Use of a Checkbox Format for Electronic Remote Symptom Monitoring After Surgery

Comparative studies demonstrate that patients who use electronic patient-reported outcomes (ePROs) experience better outcomes; however, research comparing ePRO designs to determine optimal strategies for routine clinical practice is limited. We aimed to determine the impact of a novel checkbox format for presenting items in a postoperative symptom-assessment ePRO tool.

Patients undergoing prostatectomy, nephrectomy, mastectomy, hysterectomy, or thyroidectomy at a tertiary cancer hospital ambulatory surgery center through July 2024 were included. All patients were assigned the ePRO tool for 10 days postoperatively to assess surgical recovery. Historically, patients were asked to rate severity of all symptoms in the tool. An updated checkbox format was then implemented that asked if symptoms were present (yes/no) before eliciting qualitative severity ratings only for selected symptoms. An interrupted time-series design was used to compare patient engagement and psychometric properties before and after implementation of the checkbox format.

31,702 patients undergoing 38,929 operations were assigned the ePRO tool with (n = 17,432) or without (n = 21,497) the checkbox format. Without checkboxes, 75% of patients completed at least one questionnaire; mean completion time was 2 minutes. With checkboxes, completion rates improved by an adjusted absolute difference of 13% (95% CI, 12% to 14%; P < .001) and completion times decreased by 44 seconds (95% CI, 42 to 46; P < .001). Symptom scores were lower in the checkbox group and had better correlation with known predictors.

Presenting ePRO items in a conditional checkbox format improved patient engagement, reduced survey burden, and was associated with better psychometric properties. The checkbox format should be standard for ePRO delivery in settings such as after surgery, where patients are likely to report only a subset of possible symptoms.