i­cant amount of work that the coor­di­nat­ing nurs­es pro­vide. This leads to the ques­tion: how many patients per year can be fol­lowed by a nurse? Accord­ing to our study, it would be about 125 to 150 patients over the year. For this, they work full-time, some­times under extreme con­di­tions. They play an excep­tion­al role in remote mon­i­tor­ing, and it is their invest­ment in this fol­low-up that makes a real difference.

Final­ly, our results lead us to say that this type of mon­i­tor­ing works. We believe that it is the whole design that worked: the organ­i­sa­tion adopt­ed by the nurs­es and the omnipres­ence of dig­i­tal tech­nol­o­gy. This type of sys­tem design is the result of shared clin­i­cal and man­age­ment sci­ence exper­tise. With these solu­tions already in place, the design could be repro­duced for oth­er types of fol­low-up care. 

Interview by Pablo Andres