Remote Patient Monitoring to Transform Management of Febrile Neutropenia in Cancer Patients

Febrile neutropenia (FN) is among the most common and costly acute complications experienced by patients receiving cancer-directed therapy. Ambulatory management of FN in patients at low risk of decompensation may decrease patients' burden of illness and improve their quality of life, and it is advocated by American Society of Clinical Oncology (ASCO) guidelines. However, in the United States, inpatient management remains the dominant standard. A major reason for this is the absence of viable and safe alternatives to inpatient care. On the basis of telehealth growth in cancer practice and experience with a multiregional remote patient monitoring (RPM) program for patients with cancer and Covid-19, the authors hypothesized that RPM could serve as an ambulatory solution for FN management. With multistakeholder collaboration, from 2021 to 2022, a team designed and implemented the DEFeNDR (Decreasing the burden of Febrile Neutropenia through Dynamic RPM) program, which leverages in-home technology and centralized virtual nurse monitoring to facilitate ambulatory management. Adult patients with cancer hospitalized with FN were screened daily for program eligibility, which included a Multinational Association for Supportive Care in Cancer score of greater than or equal to 21 (per ASCO guidelines) and no cellular therapy (chimeric antigen receptor T-cell therapy or bone marrow transplant) in the prior 100 days. Eligible patients agreeing to participate in the 30-day program received a kit containing a cellular-enabled tablet with preconnected devices for twice-daily vital signs and symptom assessments. Patient-generated data were integrated in the electronic health record in near real time. Embedded decision trees facilitated alerts for adverse trends. Virtual RPM nurses responded to alerts and utilized predefined care pathways designed by a multidisciplinary team to facilitate care. This model alleviates the transitional care responsibilities of the primary oncology care team. Care utilization outcomes, safety, and patient satisfaction were assessed. The primary clinical end point was the mean proportion of evaluable days spent inpatient (mPEDI) within 30 days of eligibility comparing those who participated in the program (RPM) with those who declined (no RPM). Among 85 eligible patients identified over 12 months from program implementation, 62 were offered DEFeNDR participation. Of those, 34 (54.8%) participated, and 28 (45.2%) declined. Patients using RPM experienced significantly lower mPEDI than unmonitored patients (5.1% standard error, 1.9% vs. 12.4% standard error, 2.1%; Wilcoxon rank-sum test P value of 0.032). Patients using RPM also experienced a significant reduction in mean inpatient days and trend for lower 30-day readmission rate as well as shorter mean length of stay and lower rate of ICU utilization when readmitted. Patient satisfaction was strong, as 100% of patients using RPM who completed a survey (n = 11) indicated that they would recommend the program to patients with a similar condition. In summary, patients with cancer and FN participating in the DEFeNDR program were highly satisfied and experienced a significant reduction in mPEDI and inpatient days compared with those who declined RPM program participation.