R. Fearn, S. Mehta, M. Seres
Ostomy care is expensive. The cost of all ostomy care including surgery, readmission to hospital and dealing with everyday problems that can occur with an ostomy is close to $1bn per year. This is just the fiscal cost to healthcare and the figure underestimates the actual cost to the patient in terms of days lost to work for example. Empowering stoma patients, or ostomates, to self-manage through education and peer support has consistently been shown to reduce complications and prevent readmission to hospital. The Alfred SmartCare Ostomy system helps to do just that through the use of smart connected technology and a unique and highly successful Patient Coaching program.
The Alfred SmartBag System, an FDA cleared product, consists of a smart bag that measures the output from a stoma and the surrounding skin temperature to help the patient better manage two of the most frequently occurring complications – dehydration and skin irritation. In addition, the platform provides the patient with telehealth access to a Patient Coach who can help them through a variety of problems in real time and even escalate their issue to a nurse, doctor or surgeon should the need arise. All of this information is transmitted to a cloud service that allows remote monitoring of a patient to help prevent of complications and ultimately improve an ostomate’s well-being overall
Here, we are excited to present the results from the first 12,000 patient-days of monitoring.
We have been able to monitor 129 ostomates since October 2018 using our Alfred SmartBag system. The average remote monitoring period was 85 days continuously which equates to just under 4800 hours. During that time, just over 2700 ostomate to Patient Coach interactions were made and a third of these required escalation to nursing support. The most frequent reasons for these interactions were for skin irritation and dehydration. Other causes included SmartBag technical support and gastrointestinal problems such as bowel obstruction. Interestingly, 73% of these interactions were by instant messaging within the Alfred SmartBag app rather than via phone calls.
From all of this data, a total of 28 complications in 21 patients (ie some patients had more than one complication) resulted in re-hospitalisation before 30-days after originally being discharged from hospital. The rate of dehydration in this group of smart connected ostomates was only 1.5% which is significantly lower than the national average in the USA of around 30%
We have shown here that a smart care model incorporating Patient Coaching and remote monitoring can reduce the burden on both nursing care and hospital readmissions in ostomy care. Ultimately, we aim to improve patients' lives and simultaneously reduce the cost of healthcare with smart, connected wearable technology.
Patients living with an ostomy suffer impaired quality of life, dehydration, peristomal skin complaints and hospital readmissions(1). The mean cost per readmission for this group has been calculated at $15,434 and complications of ostomy surgery alone contribute up to $1 billion in healthcare expenditure per year (1).
The Alfred SmartBag System, an FDA cleared product providing data on stoma output and skin temperature (2), forms the remote monitoring component of a novel care pathway designed around the perioperative journey of a potential ostomate. Additional components include peer support, educational resources and telehealth nursing. Here we report the results of a multicenter service evaluation pilot analyzing the impact of the Alfred SmartCare Platform since October 2018.
User-level data is collected by the platform in real time through account registration, remote monitoring telemetry data and app interactions. Contacts with peer support health coaches and telehealth nursing staff initiated through the platform are logged in a HIPAA compliant electronic healthcare record. This routinely collected data was anonymized and evaluated.
Absolute numbers of interactions and trends were reviewed to identify patterns in user behavior. Free-text clinical documentation was organized into quality of life domains using directed content analysis mapped to key domains of the City of Hope Quality of Life Questionnaire for a Patient with an Ostomy as previously described (3).
Figure 1: The distribution of stoma type in a population enrolled into the Alfred SmartCare Platform.
129 patients (54% female) have been enrolled into the Alfred SmartCare Platform since October 2018. Mean (+-SD) age was 44 (15) years. The mean duration of follow up is 85 (99) days. This equates to 12,000 patient days. In addition, 4,797 hours of remote monitoring data have been made available to the remote care team (patient coach, telehealth nurse and usual clinical team). A total of 2,739 interactions took place between patient and coach. 73% of these were by text message or messaging app. 23% were by call and 4% by email. Mean interaction duration was 7.9 minutes. Stoma type and underlying disease are summarized in figures 1 and 2.
Figure 2: Distribution of underlying diseases in users of the Alfred SmartCare Platform.
Of 1,964 encounters where health related quality of life support was delivered, 44% of patients were seeking support on physical health issues, 39% for psychological health issues and 16% for social issues. The detail of support provided for physical health issues is provided in figure 3.
Thirty-six patients received nursing support through the platform representing 28% of the total cohort. There were 77 nursing interactions in total, with a mean of 2.13 nursing interactions per patient (for patients that received any nursing support). When the principle content of nursing encounters was analyzed, 30% were for peristomal skin issues, 29% for hydration support, 19% for appliance or supply support, 16% for support regarding other medical or surgical issues (including three cases of suspected obstruction or anastamotic leak).
Figure 3: Subcategorization of quality of life support sought by patients specifically within the health-related quality of life domain based on free-text analysis of 864 telehealth coaching encounters.
