An NCI-designated Comprehensive Cancer Center
By Samantha Bonar | June 20, 2017
breakthroughs - Virgina Sun Virginia Sun, Ph.D., R.N., M.S.N.
Tracking patients using wireless wrist monitors like Fitbits is a good way to evaluate their recovery after major surgery, according to new research published in JAMA Surgery by City of Hope’s Virginia Sun, Ph.D., R.N., M.S.N., an assistant professor in the Division of Nursing Research and Education.
Previous studies have shown that changes in symptom intensity and overall physical health were significantly associated with changes in average daily steps — psychological and physical complaints may limit a patient’s willingness to walk.
In this pilot study, 20 abdominal cancer (gastric, colorectal, liver and pancreas) patients were given wristband pedometers and completed online surveys about their symptoms and quality of life three to seven days before major abdominal surgery, through hospitalization and for two weeks postdischarge. 
Such surgeries are complex and have a higher risk of postoperative complications, according to the study. The research team received alerts for all moderate to severe scores for symptoms and quality of life. 
“The idea really emanated from my curiosity as a nurse,” Sun explained. “I realized that patient-centered outcomes, including symptoms and quality of life, are not utilized or assessed routinely in surgery.” 
At the same time, she said, due to surgical advances, as well as changes in the health care system, “surgeons are asked to discharge patients earlier after surgery. As a result, the majority of postoperative care and recovery takes place in the community. This poses a challenge for providers as potential postoperative complications that normally arise in the hospital may also be developing, potentially unnoticed, in the community and at home.”
Sun said she wanted to find the answers to four distinct questions:
  1. What is happening with patients at home while they are waiting for surgery? 
  2. What is happening with patients after discharge?
  3. Given mandates for shorter hospital stays, how can we utilize the preoperative setting to improve postoperative outcomes? 
  4. How can we facilitate early and safe patient discharge and recovery at home?
In the study, up to 88 percent of participants wore their wrist monitors, and 65 to 75 percent completed the online surveys, which measured mobility, self-care, usual activities, pain/discomfort and anxiety/depression. 
Surveys about symptoms were given three times a week, and quality-of-life surveys once a week. An email alert to research staff was automatically generated within one minute of survey completion for all moderate to severe scores for symptoms and quality of life. A telephone call from the research staff to the patient for further assessment, as well as notification of the surgical team, followed. 
According to the study’s results, overall symptom severity and symptom interference with activities were mild postdischarge. Pain, fatigue and appetite loss were moderate after surgery. Quality-of-life scores were lowest at discharge but improved by week 2. 
Patients’ steps data was shared with the research team via a secure online group account. Significantly, while patient-reported outcomes returned to baseline at two weeks, the number of steps taken, as tracked by the movement monitors, was only one third of the preoperative baseline. (Studies show that it can take a full six months after major abdominal surgery for patients to achieve recovery.) About one-third of online survey results triggered alerts and intervention.
Sun called this outcome “expected in a patient population that had undergone a complex and extensive abdominal surgical procedure.” But it was the first time the data was “presented in a way where we can graphically depict the anticipated abrupt pre- and postoperative changes that we observed.” Wristband pedometers “allow real-time efficient, unobtrusive monitoring,” according to the study.
The tracking provided “a way for providers to proactively monitor for any postoperative issues,” Sun said. “Once we identify these issues, we can act efficiently and manage them in real-time, and not wait until conditions become critical such that patients are either admitted to our hospital or to another outside facility.”
Tracking “may also allow us to identify early on which patients might be more at risk for postoperative complications, and direct health care resources to these high-risk populations,” she added.
The study indicates that wristband pedometers can be useful for specific surgery populations such as older cancer patients, Sun said. 
“With the anticipated ‘silver tsunami’ of a growing aging population, more and more older cancer patients will undergo major surgery. This population is particularly vulnerable to postoperative functional impairments, so it is important to better understand their experience.”
In addition, the tracking can be used to examine differences in patient outcomes based on alternative surgical techniques, particularly traditional open procedures versus minimally invasive surgery (40 percent of study participants underwent minimally invasive surgery). 
“As part of value-based cancer care, we can examine whether minimally invasive procedures have an advantage in postoperative functional recovery compared to open procedures,” she said. 
Sun next plans to broaden the study to 283 patients who are more geographically and socio-economically diverse, perhaps with a monitoring period as long as 60 days, to get a more complete picture of the value of digital wristband and online survey monitoring. 
But her current study was an important first “step.”

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