Eighty-four percent of nursing interactions were managed with reassurance or education alone with no further escalation. 10% were redirected to primary care or their usual clinical team. 5% resulted in redirection to the emergency room.
28 clinical complications that resulted in hospitalization (via ER or direct admission) were documented in 21 patients. The breakdown of the causes of readmission are listed in table 2 and visualized in figure 6 below. 57% of issues recorded were directly attributable to the surgery or presence of a stoma. Of these, dehydration was the single greatest cause for readmission affecting 7 patients (5.4% of the cohort).
The mean (range) number of days to hospitalization incident was 76 (4-288). 11 incidents (in 10 patients) occurred within 30 days of surgery and these are summarized in table 3 and figure 7. The overall 30-day readmission rate was 7.7% and 30-day readmission for dehydration 1.5%.
Figure 4: Reasons for readmission within 30 days of surgery based on free-text analysis of 11 episodes recorded in coaching or nursing notes.
Here we have demonstrated that a smart care remote monitoring and telehealth platform can deliver meaningful care and improved outcomes to patients undergoing major gastrointestinal surgery. The mean duration of patient journey (85 days) implies acceptability of the program and durability of the response. 73% of interactions were by messaging application which may be of interest to telehealth policy makers who often assume that care encounters will take place over an audio-visual medium.
Empowering stoma patients to self-manage through education and peer support has consistently been shown to reduce complications including readmission and dehydration (4, 5, 6). Just under a third of coaching interactions for health-related support concerned hydration. Coaches are trained to educate on the risk of dehydration in ostomy patients, the mechanisms and early identification and preventative steps. Dehydration and renal failure are a major cause of morbidity in ostomates (7, 8). In this data, dehydration remained the most common cause of all-cause readmission, however the absolute rates were lower than previously reported (7.7% all cause 30-day readmission). This data is shown in figure 4.
Skin complications are observed in 18%-55% of stoma patients (9). In this cohort 49% of nursing interactions were related to skin or appliance issues, but this accounted for only 38 encounters out of 268 enquiries to a coach for such issues, an 86% reduction in nursing burden, again attesting to the benefit of coaching and early detection.
Readmission after surgery is associated with over $41 billion in hospital costs each year (10). Complications of ostomy surgery alone contributes up to $1 billion in annual healthcare expenditure (1). We have shown here that a smart care model incorporating peer-to-peer coaching, educational resources and remote monitoring can reduce the burden on both nursing care and hospital readmissions in ostomy care. Ultimately, we aim to improve patients’ lives and simultaneously reduce the cost of healthcare with smart, connected wearable technology.
1. Chen SY, Stem M, Cerullo M, Canner JK, Gearhart SL, Safar B, et al. Predicting the Risk of Readmission From Dehydration After Ileostomy Formation: The Dehydration Readmission After Ileostomy Prediction Score. Dis Colon Rectum. 2018;61(12):1410-7.
2. Fearn R, Ziring D, Solis K, Dorofeeva I, Landon C. Validation of a novel connected "smart" stoma bag to monitor output and skin condition in ostomates. Society of American Gastrointestinal and Endoscopic Surgeons 2019 (17th World Congress); Baltimore, Maryland2019.
3. Grant M, McCorkle R, Hornbrook MC, Wendel CS, Krouse R. Development of a chronic care ostomy self-management program. J Cancer Educ. 2013;28(1):70-8.
4. Nagle D, Pare T, Keenan E, Marcet K, Tizio S, Poylin V. Ileostomy pathway virtually eliminates readmissions for dehydration in new ostomates. Dis Colon Rectum. 2012;55(12):1266-72.
5. Hardiman KM, Reames CD, McLeod MC, Regenbogen SE. Patient autonomy-centered self-care checklist reduces hospital readmissions after ileostomy creation. Surgery. 2016.
6. Thorpe G, McArthur M, Richardson B. Healthcare experiences of patients following faecal output stoma-forming surgery: a qualitative exploration. Int J Nurs Stud. 2014;51(3):379-89.
7. Justiniano CF, Temple LK, Swanger AA, Xu Z, Speranza JR, Cellini C, et al. Readmissions With Dehydration After Ileostomy Creation: Rethinking Risk Factors. Dis Colon Rectum. 2018;61(11):1297-305.
8. Paquette IM, Solan P, Rafferty JF, Ferguson MA, Davis BR. Readmission for dehydration or renal failure after ileostomy creation. Dis Colon Rectum. 2013;56(8):974-9.
9. Sarkut P, Dundar HZ, Tirnova I, Ozturk E, Yilmazlar T. Is stoma care effective in terms of morbidity in complicated ileostomies? Int J Gen Med. 2015;8:243-6.
10. Hines A, Barrett M, Jiang J, Steiner C. Healthcare Cost and Utilization Project: Statistical Brief #172 2014 [Conditions with the largest number of adult hospital readmissions by payer, 2011]. Available from: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb172-Conditions-Readmissions-Payer.pdf.